Manual Therapy Journal - Volume 11, Issue 1, Pages 1-90 (February 2006)

VOLUME 11 NUMBER 1 PAGES 1–92 FEBRUARY 2006

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) J. Langendoen (Kempten, Germany) 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) C. McCarthy (Coventry, UK) J. McConnell (Northbridge, Australia) S. Mercer (Queensland, Australia) 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 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(06)00005-1

ARTICLE IN PRESS

Manual Therapy 11 (2006) 1 www.elsevier.com/locate/math

Editorial

New years resolutions and personal and professional development 2006 Happy New Year to all readers of Manual Therapy Journal now in its 11th year of publication. The busy autumn musculoskeletal therapy focused conference season is now passed and we can look forward to a more leisurely scientific conference pace for at least a few more weeks! But of course it is a new year and time for each of us to contemplate our resolutions for 2006. As individuals what targets will we set ourselves? How will we achieve these targets? And what outcomes will we use to ensure that our targets have been reached? Targets may include the undertaking of personal, professional and academic development activities which are designed to improve our performance as clinicians/ managers/researchers/clinical educators/teachers. With this number of potential areas for development, it is sometimes difficult to decide where to focus ones energies because there are so many developmental opportunities to choose from. It is useful therefore, before planning any personal development activities for 2006 to reflect on what happened in 2005. What was the balance at an individual level of personal, clinical, academic and research development and what were the tangible pay-offs and benefits? If there were any benefits, how were these evaluated? Did we only evaluate them from our own individualistic perspective or did we involve other key players such as patients, colleagues and students in this evaluation. If we did not evaluate within this context, why didn’t we, and would not wider evaluation have been beneficial? Speaking recently to some delegates at an international conference for musculoskeletal therapists, the delegates were saying how glad they were that they had chosen this particular conference and what a difficult decision it was nowadays to choose which conference/ course to attend. These decisions of course were related in part to economic issues, but one conference delegate said ‘‘It is so difficult to know which events to attend there is something I would like to attend on every week!’’ So with the plethora of courses and international/national conferences, it becomes increasingly

1356-689X/$ - see front matter r 2006 Published by Elsevier Ltd. doi:10.1016/j.math.2006.01.001

important that individuals plan attendances wisely, choosing events which are evidence based and not full of clinical dogma or guruism. Everyone should ensure that they have a strategy for capitalizing on their attendance at any educational event from the academic content, and the clinical application through to the social and professional networking activities (both highly valued and often very productive!). It is always essential that participants in conferences and courses evaluate these events from a personal and professional perspective and give feedback to the organizers, for without feedback how can improvements be gained? Feedback from the 2nd international Conference on Movement Dysfunction held in Edinburgh towards the end of 2005 has been very good. The conference was sponsored by Elsevier and Manual Therapy Journal and we will be publishing a special issue later in the year which will include peer review articles based on the keynote addresses and free papers presented at this conference. It was a good event and the Manipulation Association of Chartered Physiotherapists in the UK and Kinetic Control are to be congratulated on putting together an excellent scientific programme. We hope that all the delegates at that conference reflected carefully on the content of the papers and the personal interactions that they had with other delegates at an academic level, and we hope that the conference impacted on their practice, and their personal development, and that the sessions will have promoted an increase in academic debate, audit and research activities amongst the delegates who were present. A peaceful, prosperous and constructive new year to everyone.

Ann Moore, Gwendolen Jull University of Brighton, Aldro Building, 49 Darley Road, Eastbourne, East Sussex BN20 7UR, UK E-mail address: [email protected] (A. Moore)

ARTICLE IN PRESS

Manual Therapy 11 (2006) 2–10 www.elsevier.com/locate/math

Masterclass

The interpretation of experience and its relationship to body movement: A clinical reasoning perspective Ian Edwardsa,, Mark Jonesb, Susan Hillierc a

School of Health Sciences, University of South Australia, Australia Graduate Programs in Musculoskeletal and Sports Physiotherapy, School of Health Sciences, University of South Australia, Australia c Biomechanics and Neuroscience, School of Health Sciences, University of South Australia, Australia

b

Received 30 August 2005; accepted 17 October 2005

Abstract In this paper, we present findings from literature which suggests an intrinsic relationship in patients with chronic pain between the development of rigid and limited perspectives based on the interpretation of experience and the development of decreased repertoires of movement patterns. We present a research-based clinical reasoning model for conceptualising the teaching of movement for patients with chronic pain and contend that therapists can intentionally teach movement using fundamentally different reasoning and learning processes. We propose that these different kinds of learning will assist clinicians to translate the findings of diverse and complex pain research to clinical practice and, in particular, the teaching of these patients both new perspectives and movement patterns. r 2005 Elsevier Ltd. All rights reserved. Keywords: Chronic pain; Interpreted experience; Clinical reasoning; Movement; Teaching

1. Introduction The learning of movement and its therapeutic application with patients through teaching is arguably the most central role of physiotherapists. For manual therapists there remains a significant challenge in assisting patients with chronic pain to learn or re-learn various movement patterns. In part this paper focuses, from a clinical reasoning perspective, on how the interpretation of pain and illness experience over time influences the learning or unlearning of movement in these patients. Historically manual therapists have addressed the physical impairments identified as contributing to loss of functional abilities and participation in the various fora (family, social and work) of patients’ lives. Recent literature suggests that manual therapists also understand patients’ interpretations of their illness and/or pain experience in order to address their decision making around activity and participation capabilities Corresponding author. Tel.: +61 883022065.

E-mail address: [email protected] (I. Edwards). 1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.10.002

which are, in turn, influenced and informed by these interpretations (e.g. Osborn and Smith, 1998; World Health Organization (WHO), 2001; Main and Watson, 2002; Butler and Moseley, 2003; Waddell, 2004; Jones and Edwards, in press). Clinical reasoning is concerned not only with understanding these patient perspectives but also with understanding the nature of our own thinking and decision making as practitioners. What are the underlying assumptions upon which therapists base their interpretation of diverse data (e.g. patient beliefs and perspectives as well as physical impairments) in order to make diagnostic and treatment decisions? How does the manner in which therapists interpret patient data, even allowing for such diversity of data, influence the way in which they choose and implement management strategies? What are the implications for clinical management (e.g. teaching movement) of being aware of and intentionally varying these reasoning processes? In order to address these questions this paper is structured in three sections. Firstly, we consider the manner in which patients with chronic pain often

ARTICLE IN PRESS I. Edwards et al. / Manual Therapy 11 (2006) 2–10

constrain body movements and so diminish their previous repertoire of movements and, by extension, functional abilities. In the physiotherapy literature there has been an emphasis on the identification of so-called ‘chronic pain behaviours’ (e.g. fear avoidance) and the design of remedial strategies to address these more than there has been on an understanding of how these behaviours are the consequence of interpretive and decision making processes by patients (Jones and Edwards, in press). In the second section, we describe a model of clinical reasoning emanating from a qualitative research study (Edwards et al., 2004) which describes how expert therapists reason, even with a particular patient and within one treatment session, using an interplay of fundamentally different clinical reasoning processes. Significantly, in a departure from previous clinical reasoning theory (e.g. Hayes Fleming, 1994; Benner et al., 1996), these reasoning processes are not deployed in a manner where one type of reasoning is employed for interacting with patients and another type for choosing and implementing treatment procedures. In the third section we explore how these fundamentally different reasoning processes both have important roles in the teaching and learning of movement.

2. The interpretation of experience in chronic pain Patients render their experiences sensible to themselves and others through the act of interpretation. Patients’ interpretations of illness, pain and/or disability experiences are formed in relation to the depth and diversity of their ‘interpretive resources’ (White, 1998, p. 1). The term ‘interpretive resources’ refers to a pool of beliefs, values and behaviours which are derived from cultural and social influences as well as patients’ own unique personal circumstances and histories ((Mezirow, 1991; White, 1998; Sim and Smith, 2004). These cultural and social influences constitute a way of understanding experiences (often tacitly rather than consciously) which enables patients to bring the particular events of their lives into some kind of general comparison with the similar experiences of others (e.g. the experience of being off work with low back pain) (White, 1998). From this ‘generalizing’ of experience is a resultant learning to adopt the language and behaviour expected of someone with a chronic condition (Osborn and Smith, 1998). The notion of the ‘sick role’ (Parsons, 1978) and the ‘validating’ of illness or disability through the ‘generalizing’ of experience (i.e. what is deemed legitimate sickness behaviour) is an example of meanings being shaped at a social level. Associated with this patients with chronic pain report a sense of distress in their attempts to find a balance between their own interpretations of their illness experience and what others understand and expect of them (Osborn and

3

Smith, 1998; Steen and Haugli, 2000; Gustaffson et al., 2004). In such a scenario, patients’ descriptions of their illness experience tend to become ‘monographic’ (i.e. single theme), flat descriptions of life which for them render events predictable (White, 1998, p. 2). This can be to the point that they often express fixed and limited perspectives on situations such as their condition, ability to work, and their ability to participate in family life and even physiotherapy. Readers may recognize the often stereotypical accounts of symptoms and history during interviews with patients with chronic pain. The perspectives of these patients regarding their pain (expressed in therapy and elsewhere) are ‘less permeable’ in so much as they are less open to change and ‘less dependable’ in that they do not appear to ultimately ‘work’ for the person (Mezirow, 1991; Osborn and Smith, 1998). Illness representation or schema research emanating out of cognitive psychology echoes this notion of narrowing and rigidity of perspectives (Leventhal et al., 1980; Bishop, 1991; Skelton and Croyle, 1991; Turk and Rudy, 1992; Pincus and Morley, 2001). Illness representations or schema are also learned through both social and personal experiences and function as individuals’ implicit theories of illness that they use to interpret and respond to health threats. In schema theory it is not only the person’s existing beliefs and assumptions that make up their mental representation and contribute to determining their coping but also their appraisal of the threat their problem/pain or the situation poses (e.g. seriousness, social desirability, personal responsibility, controllability and changeability) (Bishop, 1991; Salkovskis, 1996). This appraisal in turn shapes how further experiences are interpreted. The interpretation of experience, therefore, is not a fixed ‘cause’ and ‘effect’ system. Rather, it is a changing one. Pincus and Morley (2001) propose that everyone has their own schema for pain, illness and the self that normally have some degree of overlap. As schema evolve over time, in situations such as chronic pain, these schema become ‘enmeshed’. That is, repeated simultaneous activation of aspects from different schema is thought to be a mechanism of learning that results in a blurring of representations such that elements from one schema become incorporated in another. This ‘enmeshment’ of schema is believed to be one explanation for why events leading to activation of one schema with relatively benign consequences can develop into a schema eliciting more significant effects (Pincus and Morley, 2001). While the notion of illness and pain schema are likely already considered by those interested in pain and psychosocial influences, the concept of a self-schema may be less familiar. Selfschema is a complex multifaceted construct that relates to who you are with reference to who you used to be (prior to your perceived change in self) and who you would like to be in the future. It includes an evaluative

ARTICLE IN PRESS 4

I. Edwards et al. / Manual Therapy 11 (2006) 2–10

dimension that contributes to an individual’s sense of self-worth. Pain has the ability to disrupt aspects of the self such that repeated failures to function ‘normally’ and the negative emotions that result, can lead to changes in a person’s self-image (Osborn and Smith, 1998; Steen and Haugli, 2000). While Pincus and Morley (2001) focused on mental representations of illness, pain and self, research investigating body schema (or the real-time representation of the body in space, reflecting sensory input with corresponding motor consequences), provides evidence for further influences of pain (e.g. Moseley, 2004; Moseley et al., 2004; Van Damme et al., 2004; Hudson et al., in press). Using different methodologies these two research groups reported significant findings with subjects having difficulty disengaging from chronic pain, experimentally induced acute pain and even from cues signalling impending pain. A number of hypotheses are entertained in the discussions from this research with the prevailing opinion being that information-processing biases reflect a limitation in ‘‘disengagement’’ from the painful, or anticipated painful, body part. This difficulty allocating attentional resources away from pain correlates well with other findings that greater worry about pain is associated with greater hypervigilance, or somatic attention, with potential for amplification of somatosensory input and subsequent validation of patients’ beliefs and fears (Eccleston, 1995; Eccleston et al., 1997; Crombez et al., 1998a, b). Somatic vigilance may also be related to catastrophic cognitions which in turn may be related to the ‘‘meaning’’ individuals attribute to their pain as reflected in their attitudes and beliefs about pain (Moseley, 2004). It is intriguing to consider whether body schema could similarly be affected by chronic pain and disability experiences, and if so, could body schema and the motor system with which it is integrated be enmeshed along with pain, illness and self-schema as proposed by Pincus and Morley (2001)? Clearly this would require further research to establish. However, with contemporary perspectives that sensory, cognitive, emotional and motor ‘systems’ are not separate in the brain (e.g. Melzack, 1996; Ratey, 2002; Moseley, 2003) it appears a reasonable proposition. Next we consider this further and question whether these various schema, and in particular a person’s flexibility of perspectives, or their scope of ‘interpretive resources’ may correlate with the limitations in body (posture and movement) awareness and movement commonly observed in patients with chronic pain. In clinical practice, the interpretations of experience described so far in patients with chronic pain appear to have a parallel with similar expressions of stereotyped and impoverished movement patterns in these patients: movements which could be described as exhibiting a narrower repertoire and of being less ‘rich’ in terms of spontaneity and complexity.

Traditionally manual therapists have approached the problem of impoverished movement patterns in patients with chronic pain through structurally oriented management strategies aimed at, for example, improving posture, flexibility and coordination. Clinical management strategies have tended to be based in recent years on behavioural or neural processing explanations. Fearavoidance has been a prominent behavioural descriptor while other behaviourally related ‘diagnoses’ such as ‘secondary gain’ and ‘abnormal illness behaviour’ have been widely used. More recently, such an approach has been informed by the biopsychosocial model with the use of such strategies as ‘cognitive-behavioural therapy’ (Harding, 1998; Waddell, 2004; Klaber Moffett et al., 2005). This latter method, although offering much to the therapist in what is a difficult area of practice, has been criticized for its emphasis on the changing of behaviour (as expressions of people’s beliefs) with the importance of examining the origins of such beliefs being more a subsidiary strategy (Sharp, 2001). Recent research by Moseley and colleagues with patients who have chronic pain has focussed on ‘interpretive’ rather than ‘behavioural’ activities. They have investigated the effects of specific explanations regarding the neurophysiology of pain to patients with chronic pain and shown positive changes in beliefs and attitudes (Moseley et al., 2004) in pain and movement (Moseley, 2004) and in the way the brain allocates importance to injury or physical self-related cues (Burnett and Moseley, 2005). The pain neuromatrix model’ (Moseley, 2003) describes the brain as an ‘orchestra’ (involving the many ‘players’ and ‘instruments’ of the brain) which plays the pain ‘tune’ as a memoried and stored response to perceived threat. Learning to constructively re-interpret the ‘threat’ which patients perceive leads to beneficial changes in patient experience and function. We encourage readers, as would Moseley (personal communication), to understand ‘threat’ not only in terms of patients’ fears. Experiences such as ‘loss of hope’ and ‘loss of social participation’, ‘helplessness’ and even ‘sense of shame’, have been found to be potential pain perpetuating experiences of those with chronic pain (Salkovskis, 1996; Osborn and Smith, 1998; Gustaffson et al., 2004; Sim and Smith, 2004). For example ‘loss of hope’ has to do with the attribution of meaning. Similarly, ‘loss of social participation’ and ‘sense of shame’ and ‘helplessness’ have socially determined elements. In other words, self-image and a projected future for the ‘self’ may be part of the ‘threat’ influencing the interpretation of pain and movement. The mind-body dynamics discussed in the diverse literature of neuroscience (neuromatrix theory), psychology (schema enmeshment) and sociology (diminished ‘interpretive resources’) together suggest an

ARTICLE IN PRESS I. Edwards et al. / Manual Therapy 11 (2006) 2–10

intrinsic relationship between the interpretation of experience and movement. However, an integrated conceptual framework of biomedical and psychosocial thinking is still needed to guide manual therapists’ inquiries, interpretations and decision making in order to implement such findings in clinical practice. We propose that clinical reasoning provides such a conceptual framework.

3. Clinical reasoning and movement: it is not only what therapists see but how they see it Edwards et al. (2004) carried out a qualitative, grounded theory study of the clinical reasoning of expert clinicians in three different fields of physiotherapy: manual/musculoskeletal; neurophysiotherapy; domiciliary care (home based) physiotherapy. Grounded theory is a method often used to generate theory or explanations which are grounded in the data, and regarding a phenomenon about which little is known (Strauss and Corbin, 1994). The aim of this research was to study the clinical reasoning of these therapists in the natural settings of the clinicians’ usual clinical practice. Data were collected through the ‘shadowing’ of these therapists over the course of at least 2 days of clinical practice. All treatments and subsequent interviews were audiotaped and field notes written. The tapes were transcribed and analysed using a grounded theory coding process and a case study method (Edwards et al., 2004). The study’s findings were that, regardless of field, each therapist reasoned in a number of focussed and identifiable areas of reasoning in practice which we term ‘clinical reasoning strategies’. Clinical reasoning strategies cover a broad range of clinical practice responsibilities; including reasoning related to diagnosis, procedure, interaction, teaching, collaboration, prediction and ethics (Table 1). These activities can be viewed through two fundamentally different reasoning processes: hypothetico-deductive reasoning and narrative

5

reasoning. These reasoning processes have underlying assumptions parallel to those underlying quantitative and qualitative research paradigms (Fig. 1). The quantitative (experimental) paradigm and corresponding hypothetico-deductive mode of reasoning hold that knowledge is objective, measurable, predictive and generalizable (Denzin and Lincoln, 1994; Higgs and Titchen, 2000) (Fig. 1). Quantitative research generates knowledge through the deductive ‘testing’ of hypotheses. Similarly, hypothetico-deductive (diagnostic) reasoning involves the generation and subsequent testing of hypotheses in a similar deductive (or cause and effect) manner in order to reach a diagnostic or procedural decision (Elstein et al., 1978). Qualitative research often produces knowledge through an inductive generation of hypotheses in areas where less is known about a phenomenon. In broad terms qualitative research approaches (in particular the interpretive paradigm) and narrative reasoning hold that knowledge is socially constructed, context dependent and that there are multiple realities rather than a single truth waiting to be discovered (Fig. 1). Narrative reasoning is based, therefore, on the premise that individuals construct their own unique interpretation of their experiences (e.g. of their pain or disability

quantitative

qualitative

Scientific/ experimental/ positivist

Interpretive

Underlying assumptions about truth/ reality

objective measurable predictable generalizable

context dependent socially constructed multiple realities

Reasoning processes

hypothetico-deductive

Knowledge generation: research paradigm

narrative

Fig. 1. Assumptions underlying research paradigms and reasoning processes.

Table 1 Clinical reasoning strategies Diagnostic reasoning: The formation of a diagnosis related to physical disability and impairment with consideration of associated pain mechanisms, tissue pathology and the broad scope of potential contributing factors. Narrative reasoning: The apprehension and understanding of patients’ illness experiences, ‘‘stories’’, contexts, beliefs and cultures. Reasoning about procedure: The determination and implementation of treatment procedures. Interactive reasoning: The purposeful establishment and ongoing management of therapist–patient rapport. Collaborative reasoning: The nurturing of a consensual approach towards the interpretation of examination findings, the setting of goals and priorities, and the implementation and progression of treatment. Reasoning about teaching: The activity of individualized and context sensitive teaching. Predictive reasoning: The active envisioning of future scenarios with patients including the exploration of their choices and the implications of those choices. Ethical reasoning: The apprehension of ethical and practical dilemmas that impinge on both the conduct of treatment and its desired goals, and the resultant action towards their resolution.

ARTICLE IN PRESS I. Edwards et al. / Manual Therapy 11 (2006) 2–10

6

Knowledge generation: research paradigm

quantitative Scientific/ experimental/ positivist

Interpretive Instrumental learning/ action

Underlying assumptions about truth/ reality

objective measurable predictable generalizable

Reasoning processes

hypothetico-deductive

Action/ learning

qualitative

Instrumental

context dependent socially constructed multiple realities

narrative

Communicative

objective measurable predictive generalizable

Movement

Fig. 3. Assumptions underlying instrumental learning of movement.

Communicative learning/ action

context dependent socially constructed Movement multiple realities

Fig. 2. Assumptions underlying instrumental and communicative learning and action.

experience, including its social consequences). Two people may have very similar impairments in terms of tissue pathology but have very different levels of disability due not only to their particular circumstances but also to their particular interpretation of their pain/ illness experience and the meaning (and implications) they attribute from this interpretation of their problem (s) to their lives. In this clinical reasoning strategies model, physiotherapy management (as Table 1 suggests), includes a scope of knowledge and clinical skills beyond just the selection of an appropriate procedure(s), its application and reassessment. The terms instrumental and communicative (Fig. 2) emphasize the respective implementation of hypothetico-deductive and narrative decision-making processes in various forms of clinical management (from application of specific therapeutic procedures through to education directed at challenging and assisting patients to ‘reinterpret’ unhelpful thoughts and beliefs). Learning is a tangible outcome of skilled clinical reasoning. The clinical actions taken as a result of that reasoning can lead to learning for both patient and therapist. When therapists employ an instrumental action and learning they look through a clinical reasoning ‘lens’ which enables them to see a decision or action with respect to assumptions about knowledge which are objective, measurable, predictive, and generalisable (Fig. 3). This often involves the manipulation or control of observable events be they physical (e.g. joint or muscle function) or interactive (e.g. behaviourally applied graded exposure to perceived threats) (Edwards et al., 2004). In instrumental action and learning, therefore, therapists’ reasoned decisions, actions and subsequent learning are structured in a way where concepts of normality or what is correct underpin generalized interpretations. That is, treatment techniques may be selected and applied with their effects measured and predicted through reassessment often based on population ‘norms’.

Fig. 4. Assumptions underlying communicative learning of movement.

In communicative action and learning different underlying assumptions concerning knowledge are that it is context dependent, socially constructed and there are multiple realities (Fig. 4). Communicative learning is concerned with understanding what others mean when they communicate their perspectives about such things as intention, motivation, experience and values (Mezirow, 1991). Communicative action in a clinical situation may involve therapists firstly understanding these perspectives and then fostering reflection on the adequacy of these perspectives in their patients. An example of how this type of learning and how instrumental and communicative learning and action inform each other is found in the vignette ‘Moira’s headaches’ (taken from Edwards, 2001 and cited in Jones et al., 2002). Vignette: Moira’s headaches Moira (a pseudonym) is a patient (from the study by Edwards, 2001) who presented with a gradual onset and 18-month history of continual facial/TMJ area headaches with associated disabilities in work (nurse practitioner) and family/home care activities. One feature of Moira’s presentation was her ineffective coping style while under pressure (work and demands of a 2-year-old), and resultant learned motor patterns (e.g. continual mandibular clenching in response to stress). Evident in the assessment was not only her lack of awareness of the factors contributing to her symptom provocation (e.g. stress and anger resulting from the work-load and pressure of being a working mother with a 2-year-old son and having difficulty coping with a demanding mother-in-law’s expectations) but the apparent perception of herself as a poor coper and, to a certain extent, her inadequacy as a mother. An avoidance of conflict with her mother-in-law meant her anger was poorly dealt with allowing her teeth clenching

ARTICLE IN PRESS I. Edwards et al. / Manual Therapy 11 (2006) 2–10

(and headaches) to persist without insight into these potential contributing factors. An example of instrumental action and learning in this case took place when the therapist, as part of management, was able to demonstrate to the patient an asymmetry, for example, in excursion of temporomandibular movements. Masseter and temporalis were palpated (and shown to Moira on a chart and in front of a mirror) and proprioceptive neuromuscular techniques such as hold–relax were employed to achieve a relaxation/lengthening of these muscles. The TMJ excursion was reassessed and the differences in range and/or symmetry of movement was observed and noted by the therapist together with Moira. In other words, Moira learned (was taught) to perform a manoeuvre where through the selective contraction of muscles and their subsequent relaxation, there was a demonstrable effect on a particular variable (i.e. TMJ excursion) as a part of a larger analysis of the situation. The effect of this was empirically observable and measurable at least in terms of quality of movement. The communicative teaching in this situation, however, was quite different but, nevertheless, took place in conjunction with the instrumental teaching above. This kind of teaching can be achieved through a number of strategies. One simple example which introduces the idea of self-reflection to Moira was where the therapist told a narrative concerning another patient which provided an alternative or new perspective by which Moira could reflect on her own situation: I had a guy, who was a plasterer, and he had terrible headaches, and I said to him, ‘‘What do you notice happening?’’yand he really didn’t notice very much. But he asked the people whom he worked with, and he said, ‘‘Well, how do I look when I’ve got a headache?’’ and they said, ‘‘You smile all the time,’’ and he realized he was clenching his teeth, trying to look like he wasn’t in painybut teeth clenching was really perpetuating the headaches. Here, the intent is to foster insight for Moira with regard to the factors which were potentially contributing to the ongoing production of her headaches. The relationship between behaviours (e.g. chronic teeth clenching), and symptoms (e.g. headaches), were not self-evident to her. In fact, during the day the points at which teeth clenching behaviour were most prevalent may not have even been evident to her. Similarly, the relationship between her interpretations of her situation, her view of herself and her unhelpful and habitual jaw clenching behaviours may have been lost in the understandable focus on her symptoms. This pointed to the need for Moira to, firstly, gain insight through personal reflection and then, possibly with the help of others, such as her physiotherapist, to be able to practise observing such connections. If Moira’s beliefs and

7

attitudes were to remain entrenched then a referral to a suitably qualified practitioner (e.g. psychologist) may be appropriate. 4. Instrumental and communicative learning of movement Moira’s story reminds us, as does current pain research of the importance of providing patients with a plausible account of the ‘irrationality’ of chronic pain. Thus, the so-called irrational and recalcitrant behaviour of pain experienced by those with central pain states is externalized from the patient to the problem. No longer is the patient themselves held to be the primary source of irrationality in the situation (Steen and Haugli, 2000). For example, a biomedically focussed form of reasoning has indicated to practitioners and patients alike in the diagnosis of chronic pain that if there were not sufficient ‘hard’ objective signs on examination or through investigation that patients’ pain could not be substantiated (Main and Watson, 2002; Waddell, 2004). The ‘objective’, ‘measurable’, ‘predictable’ and ‘generalisable’ nature of the biomedical model (similar to instrumental forms of reasoning and learning) is an example that a model, which contributes so much to the development of health care, can also have unproductive and even negative effects when applied in the wrong context—in this case with respect to the interpretation of lived experience (Waddell, 2004). There is evidence that manual therapists’ perception, reasoning and management approaches may be constrained in clinical practice by a biomedical (or instrumental) reasoning ‘lens’ (Jorgensen, 2000; Ostelo et al., 2003; Potter et al., 2003; Struber, 2003; Daykin and Richardson, 2004; Frost et al., 2004). A communicative form of reasoning and learning, using a ‘lens’ of reality as ‘context dependent’, ‘socially constructed’ and the notion of ‘multiple realities’ casts a different analytical light on the interpretation of experience. Instead of being caught between the imperative to act out particular social roles (either ‘successfully or unsuccessfully’ (Osborn and Smith, 1998; Steen and Haugli, 2000)) and deal with the resultant guilt imputed to them for pain which cannot be substantiated, patients are enabled to begin to identify the effects of the problem (pain) on their lives rather than viewing themselves and their pain as inextricable identities (White and Epston, 1990; Orchison, 1997). This may not be dissimilar to a process of ‘un-enmeshing’ enmeshed body schema discussed earlier. We now discuss how ‘enmeshment’, as a negative aspect of the relationship between interpretation of experience and body movement, can be further addressed through enlarging repertoires of patient perspectives and movement patterns. Physiotherapists have typically addressed patient movement impairment in an instrumental manner

ARTICLE IN PRESS 8

I. Edwards et al. / Manual Therapy 11 (2006) 2–10

characterized by prescribed therapeutic interventions with specific goals. These goals are derived from the empirical measurement of physical impairments which, are in turn, related to evidence gained from population norms (Carpenter, 1996; Struber, 2003). It is important to add, however, that instrumental approaches to movement training (exemplified by the precision required in the teaching and learning of isolation strategies for activation of particular muscle groups) remain important diagnostic and management strategies for manual therapists. In this section, we argue against a simplistic separation of body and mind by proposing that clinical reasoning and the management arising from clinical decisions (such as the teaching and learning of movement) need not be dichotomized to either the physical or non-physical but be applied to both. We contend that therapists can intentionally teach, and patients learn, movement with either instrumental or communicative assumptions or a combination of the two depending on the needs of the particular patient. As therapists we are generally more familiar with instrumental approaches to practice, A communicative approach to teaching and learning of movement is not primarily or exclusively directed at physical impairments but rather is concerned with the exploration of movement as a catalyst for further learning. An example of such an approach to learning movement, known and valued by many manual therapists, is Feldenkrais’ (1972) ‘Awareness through movement’. We do not attempt a full exposition of Feldenkrais’ methods here. Instead we discuss this work as a vehicle for illustrating how movement can be taught and learned using the assumptions underlying communicative learning. On the one hand we make the point that viewed through a communicative ‘lens’ of reasoning and learning, Feldenkrais’ approach need not be considered as ‘alternative’ or outside mainstream thinking in physiotherapy as it is when viewed through an instrumental or biomedical reasoning ‘lens’. On the other hand we propose that movement can be taught and learned using communicative assumptions in a generic manner and not confined to a particular philosophy such as Feldenkrais, notwithstanding its significant contribution to understanding movement. Feldenkrais described a relationship between a person’s self-image (with its educational, cultural and social contributions) and the expression of that selfimage in unhelpful, inefficient and even painful habits and patterns of body movement. His approach to movement is not prescriptive in that it does not seek to retrain movement by addressing specific impairments toward some ideal of ‘normalcy’. Instead it conceptualizes movement as having a social construction in so much as it is, in large part, an expression of a socially and culturally constructed self-image. Our patient,

Moira’s excessive and pain producing TMJ activity (and quite possible other postures and movement patterns) is, through a communicative reasoning ‘lens’, an expression of interpreted experience. A strong theme in the treatment session with Moira in the Edwards (2001) study was Moira’s perception of herself (i.e. selfimage) as a poor coper and as one who did not live up to the perceived expectations of her mother-in-law. In Jones et al. (2002) we used this example to point to the need for therapists to assist patients to reflect on, and identify for themselves, the links between interpretations of experience and a resultant behaviour such as mandibular clenching. In this paper, we go further and suggest (in conjunction with the literature discussed earlier) that interpretations of experience (i.e. the meanings imputed to experience) are embodied in particular movement patterns. Where repertoires of patients’ perspectives may be described as limited, rigid and habitual in their expression so too may their movement patterns. The aim of a communicative approach to learning movement, with someone like Moira, is to enlarge these repertoires, acknowledging their intrinsic relationship, and therefore assist patients to ‘deconstruct’ the habitual, fixed nature of both their perspectives and their movement patterns. Since each person’s self-image is unique, so too, Feldenkrais (1972) argues that increasing awareness of that image or identity through movement exploration reflects one person’s particular or unique set of realities. That is, there is not necessarily one right set of movements or method of addressing impairments for everyone. In this context movement ‘change’ is based on an open exploration of possibilities beyond or around any current stereotypical patterns. Persons with chronic pain may have longstanding histories where they have ‘learned’ not to succeed or, alternatively, ‘un-learned’ how to succeed at various tasks. Feldenkrais uses movement learning lessons that incorporate changes in spatial relations between body parts and also ‘create’ conditions of greater support (e.g. floor positions for exploring postures usually associated with the upright position) in order to dissociate movement from its habitual context (Reese, 2005). In this manner, habits of movement just like habits of thinking may be ‘deconstructed’ and new, even novel (in the sense of being unusual) movements and abilities are explored. Variation of movement (i.e. toward a larger repertoire) is a key to further learning and adapting to the demands of a changing environment (physical and social). In a communicative reasoning and learning approach (as for Feldenkrais) movements are intended to further knowledge and perception (about oneself and the world), and not seen as an end in themselves (Reese, 2005). In Moira’s case learning to identify and address length changes in the mandibular muscles through specific relaxation techniques took place in a largely

ARTICLE IN PRESS I. Edwards et al. / Manual Therapy 11 (2006) 2–10

instrumental manner. A communicative learning of movement in her case might also explore combinations of movement which ‘deconstruct’ habits of posture and movement viewed as both ‘interpretation’ and ‘motor response’ to the particular experience of her environment (physical and social). Enlarging movement repertoires in this way, Moira’s learning would not be confined to the learning of technical or functional skills but include the intentional learning of new or alternative interpretations of experience, in part through movement, particularly around meanings that have been attributed to various movements and postures. This may well be a form of learning through movement (as well as cognition) which addresses ‘self-image’ as Feldenkrais stated long ago.

5. Conclusion Communicative action and learning offers clinicians, in conjunction with instrumental learning and action, a way of acknowledging, in clinical practice, the complexity of mind–body relationships described in contemporary accounts of pain such as ‘schema enmeshment’, ‘interpretive resources’ and ‘threat reduction’ in neuromatrix theory. We have focussed in this paper on the interpretation of experience and body movement of patients with chronic pain. However, in order to understand the thinking of these patients, manual therapists must also understand the basis of their own thinking or reasoning. Instrumental and communicative forms of reasoning and learning suggest that in reasoning about and teaching movement is not only what therapists see but how they see it which is important.

Acknowledgements The authors would like to thank Lorimer Moseley and Nicole Christensen for their helpful comments in the preparation of this paper. References Benner P, Tanner C, Chelsa C. Expertise in nursing practice: caring, clinical judgement and ethics. New York: Springer Publishing Company; 1996. Bishop GD. Understanding the understanding of illness: lay disease representations. In: Skelton JA, Croyle RT, editors. Mental representation in health and illness. New York: Springer; 1991. p. 32–59. Burnett, Moseley L. Does explaining pain reduce the threat value of spine and pain-related words? A blinded randomised clinical trial. In: International Association for the Study of Pain 11th World Congress on Pain, Sydney, 2005. Butler D, Moseley GL. Explain pain. Adelaide: NOI Group Publishing; 2003.

9

Carpenter C. The evolving culture of physiotherapy. Barbara Edwardson Lectureship. Physiotherapy Canada 1996;48:11–5. Crombez G, Eccleston C, Baeyens F, Eelen P. When somatic information threatens, catastrophic thinking enhances attentional interference. Pain 1998a;75:187–98. Crombez G, Eccleston C, Baeyens F, Eelen P. Attentional disruption is enhanced by the threat of pain. Behaviour Research and Therapy 1998b;36:195–204. Daykin A, Richardson B. Physiotherapists’ pain beliefs and their influence on the management of patients with chronic low back pain. Spine 2004;29(7):783–95. Denzin NK, Lincoln YS. Introduction. In: Denzin NK, Lincoln YS, editors. Handbook of qualitative research. London: Sage Publications; 1994. Eccleston C. Chronic pain and distraction: an experimental investigation into the role of sustained and shifting attention in the processing of chronic persistent pain. Behaviour Research and Therapy 1995;33:391–405. Eccleston C, Crombez G, Aldrich S, Stannard C. Attention and somatic awareness in chronic pain. Pain 1997;72:209–15. Edwards IC. Clinical reasoning in three different fields of physiotherapy—a qualitative case study approach, vols. I and II. Unpublished thesis submitted in partial fulfilment of the Doctor of Philosophy in Health Sciences, University of South Australia, Adelaide, Australia. The Australian Digitized Theses Program. Available at: http:// www.library.unisa.edu.au/adt-root/public/adt-SUSA-20030603-090552/ index.html, 2001. Edwards I, Jones MA, Carr J, Braunack-Mayer A, Jensen GM. Clinical reasoning strategies in physical therapy. Physical Therapy 2004;84:312–35. Elstein AS, Shulman LS, Sprafka SA. Medical problem solving. An analysis of clinical reasoning. Cambridge, MA: Harvard University Press; 1978. Feldenkrais M. Awareness through movement. New York: Harper & Row; 1972. Frost H, Lamb SE, Doll H, Carver PT, Stewart-Brown S. Randomised controlled trial of physiotherapy compared with advice for low back pain. BMJ 2004;329:708 [originally published online 17 September 2004]. Gustaffson M, Ekholm J, Ohman A. From shame to respect; musculoskeletal pain patients’ experience of a rehabilitation programme, a qualitative study. Journal of Rehabilitation Medicine 2004;36:97–103. Harding V. Application of the cognitive-behavioural approach. In: Pitt-Brooke J, Reid H, Lockwood J, et al., editors. Rehabilitation of movement: theoretical bases of clinical practice. London: WB Saunders; 1998. p. 539–83. Hayes Fleming M. The therapist with the three track mind. In: Clinical reasoning: forms of inquiry in a therapeutic practice. Philadelphia: F.A. Davis Company; 1994. Higgs J, Titchen A. Knowledge and reasoning. In: Higgs J, Jones MA, editors. Clinical reasoning in the health professions. 2nd ed. New York: Butterworth-Heinemann; 2000. Hudson ML, McCormick K, Zalucki N, Moseley GL. Expectation of pain replicates the effect of pain in a hand laterality recognition task: bias in information processing toward the painful side? European Journal of Pain, in press. Jones MA, Edwards I. Learning to facilitate change in cognition and behaviour In: Gifford L, editor. Topical issues in pain. Falmouth: CNS Press, in press. Jones MA, Edwards I, Gifford L. Conceptual models for implementing biopsychosocial theory. Manual Therapy 2002; 7:2–9. Jorgensen P. Concepts of body and health in physiotherapy: the meaning of social/cultural aspects of life. Physiotherapy Theory and Practice 2000;16:105–15.

ARTICLE IN PRESS 10

I. Edwards et al. / Manual Therapy 11 (2006) 2–10

Klaber Moffett JA, Jackson DA, Richmond S, Hahn S, Coulton S, Farrin A, et al. Randomised trial of a brief physiotherapy intervention compared with usual physiotherapy for neck patients: outcomes and patients’ preferences. BMJ 2005;330:75 [originally published online 7 December 2004; BMJ]. Leventhal H, Meyer D, Nerenz D. The common sense representation of illness danger. In: Rachman S, editor. Contributions to medical psychology, vol. 2. New York: Pergamon Press; 1980. Main C, Watson P. The distressed and angry low back pain patient. In: Gifford L, editor. Topical Issues in Pain 3. Sympathetic nervous system and pain. Pain management. Clinical effectiveness. Falmouth: CNS Press; 2002. p. 175–92. Melzack R. Gate control theory. On the evolution of pain concepts. Pain Forum 1996;5(1):128–38. Mezirow J. Transformative dimensions of adult learning. San Francisco, CA: Jossey-Bass; 1991. Moseley GL. A pain neuromatrix approach to patients with chronic pain. Manual Therapy 2003;8(3):130–40. Moseley GL. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. European Journal of Pain 2004;8:39–45. Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clinical Journal of Pain 2004;20:324–30. Orchison R. From pain-full narratives to pain-less lives. Dulwich Centre Newsletter, Adelaide 1997;4:31–5. Osborn M, Smith JA. The personal experience of chronic benign lower back pain: an interpretative phenomenological analysis. British Journal of Health Psychology 1998;3:65–83. Ostelo RW, Stomp-van den Berg SG, Vlaeyen JW, Wolters PM, de Vet HC. Health care provider’s attitudes and beliefs towards chronic low back pain: the development of a questionnaire. Manual Therapy 2003;8(4):214–22. Parsons T. Health and disease: a sociological and action perspective. In: Parsons T, editor. Action theory and the human condition. London: Macmillan; 1978. Pincus T, Morley S. Cognitive-processing bias in chronic pain: a review and integration. Psychological Bulletin 2001;127:599–617. Potter M, Gordon S, Hamer P. The difficult patient in private practice physiotherapy: a qualitative study. Australian Journal of Physiotherapy 2003;49:53–61.

Reese M. The Feldenkrais method and dynamic system principles. Feldenkrais Southern California Movement Institute. Online available at http://www.feldenkraislearning.com/articles/dynamic_ systems.htm Accessed 30th August 2005. Ratey J. A user’s guide to the brain: perception, attention and the four theatres of the brain. New York: Vintage Books; 2002. Salkovskis P. The cognitive approach to anxiety: threat beliefs, safetyseeking behaviour, and the special case of health anxiety and obsessions. In: Salkovskis P, editor. Frontiers of cognitive therapy. London: The Guilford Press; 1996. p. 48–74. Sharp TJ. Chronic pain: a reformulation of the cognitive-behavioural model. Behaviour Research and Therapy 2001;39:787–800. Sim J, Smith MV. The sociology of pain. In: French S, Sim J, editors. Physiotherapy a psychosocial approach. Edinburgh: Elsevier; 2004. p. 117–39. Skelton JA, Croyle RT. Mental representation, health, and illness: an introduction. In: Skelton JA, Croyle RT, editors. Mental representation in health and illness. New York: Springer; 1991. p. 1–9. Steen E, Haugli L. Generalised chronic musculoskeletal pain as a rational reaction to a life situation? Theoretical Medicine 2000;21:581–99. Strauss A, Corbin J. Grounded theory methodology: an overview. In: Denzin NK, Lincoln YS, editors. Handbook of qualitative research. London: Sage Publications; 1994. Struber J. Physiotherapy in Australia—where to now? The Internet Journal of Allied Health Sciences and Practice 2003;1(2). Turk DC, Rudy TE. Cognitive factors and persistent pain: a glimpse into pandora’s box. Cognitive Therapy and Research 1992; 16:99–122. Van Damme S, Crombez G, Eccleston C, Goubert L. Impaired disengagement from threatening cues of impending pain in a crossmodal paradigm. European Journal of Pain 2004;8:227–36. Waddell G., 2nd edn. The back pain revolution. Edinburgh: Churchill Livingstone; 2004. White M. Narrative therapy. Adelaide: Dulwich Centre; 1998. White M, Epston D. Narrative means to therapeutic ends. New York: W.W. Norton and Company; 1990. World Health Organization (WHO). ICF Checklist Version 2.1a, clinician form for international classification of functioning, disability and health. [Online] Available http://www.who.int/ classification/icf/checklist/icf-checklist.pdf, 2001.

ARTICLE IN PRESS

Manual Therapy 11 (2006) 11–21 www.elsevier.com/locate/math

Original article

Subjective and objective descriptors of clinical lumbar spine instability: A Delphi study Chad Cooka,, Jean-Michel Brisme´eb, Phillip S. Sizer Jrb a

Duke University Medical Center 3907, Durham, NC 27710, USA Department of Rehabilitation Sciences, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA

b

Received 12 May 2004; received in revised form 3 December 2004; accepted 4 January 2005

Abstract Accurate ability to diagnose lumbar spine clinical instability is controversial for numerous reasons, including inaccuracy and limitations in capabilities of radiographic findings, poor reliability and validity of clinical special tests, and poor correlation between spinal motion and severity of symptoms. It has been suggested that common subjective and objective identifiers are specific to lumbar spine clinical instability. The purpose of this study was to determine if consensual, specific identifiers for subjective and objective lumbar spine clinical instability exist as determined by a Delphi survey instrument. One hundred and sixty eight physical therapists identified as Orthopaedic Clinical Specialists (OCS) or Fellows of the American Academy of Orthopaedic Manual Physical Therapists participated in three Delphi rounds designed to select specific identifiers for lumbar spine clinical instability. Round I consisted of open-ended questions designed to provide any relevant issues. Round II allowed the participants to rank the organized findings of Round I. Round III provided an opportunity to rescore the ranked variables after viewing other participant’s results. The results suggest that those identifiers selected by the Delphi experts are synonymous with those represented in related spine instability literature and may be beneficial for use during clinical differential diagnosis. r 2005 Elsevier Ltd. All rights reserved. Keywords: Clinical instability; Lumbar spine; Delphi; Physical therapy

1. Introduction Since 1987, several low-back diagnostic classification systems have been created, each designed to categorize patients with low-back pain into homogenous subgroups for better clinical management decisions (McKenzie, 1981; Bernard and Kirkaldy-Willis, 1987; Delitto et al., 1995; Moffroid et al., 1994; Werneke and Hart, 2004). Data suggest that patients who are treated based on diagnosis or symptom-specific individual categorization into a classification system have superior outcomes than those who are not (Delitto et al., 1995; Deyo, 1993; Erhard et al., 1994; Riddle, 1998). Corresponding author. Tel.: +1 915 335 5370; fax: +1 915 335 5365. E-mail address: [email protected] (C. Cook).

1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.01.002

One controversial diagnostic classification is lumbar spine instability. This classification is controversial because the pathomechanical behaviour of lumbar spine instability is ambiguous and poorly defined (Paris, 1985; Dvorak et al., 1991; Panjabi, 1992; Lindgren et al., 1993; Cattrysse et al., 1997; Fritz et al., 1998; Olson and Joder, 2001). Regardless of clinical or radiographic (static or dynamic) test methods used, there is little evidence to relate the pathophysiological condition of spine instability with severity of verbal and objective symptoms (Farfan and Gracovetsky, 1984; Dupuis et al., 1985; Boden and Wiesel, 1990; Lindgren et al., 1993; Sihvonen et al., 1997). There may be several reasons for this finding. First, traditional radiographic measurement may suffer from errors during measurement of movements less than 5 mm (Shaffer et al., 1990; Harrison et al., 1998), which are frequently observed with spinal

ARTICLE IN PRESS 12

C. Cook et al. / Manual Therapy 11 (2006) 11–21

instability. Second, despite numerous attempts at standardization, quantification of the ‘‘normal’’ spinal motion is not yet precisely defined (Boden and Wiesel, 1990; Panjabi et al., 1994). Since asymptomatic spines show considerable variability of segmental motion amplitude, a diagnosis based on segmental motion alone may result in misleading or erroneous conclusions (Dupuis et al., 1985; Dvorak et al., 1991; Ogon et al., 1997). Third, traditional radiographic films concentrate on end range movements while instability is often present in midrange movements where one observes the neutral zone (Posner et al., 1982; Farfan and Gracovetsky, 1984; Dupuis et al., 1985; Frymoyer et al., 1990). Lastly, there is currently a lack of reliable and valid clinical assessment tools or special tests for spine instability (Nachemson, 1991; Taylor and O’Sullivan, 2000). Spine instability may be best classified into two categories, (1) radiologic appreciable instability and (2) clinical instability. Radiologic appreciable instability reflects marked disruption of passive osseoligamentous anatomical constraints (Dupuis et al., 1985) and is typically diagnosed by appropriate radiographic measurements (Panjabi, 1992). Clinical instability is more challenging to diagnose and may involve discrepancies in radiographic findings (Panjabi, 1992). Theoretically, clinical dynamic stabilizers include the neural feedback systems, muscles and tendons of the spinal column and comprise force or motion transducers that include muscle spindles and Golgi tendon organs that exhibit proprioceptive and kinesthetic neural properties. Clinical instability commonly demonstrates subtle quantifiable clinical features (Niere and Torney, 2004) with negative or inconsistent findings during traditional radiographic analysis (Hayes et al., 1989; Takayanagi et al., 2001; Iguchi et al., 2003). Despite indistinct findings for clinical instability, several authors have suggested that commonalities exist in subjective and objective descriptors (Paris, 1985; Lundberg and Gerdle, 2000; Taylor and O’Sullivan, 2000). Common subjective reports include ‘‘giving way’’, ‘‘locking’’, (O’Sullivan, 2000) or sensations of ‘‘slipping out’’ during the normal demands of spinal mobility (Ogon et al., 1997). Afflicted individuals may complain of a ‘‘catch’’ sensation during extension motions of the low back when returning from a flexed posture (Taylor and O’Sullivan, 2000) or the necessity to ‘‘twist the back into position’’ (Paris, 1985). Selected authors report instability is associated with pain immediately upon sitting, and relieved through standing or temporary movement (Paris, 1985; Maigne et al., 2003). Others suggest the presence of ‘‘through range pain’’ and a painful arc during active motions (Kirkaldy-Willis and Farfan, 1982; O’Sullivan, 2000). Individuals with clinical instability may report single or multiple causal incidents and frequently report poor

outcomes with general resistance exercise programs, spinal manipulation, and mobilization-based treatments (Kirkaldy-Willis and Farfan, 1982; O’Sullivan, 2000). During the physical examination, specific patterns are often associated with clinical instability. Investigators have reported the patient’s inability to stand erect without the assistance of the hands (Kirkaldy-Willis and Farfan, 1982; O’Sullivan, 2000). Patients often show signs of unexpected movements, accelerations and small jerks that occur intersegmentally, and hesitations or giving way during active motion (Ogon et al., 1997). Another common clinical manifestation is increased global muscular tone (Dvorak et al., 1991; Panjabi, 1992), representing the body’s attempt to stabilize the hypermobile segment. 1.1. Purpose of the study The purpose of this study was to establish consensus regarding the common subjective and objective symptoms associated with clinical instability of the spine. Clinical instability is a challenging yet common disorder seen by physical therapists, which lacks a definitive method for diagnosis (Taylor and O’Sullivan, 2000). By using a Delphi survey instrument, expert practitioners defined common identifiers of lumbar clinical instability. In turn, the consensus agreement could be valuable for enhancing the clinician’s differential diagnosis and appropriate classification of spinal instability.

2. Materials and methods 2.1. Study design This investigation implemented a Delphi survey instrument that incorporated both a respondent group and a work group. The respondent group was comprised of the target population of experts used within this study. The work group was comprised of those investigators who summarized the returned data from Round I and redesigned the follow-up instruments. 2.2. Respondent group The population pool selected for the study consisted of volunteers from two ‘‘expert’’ categories. First, all Board Certified Orthopaedic Clinical Specialists (OCS) from the American Physical Therapy Association (APTA) who identified cervical and lumbar dysfunction as their primary practice specialty, were targeted as population pool number one. The APTA proposes that designation of orthopaedic board certification through the APTA depicts a clinician with ‘‘knowledge, skill and experience exceeding that of the physical therapist at entry to the profession and unique to the specialized

ARTICLE IN PRESS C. Cook et al. / Manual Therapy 11 (2006) 11–21

area of practice’’ (APTA, 2004). Second, Fellows of the American Academy of Orthopaedic Manual Physical Therapists were additionally targeted, based on their clinical expertise obtained through residency. For completion of a fellowship, the AAOMPT requires a physical therapist to complete a credential fellowship program in orthopaedic manual physical therapy or demonstrate the equivalent of competence by successfully passing a portfolio review process and oral/ practical examination (AAOMPT, 2004). Since 2001, the APTA and AAOMPT have merged their credentialing processes for post-professional orthopaedic residency and manual therapy fellowship training to establish clear standards for professional development and credentialing. All targeted participants were contacted using traditional mail-outs and e-mails (when possible), and were pooled into one group upon agreement to participate. 2.3. Work group This group was comprised of three individuals, including the primary investigator and two individuals experienced in qualitative research. All three work group members were Physical Therapists with at least 14 years of both research and clinical experience in orthopaedic manual therapy. 2.4. Instrumentation For the present study, a Web-based three-round Delphi survey instrument was generated. A typical Delphi survey instrument consists of three rounds of questionnaires that respondents consecutively answer in a timely fashion (Binkley et al., 1993). Generally, at the end of the third round, consensus is generated among respondents. Round I consisted of a series of openended questions designed to identify specific issues relevant to the overall survey topic (Cleary, 2001). Round I of the instrument included questions regarding basic demographic information and open-ended questions inquiring about subjective identifiers and objective clinical findings in patients with lumbar instability. After defining lumbar instability, the first open-ended question in Round I asked respondents to identify the subjective factors they deemed were associated with lumbar spine instability. The second open-ended question asked respondents to identify objective or physical factors they deemed were associated with lumbar spine instability. Round II of the instrument was comprised of a list of descriptor statements that defined each subjective and objective factor that were constructed from the work group’s qualitative analysis of Round I. Respondents were asked to use Likert-type grading scales to score

13

each of these factors in terms of whether each is related to lumbar spine instability. Round III of the instrument was comprised of the same list and grading scale as Round II, with additional tables and graphs for each descriptor statement demonstrating the descriptive statistical score outcomes for each factor. The graphic information identified the percentage of total respondents that selected each possible score for the given item in Round II. The respondents were instructed to rescore each item with the scale after viewing the scoring results from Round II. 2.5. Procedure Expedited approval of the experiment was granted by the Institutional review Board at Texas Tech University Health Sciences Center. Invitations to Round I of the instrument were automatically distributed through Email to all potential respondents and provided a Web link to the Web-based consent form. Respondents that did not answer the request for participation were emailed a reminder notice to encourage compliance using a method suggested by Dillman (2000). Two consecutive follow-up reminders were delivered at 10 and 20 days after the initial questionnaire was provided, respectively (Lopopolo, 1999; Pesik et al., 1999; Vaughan-Williams et al., 1999). After respondents completed Round I, the WebSurveyor program (WebSurveyor, 2004) automatically downloaded response data onto a spreadsheet for work group analyses. Work group members coded each single subjective and objective factor data entry on different levels in accordance with suggestions provided by Berg (2001). First, members performed a quantitative analysis whereby data entries were coded based on similar words or phrases (known as ‘‘literal coding’’), where word groupings were used to create categories that represented the group content with names such as ‘‘changes with manipulation.’’ Work group members used a thesaurus when words demonstrated similarity but were unfamiliar to the member. Once these categories were established, then the remaining data entries were coded in a qualitative fashion, whereby data were entered into the specific categories based on similar meanings and contexts. When a data entry did not fit into previously created categories, then a new category was formed. The coding process was first conducted for the data entries received under the Subjective Factors heading, and then for the data under the Objective Factors heading. The work group moved a data entry when it appeared more appropriate under the other heading (i.e. subjective vs. objective). Upon completion of the individual coding process, the work group convened to begin the group coding process, whereby each individual data entry was discussed and entered into a collective

ARTICLE IN PRESS 14

C. Cook et al. / Manual Therapy 11 (2006) 11–21

category. However, each data entry was coded into a collective category only when all three work group members unanimously (100%) agreed on the category assignment. If the members persisted in disagreement, then the entry was discarded. After completing the group coding process, the work group created descriptor statements that summarized the content within each collective category. For example the work group used the following title ‘‘Frequent clicking, grinding, crepitation, and popping during movement’’ to represent a descriptor category that included data entries describing any of those behaviours reported by a patient. The descriptors were used to compose Round II of the Delphi instrument. The purpose of this Round II was to allow informants to: (1) review the categories of responses from Round I for the clarification and correction of terminology; and (2) identify categories of responses they considered the most important with respect to the research (Lopopolo, 1999). Invitations to Round II of the instrument were automatically distributed through e-mail to all respondents from Round I, providing the respondents with a Web link to Round II. After viewing each descriptor under each heading in Round II, respondents were asked to score the importance of the descriptor using the following scale: 1 ¼ Strongly Agree; the selected identifier has a very strong relationship with lumbar spine instability 2 ¼ Agree; the selected identifier is related to lumbar spine instability 3 ¼ Undecided; uncertainty of the relationship of the selected identifier and lumbar spine instability 4 ¼ Disagree; the selected identifier is not related to lumbar spine instability 5 ¼ Strongly Disagree; there is absolutely no relationship whatsoever with the selected identifier and lumbar spine instability

statement were sorted and tallied. Tallies of respondents’ scoring were then used for statistical analyses. 2.6. Data analysis For each descriptive identifier, the scores were divided from Round III into two categories: The tally of scores ‘‘Strongly Disagree’’ and ‘‘Disagree’’ represented total percentage of scores in the ‘‘Not Related’’ category, meaning that the subjective or objective factor is not important for the diagnosis of instability. Conversely, the tally of scores in the ‘‘Strongly Agree’’ and ‘‘Agree’’ categories were placed in the ‘‘Related’’ category, meaning that the subjective or objective factor is important for that diagnosis. Consensus was established if 75% or greater of the respondents (Binkley et al., 1993) scored the subjective or objective factor as ‘‘Not Related’’ (CNR) or ‘‘Related’’ (CR). Fig. 1 provides an example of a consensus-scoring tally. If the tally for ‘‘Not Related’’ or ‘‘Related’’ was between 50% and 74.9%, then consensus was not established and a decision was forced between Nearconsensus (Triezenberg, 1997) and Undecided. To arrive at the answer to the decision between Near-consensus and Undecided, a logic analysis was conducted. If the tally for ‘‘Strongly Agree’’ and ‘‘Agree’’ was greater than the tally for ‘‘Agree’’ and ‘‘Disagree’’, then the descriptor was labelled as ‘‘Near-consensus, Related (NCR)’’. Similarly, if the tally for ‘‘Strongly Disagree’’ and ‘‘Disagree’’ was greater than the tally for ‘‘Agree’’ and ‘‘Disagree’’, then the descriptor was labelled as ‘‘Near-consensus, Not Related’’. However, if the tally for ‘‘Agree’’ and ‘‘Disagree’’ was greater than the tally for ‘‘Strongly Agree’’ and ‘‘Agree’’ or the tally for

70

Related Category 89.53%

Not Related Category 5.32%

After respondents completed Round II, the WebSurveyor program was again used to download response data automatically. Tallies of respondents’ scoring were then graphically represented based on the percentage of respondents who selected each score from the previously described scales. Invitations to Round III of the instrument were automatically distributed in a similar fashion to Round II, once again providing a Web link to Round III. Respondents were asked to rescore each descriptor after viewing the descriptor statement along with its corresponding graph. Respondents used the previously described scale to rescore each descriptor after viewing the scoring distribution produced for that descriptor in Round II. After respondents completed Round III, the WebSurveyor program automatically downloaded response data as before, where data under each descriptor

Number of Respondents

60 1. Strongly Agree 2. Agree 3. Not Applicable 4. Disagree 5. Strongly Disagree

50 40 65 53.28%

30 20

43 35.25%

10 0

7 5.74%

6 4.92%

1 0.82%

Mean = 1.83 Std. Dev. = 0.81 N = 122

1 2 3 4 5 Greater pain returning to erect position from flexion Fig. 1. Example of a consensus-scoring tally indicating consensus or not. The text represents the numeric value associated with the Likertlike value. Because over 75% of scores were in Likert scores 1 and 2, it was deemed that consensus was reached.

ARTICLE IN PRESS C. Cook et al. / Manual Therapy 11 (2006) 11–21

‘‘Strongly Disagree’’ and ‘‘Disagree,’’ then the descriptor was labelled as ‘‘Undecided (U)’’. After consensus was established, the subjective and objective factors were ranked. This was accomplished by first assigning a composite score to each factor. The composite score was determined using the following formula: Composite Score ¼ ðn1
5Þ þ ðn2
4Þ þ ðn3
3Þ þ ðn4
2Þ þ ðn5
1Þ, where the subjective or objective factors were tallied as: n1 is the number of respondents who scored the factor as ‘‘Strongly Agree’’, n2 the number of respondents who scored the factor as ‘‘Agree’’, n3 the number of respondents who scored the factor as ‘‘Undecided’’, n4 the number of respondents who scored the factor as ‘‘Disagree’’, n5 the number of respondents who scored the factor as ‘‘Strongly Disagree’’. A graphic example of this composite score tally is presented in Fig. 2. Here, the composite score value was derived from the tally of scores for each descriptor statement. Consequently, the skill in Fig. 2 was assigned a composite score of 509. The composite scores were subsequently used for ranking under each heading (subjective or objective factors) with the highest score representing the most important factor under each heading. In a Delphi design, the respondents rank composite scores both without (Round II) and with (Round III) graphic feedback from the other respondents, thus it is expected that some changes will occur between rounds. Using Megastat version 9.0, a Mann–Whitney U (a ¼ 0:05) was used to determine if a meaningful difference between ranked scores between Rounds II and III is present for both subjective and objective factors.

15

3. Results 3.1. Results from Round I One thousand one hundred and eleven orthopaedic certified specialists from the APTA and 334 Fellows in the AAOMPT were solicited for participation in the present study. Of the 1111 individuals, 92 were not accessed due to incorrect electronic mail address, server difficulties, or relocation without a new address. One hundred and sixty-eight individuals (11.6% return rate) chose to respond to Round I. Participant demographic and clinical characteristics are outlined in Table 1. The work group agreed to eliminate data points when: (1) The members could not reach 100% consensus regarding the appropriate descriptor category to which a data point belonged; (2) a data point could fit into more than one descriptor category without any persuasion towards any particular category; and/or (3) a data point appeared irrelevant, incomprehensible, or incomplete. Group coding produced 33 descriptors under the Subjective Factors heading, while 28 descriptors were produced under the Objective Factors heading (see Appendix A and B). Table 1 Respondent demographics, credentials, work setting, and report of the first, second and third most influential manual therapy models that have influenced their personal clinical practice experiences Age

Mean ¼ 43, range 27–61 years Missing values ¼ 3

Gender

Male ¼ 96 Female ¼ 72 Missing values ¼ 4

Credentials

FAAOMPT ¼ 66 OCS ¼ 78 Both ¼ 49 Missing values ¼ 28

Years of experience

Mean ¼ 17.5 years, range 3–39 years

70

Number of Respondents

60

Missing values ¼ 3

50 40 65 53.28%

30 20

1. Strongly Agree 43 X 5 = 2. Agree 65 X 4 = 3. Not Applicable 7 X 3 = 4. Disagree 6X2= 5. Strongly Disagree 1 X 1 = Composite Score =

43 35.25%

10 0

215 260 21 12 1 509

7 5.74%

6 4.92%

1 0.82%

Work setting

107450% of clinical time in non-hospital-based outpatient 38450% of clinical time in hospital- based outpatient Missing values ¼ 27

Reported background

Grimsby

4.12%

Kaltenborn Maitland McKenzie NA NAIOMPTa Osteopathic Other Paris Winkel

8.24% 24.12% 14.71% 0% 7.65% 19.41% 8.24% 12.35% 1.18%

Mean = 1.83 Std. Dev. = 0.81 N = 122

1 2 3 4 5 Greater pain returning to erect position from flexion Fig. 2. Composite score tally sheet. The text bar represents the calculations associated with composite score ranking. The total composite score is then compared to other descriptors.

a

North American institute of orthopaedic manual therapy.

ARTICLE IN PRESS 16

C. Cook et al. / Manual Therapy 11 (2006) 11–21

3.2. Results from Rounds II and III

4. Discussion

Twenty-eight subjects failed to leave e-mail contact information during Round I, thus, only 140 of the 168 respondents were contacted for participation in Round II. One hundred and thirty-three of the 140 respondents (95% retention rate between Rounds I and II; 9.2% overall response rate) completed Round II, and 122 (72.6%) completed Round III producing a 92% retention rate between Rounds II and III and an overall response rate of 8.4%. The total composite score tallies for Rounds II and III are reported in Appendix A for Subjective Factors and Appendix B for Objective Factors. Maximum and minimal composite score values for Round III were 610 for maximum agreement and 122 for maximum disagreement. For Round III, 15 Subjective Factors reached consensus as ‘‘Related’’ (CR) with lumbar spine instability, while two reached ‘‘NCR’’. Additionally, one subjective factor reached ‘‘Consensus Not Related’’ (CNR) and 15 were deemed undecided (U). For the Objective Factors, 14 reached consensus as being ‘‘Related’’ with lumbar spine instability, while two reached ‘‘Near Consensus Related’’, three reached ‘‘CNR’’ and nine were deemed as ‘‘Undecided’’. Factor rank outcomes are reported in Appendix A and B. Reports feelings of ‘‘giving way’’ or back ‘‘giving out’’ ranked as the subjective factor that is most related with lumbar spine clinical instability. Self-Manipulator who feels the need to frequently crack or pop the back ranked second, followed by Frequent bouts or episodes of symptoms. Pain through the range of motion (i.e. through range pain), Intolerance of prone position, and Spine instability does not exist ranked as the three subjective factors that are least related to lumbar spine instability. Overall, Poor lumbopelvic control, including segmental hinging or pivoting with movement, as well as Poor proprioceptive function ranked as the objective factors that were most related to lumbar spine instability, followed by Poor coordination/neuromuscular control, including juddering or shaking. The third most related objective factor was Decreased strength and endurance of local muscles at the level of segmental instability. Additionally, the three objective factors that were determined to be least related with lumbar spine instability included Non-objectifiable: Segmental instability cannot be objectified in the clinic; Unresponsiveness to treatment, including manual techniques and exercise; and Segmental instability does not exist. Finally, no significant difference in composite score rankings was detected through data analysis for Rounds II and III in the Subjective Factors (P ¼ 0:43; df ¼ 33; U ¼ 482) or Objective Factors (P ¼ 0:36; df ¼ 28; U ¼ 336). This indicates that the influence of seeing the other respondent selections did not significantly alter the ranks in Round III.

The Delphi technique is a series of sequential questionnaires designed to distill and obtain the most reliable consensus from a group of experts (Powell, 2003). The method is useful in situations where frequent clinical or practical judgments are encountered, yet incomplete empirical evidence exists to provide evidence-based decision-making (Fink et al., 1984; Dawson and Barker, 1995; Powell, 2003). At present, clinical detection of lumbar spine instability using pathoanatomic, radiologic, and clinical assessment has inherent limitations (Dupuis et al., 1985; Dvorak et al., 1991; Nachemson, 1991; Lindgren et al., 1993; Ogon et al., 1997). Adler and Ziglio (1996) state that in the absence of complete information the health care provider may wait until they have enough information to create an adequate theory, or they may make the most of the available information and use this knowledge for the best possible consequence. Studies of clinical reasoning identify that expert clinicians recognize inconsistencies during an examination and have the capacity to combine clusters of information together into workable sets, based on past-experience and cooperative decisionmaking (Jensen et al., 2000). The investigations suggest that judicious use of the Delphi findings may contribute to a growing pool of data for identification of clinical instability. Thus, by using the clusters of identifiers proposed within the Delphi consensus, practitioners may glean additional information for successful assessment of clinical spine instability. 4.1. Subjective findings Recently, a questionnaire completed by patients diagnosed with lumbar instability described back pain symptoms as ‘‘recurrent’’ (70% of participants), ‘‘constant’’ (55% of participants), ‘‘catching’’ (45% of participants), ‘‘locking’’ (20% of participants), ‘‘giving way’’ (20% of participants), and/or ‘‘accompanied by a feeling of instability’’ (35% of participants) (Taylor and O’Sullivan, 2000). The Delphi participants in the present study reported consensus-related factors of giving way and giving out, frequent bouts, and a condition that is progressively worsening. They also identified the frequent need to self manipulate their spine as a pain control mechanism. The Delphi participants also recognized common subjective complaints during postures, movements, or activities. The Delphi participants outlined history of painful locking or catching during twisting or bending of the spine, pain during transitional activities, pain during return from a flexed position, pain during sudden or trivial activities, difficulty with unsupported sitting, and pain that is worsened with sustained postures as signs of

ARTICLE IN PRESS C. Cook et al. / Manual Therapy 11 (2006) 11–21

clinical lumbar instability. O’Sullivan (2000) identified pain during ‘‘forward bending’’ (75% of participants), ‘‘sudden unexpected movements’’ (75% of participants), ‘‘returning to an upright position from forward bending’’ (65% of participants), ‘‘lifting’’ (65% of participants), and ‘‘sneezing’’ (60% of participants) as signs of clinical lumbar instability. These findings are very similar to those agreed upon by the expert panel used in the present study and suggest that historical information gathered by the clinician in patients with lumbar spinal symptoms provides essential data for the appropriate differential diagnosis of clinical lumbar instability. 4.2. Objective findings Identification of muscle dysfunction, motor control abnormalities, and strength losses were the strongest identifiers of clinical lumbar instability selected by the Delphi participants. The descriptors poor lumbopelvic control including segmental hinging or pivoting with movement, muscle guarding/spasm, poor coordination/ neuromuscular control including juddering or shaking, and decreased strength and endurance of local muscles at level of segmental instability were the top three component scores. Investigators have suggested that clinicians may be capable of discriminating these criteria in an accurate fashion (Panjabi, 1992; Hodges and Richardson, 1996), which was verified in recent studies (Hides et al., 1996; O’Sullivan, 2000; Radebold et al., 2000; van Dieen et al., 2003). Such discrimination could be clinically useful, as a clinician’s analysis of specific muscular anatomical action can influence one’s clinical assessment. Additionally, appropriate identification of motor impairment allows targeting of specific muscles groups for active recovery (O’Sullivan, 2000). The Delphi participants identified segmental mobility including pain provocation techniques as specific identifiers to clinical spine instability. Additionally, this group recognized excessive motion of one of two segments during flexion extension, hypermobility during PA spring testing, positive pain during a PA spring test, and hypomobile adjacent segments as consensus identifiers. This finding that manual palpation is effective in detection of instability, simply by determining if motion is greater than that found with hypermobility has been suggested by others (Kirkaldy-Willis and Farfan, 1982; Paris, 1985). Little evidence exists to support the reliability of palpation mechanisms for spinal instability assessment (Gonnella et al., 1982; Dupuis et al., 1985; Olson et al., 1998; Panjabi et al., 1998). The sensitivity, specificity, and predictive value of the numerous clinical examination techniques, including special tests, have not been fully recognized (Nachemson, 1991; Cattrysse et al., 1997). Most manual instability assessment methods are finite, require very skilled assessment and have not

17

been substantiated by simultaneous diagnostic measurement (Maigne et al., 2003). Some spinal instability conditions are not easily quantified in the absence of an externally loaded position such as standing (Dupuis et al., 1985), and the majority of instability tests are performed in an unloaded position such as supine, sidelying or prone. Additionally, many of the previously studied segmental tests were performed in isolation and may improve when combined with other clusters of information. The Delphi participants also recognized various observed motion disparities during position changes and pain during certain postures. These identifiers included pain with sustained postures and positions, Gower’s sign, and poor posture and postural deviations including lateral shift, all similar to findings found by other authors (Kirkaldy-Willis and Farfan, 1982; O’Sullivan, 2000). Previous authors have indicated that acute instability cases often exhibit retroscoliosis (Kirkaldy-Willis and Farfan, 1982; Boden and Frymoyer, 1997). Moreover, Maigne et al. (2003) indicate that pain is often present upon immediate sitting, relieved once the individual returns to standing. O’Sullivan (2000) reported that sustained sitting, standing, and sustained slight flexion in standing were the most commonly identified postural complaints. Others have suggested the occurrence of intermittent neurological symptoms such as depressed reflexes and positive dural signs (Boden and Frymoyer, 1997) findings that were not identified by the Delphi participants. Selected authors have suggested that aberrant spinal motions during physiological movements that produce catching and disruptions of a normal smooth arc of motion are indicative of spine instability (KirkaldyWillis and Farfan, 1982; Nachemson, 1985). Using dynamic motion analysis, Ogon et al. (1997) quantified hesitation, giving way, and a ‘‘jerk’’ during active motion, which were clinical observations that were previously unverified. Patients with spine instability often demonstrate signs of unexpected segmental movements, accelerations and decelerations (Ogon et al., 1997). The Delphi participants recognized aberrant movement including lateral shift changes and motion disparity during weight bearing and non-weight bearing and during active range of motion and passive range of motion as related to clinical instability in a fashion similar to previously published findings. Selected few respondents suggested that lumbar spine instability does not exist, although the literature does strongly suggest the existence of such a condition, albeit in a controversial fashion. Conversely, the majority of respondents agreed that the condition does exist and that many of the identifiers serve as clinical assessment tools commonly used in daily practice for the recognition of clinical instability. This consensus was consistent with the previous reports in the literature. Two plausible

ARTICLE IN PRESS C. Cook et al. / Manual Therapy 11 (2006) 11–21

18

explanations exist for this agreement. First, the Delphi participants may be well informed of the literature and of specific objective identifiers of clinical lumbar instability reported in previous studies. Second, the results reported in the studies that investigated lumbar spinal instability could be strongly associated with what expert clinicians have empirically observed during dayto-day practice. 4.3. Limitations The Delphi instrument is a qualitative analysis and is immune from the sampling requirements of a randomized design. Fewer than 12% of the targeted population responded to initial recruitment. There may be several reasons for the low response rate. First, e-mail annual response rates for surveys dropped consistently from 1992 to 2000 (Sheehan, 2001). Second, it is estimated that the average e-mail user receives 39 unsolicited e-mails each day and has prompted many users to create multiple e-mail addresses, including ‘‘bulk addresses’’ unsolicited mail (Sheehan, 2001). Third, this study used an e-mail system that does not report when e-mails are no longer in service, thus chance exists that the introductory e-mails did not arrive at all the potential 1015 eligible OCS participants. Although a Delphi instrument is appropriate for sample sizes as small as 10–12 participants, it is essential that the experts selected are truly representative of the most talented clinicians in this targeted field. The assumption of this study is that the criteria required for OCS and

fellowship status within the AAOMPT do meet those specifications.

5. Conclusion This Delphi investigation was designed to identify common subjective and objective identifiers for lumbar spine instability. The findings suggest that those identifiers selected by the Delphi experts are similar to those reported in spine-related instability literature, suggesting that those identifiers are specifically associated with lumbar spine clinical instability and may be beneficial for clinical differential diagnosis. Future research should examine patterns or clusters of identifier findings in patients suspected of suffering from clinical instability. The Delphi information could be used as a scale to determine a threshold point for analysis. Additionally, a factor analysis could identify themes of instability suggested by the Delphi group. Lastly, spine instability special tests require validation with populations with measurable instability, specifically since clinical spine instability most likely exhibits more difficulty in definitive assessment.

Acknowledgements This study was approved by the Texas Tech Health Sciences Center Institutional Ethics Review Board and financially supported by the 2003 Steens/USA Grant.

Appendix A Subjective factors of consensus and rank outcomes for clinical lumbar spine instability, listed in descending rank. Descriptor

Round III consensus status

Round II composite scores

Round III composite scores

Reports feelings of ‘‘giving way’’ or back ‘‘giving out’’ Self manipulator who feels the need to frequently crack or pop the back Frequent bouts or episodes of symptoms History of painful catching or locking during twisting or bending of the spine Pain during transitional activities (e.g. sit to stand) Greater pain returning to erect position from flexion Pain increased with sudden, trivial, or mild movements Difficulty with unsupported sitting and better with supported backrest Worse with sustained postures and a decreased likelihood of reported static position that is not painful Condition is progressively worsening (e.g. shorter intervals between bouts) Long-term, chronic history of disorder Temporary relief with back brace or corset Reports frequent episodes of muscle spasms

CR CR CR CR CR CR CR CR CR

501 483 518 496 484 493 496 477 470

527 524 523 521 510 509 504 500 495

CR CR CR CR

471 457 463 482

490 478 478 474

ARTICLE IN PRESS C. Cook et al. / Manual Therapy 11 (2006) 11–21

Frequent clicking, grinding, crepitation, and popping during movements Dramatic but temporary relief with manipulation Fear and decreased willingness to move Reports of previous back injury or trauma Record of poor improvement with past treatment interventions Reports sleep disturbances including frequent position changes during sleep Inconsistent, non-specific symptoms such as pain which alternates from side to side Frequently feel ‘‘tight’’ or ‘‘stiff’’ and needs to stretch a lot Inconsistency of symptoms (i.e. pain is not provoked upon command) History of predisposing sports or labour (i.e. gymnastic, weight lifting) Transient neurological symptoms Pain with weight bearing activities. Relief with non-weight bearing activities Pain which is provoked by ADLs Pain worse at end or extreme ranges Pain that is better in the A.M. and worse as the day progresses Reports of ‘‘central’’ or ‘‘centralized’’ symptoms in low-back pain History of pregnancy or oral contraceptive use Pain through the range of motion (i.e. through range pain) Intolerance of prone position Spine instability does not exist

19

NCR NCR CR CR U U U

453 436 461 442 446 440 422

466 465 464 457 454 444 440

U U U U U U U U U U U U CNR

439 425 434 425 403 409 400 403 400 403 369 350 196

437 433 432 424 412 409 396 395 382 370 338 331 145

Definitions: CR ¼ consensus related; NCR ¼ near consensus related; CNR ¼ consensus not related; U ¼ undecided.

Appendix B Objective factors of consensus and rank outcomes for clinical lumbar instability, listed in descending rank. Descriptor

Round III consensus status

Round II composite scores

Round III composite scores

Poor lumbopelvic control, including segmental hinging or pivoting with movement, as well as poor proprioceptive function Poor coordination/neuromuscular control, including juddering or shaking Decreased strength and endurance of local muscles at level of segmental instability Aberrant movement, including changing lateral shift during AROM Pain with sustained positions and postures Gower’s sign: Patient walks up thighs when returning from flexion Excessive motion of one of two segments during flexion-extension Decreased willingness or apprehension of movement Hypermobility during posterior–anterior (PA) Spring test Increased muscle guarding/spasm Poor posture and postural deviations that include lateral shift and changes in lordosis Positive spring test (PA provocation test) Frequent catching, clicking, clunking and popping heard during movement Motion disparity between weight bearing and non-weight bearing Hypomobile adjacent segments Motion disparity between AROM vs. PROM Pain with palpation, including interspinous space and ligament Hypertrophic erector spinae Palpable segmental position change

CR

517

539

CR CR

488 522

537 533

CR CR CR CR CR CR CR CR

486 479 492 487 491 473 475 449

510 507 503 503 494 493 474 471

CR CR NCR CR NCR U U U

447 447 442 457 425 428 438 417

466 461 460 460 456 446 443 434

ARTICLE IN PRESS 20

C. Cook et al. / Manual Therapy 11 (2006) 11–21

Prone instability test that includes passive segmental rotation Positive radiographic evidence, including traction spurs Inconsistent examination findings Excessive active physiological ROM Findings of overall, generalized laxity Quadrant test painful bilaterally Non-objectifiable: segmental instability cannot be objectified in the clinic Unresponsiveness to treatment, including manual techniques and exercise Segmental instability does not exist

U U U U U U CNR CNR CNR

414 414 393 406 372 340 305 268 310

418 423 396 396 382 312 259 254 152

Definitions: CR ¼ consensus related; NCR ¼ near consensus related; CNR ¼ consensus not related. U ¼ undecided.

References Adler M, Ziglio E. Gazing into the oracle. Bristol, PA: Jessica Kingsley Publishers; 1996. Berg B, editor. Qualitative research methods for the social sciences. 4th ed. Boston: Allyn and Bacon; 2001. Bernard T, Kirkaldy-Willis W. Recognizing specific characteristics of nonspecific low back pain. Clinical Orthopedics 1987;217: 266–80. Binkley J, Finch E, Hall J, Black T, Gowland C. Diagnostic classification of patients with low back pain: report on a survey of physical therapy experts. Physical Therapy 1993;73:128–55. Boden S, Frymoyer J. Segmental instability. The adult spine: principles and practice. 2nd ed. Philadelphia: Lipponcott-Raven Publishers; 1997. Boden S, Wiesel S. Lumbosacral segmental motion in normal individuals. Have we been measuring instability properly? Spine 1990;15:571–6. Cattrysse E, Swinkels R, Oostendorp R, Duquet W. Upper cervical instability: are clinical tests reliable? Manual Therapy 1997; 2:91–7. Cleary K. Using the Delphi process to reach consensus. Journal of Cardiopulmonary Physical Therapy 2001;1:20–3. Dawson S, Barker J. Hospice and palliative care: a Delphi survey of occupational therapists roles and training needs. Australian Occupational Therapy Journal 1995;42:119–27. Delitto A, Erhard R, Bowling R. A treatment-based classification approach to low back syndrome: identifying and staging patients for conservative treatment. Physical Therapy 1995;75:470–89. Deyo R. Practice variations, treatment fads, rising disability. Do we need a new clinical research paradigm? Spine 1993;18:2153–62. Dillman D. Mail and Internet surveys. The tailored design method. New York: Wiley; 2000 (p. 363). Dupuis P, Yong-Hing K, Cassidy J, Kirkaldy-Wills W. Radiologic diagnosis of degenerative lumbar spinal instability. Spine 1985;10:262–76. Dvorak J, Panjabi M, Novotny J, Chang D, Grob D. Clinical validation of functional flexion-extension roentgenograms of the lumbar spine. Spine 1991;16:943–50. Erhard R, Delitto A, Cibulka M. Relative effectiveness of an extension program and a combined program of manipulation and flexion and extension exercises in patients with acute low back syndrome. Physical Therapy 1994;74:1093–100. Farfan H, Gracovetsky S. The nature of instability. Spine 1984; 9:714–9. Fink A, Kosecoff J, Chassin M, Brook R. Consensus methods: characteristics and guidelines for use. American Journal of Public Health 1984;74:979–83. Fritz J, Erhard R, Hagen B. Segmental instability of the lumbar spine. Physical Therapy 1998;78:889–96.

Frymoyer J, Pope M, Wilder D. Segmental instability. In: Weinstein J, Wiesel S, editors. The lumbar spine. Philadelphia: WB Saunders; 1990. p. 612–36. Gonnella C, Paris S, Kutner M. Reliability in evaluating passive intervertebral motion. Physical Therapy 1982;62:436–44. Harrison D, Harrison D, Troyanovich S. Three-dimensional spinal coupling mechanics: part one. Journal of Manipulative Physiological Therapeutics 1998;21:101–13. Hayes M, Howard T, Gruel C, Kopta J. Roentgenographic evaluation of lumbar spine flexion-extension in asymptomatic individuals. Spine 1989;14:327–30. Hides J, Richardson C, Jull G. Multifidus muscle recovery is not automatic following resolution of acute first episode low back pain. Spine 1996;21:2763–9. Hodges P, Richardson C. Inefficient muscular stabilization of the lumbar spine associated with low back pain. Spine 1996;21: 2640–50. Iguchi T, Kanemura A, Kasahara K, Kurihara A, Doita M, Yoshiya S. Age distribution of three radiologic factors for lumbar instability: probable aging process of the instability with disc degeneration. Spine 2003;28:2628–33. Jensen G, Gwyer J Shepard K, Hack L. Expert practice in physical therapy. Physical Therapy 2000;80:28–43. Kirkaldy-Willis W, Farfan H. Instability of the lumbar spine. Clinical Orthopedics 1982;165:289–95. Lindgren K, Sihvonen T, Leino E, Pitkanen M, Manninen H. Exercise therapy effects on functional radiographic findings and segmental electromyographic activity in lumbar spine instability. Archives of Physical Medicine and Rehabilitation 1993;74:933–9. Lopopolo R. Hospital restructuring and the changing nature of the physical therapist’s role. Physical Therapy 1999;79:171–85. Lundberg G, Gerdle B. Correlations between joint and spinal mobility, spinal sagittal configuration, segmental mobility, segmental pain, symptoms and disabilities in female homecare personnel. Scandinavian Journal of Rehabilitative Medicine 2000; 32:124–33. Maigne J, Lapeyre E, Morvan G, Chatellier G. Pain immediately upon sitting down and relieved by standing up is often associated with radiologic lumbar instability or marked anterior loss of disc space. Spine 2003;28:1327–34. McKenzie R. The lumbar spine: mechanical diagnosis and therapy. Waikanae, New Zealand: Spinal Publications; 1981. Moffroid M, Haugh L, Henry S, Short B. Distinguishable groups of musculoskeletal low back pain patients and asymptomatic control subjects based on physical measures of the NIOSH low back Atlas. Spine 1994;19:1350–8. Nachemson A. Lumbar spine instability. A critical update and symposium summary. Spine 1985;10:290–1. Nachemson A. Instability of the spine. Neurosurgery clinics of North America 1991;2:785–90.

ARTICLE IN PRESS C. Cook et al. / Manual Therapy 11 (2006) 11–21 Niere K, Torney S. Clinicians’ perceptions of minor cervical instability. Manual Therapy 2004;9:144–50. Ogon M, Bender B, Hooper D, Spratt K, Goel V, Wilder D, Pope M. A dynamic approach to spinal instability. Part I: sensitization of intersegmental motion profiles to motion direction and load condition by instability. Spine 1997;23:2841–58. Olson K, Joder D. Diagnosis and treatment of cervical spine clinical instability. Journal of Orthopedic Sports Physical Therapy 2001;31:194–206. Olson K, Paris S, Spohr C, Gorniak G. Radiographic assessment and reliability study of the craniovertebral side-bending test. Journal of Manual and Manipulative Therapy 1998;6:87–96. O’Sullivan P. Lumbar segmental ‘‘Instability’’: clinical presentation and specific stabilizing exercise management. Manual Therapy 2000;5:2–12. Panjabi M. The stabilizing system of the spine. Part 1 and Part 2. Journal of Spinal Disorders 1992;5:383–97. Panjabi M, Oxland T, Yamamoto I, Crisco J. Mechanical behavior of the human lumbar and lumbosacral spine as shown by threedimensional load-displacement curves. Journal of Bone and Joint Surgery, American 1994;76:413–24. Panjabi M, Nibu K, Cholewicki J. Whiplash injuries and the potential for mechanical instability. European Spine Journal 1998;7:484–92. Paris S. Physical signs of instability. Spine 1985;10:277–9. Pesik N, Keim M, Sampson T. Do US emergency medicine residency programs provide adequate training for bioterrorism? Annals of Emergency Medicine 1999;34:173–6. Posner I, White A, Edwards W, Hayes W. A biomechanical analysis of the clinical stability of the lumbar & lumbosacral spine. Spine 1982;7:374–89. Powell C. The Delphi technique: myths and realities. Journal of Advanced Nursing 2003;41:376–82. Radebold A, Cholewicki J, Panjabi M, Patel T. Muscle response pattern to sudden trunk loading in healthy individuals and in patients with chronic low back pain. Spine 2000;25:947–54. Riddle D. Classification and low back pain: a review of the literature and critical analysis of selected systems. Physical Therapy 1998; 78:708–37.

21

Shaffer W, Spratt K, Weinstein J. The consistency and accuracy of roentgenograms for measuring sagittal translation in the lumbar vertebral motion segment: an experimental model. Spine 1990;15: 741–50. Sheehan K. E-mail survey response rates: a review. Journal of Computer Mediated Communication 2001;6:1–20. Sihvonen T, Lindgren K, Airaksinen O, Manninen H. Movement disturbances of the lumbar spine and abnormal back muscle electromyographic findings in recurrent low back pain. Spine 1997; 22:289–95. Specialist Certification Program Overview Detail-APTA. Available at: http://www.apta.org/Education/specialist/WhyCertify/OverviewSpecCert, accessed November 28, 2004. Takayanagi K, Takahashi K, Yamagata M, Moriya H, Kitahara H, Tamaki T. Using cineradiography for continuous dynamic-motion analysis of the lumbar spine. Spine 2001;26:1858–65. Taylor J, O’Sullivan P. Lumbar ‘segmental’ instability: pathology, diagnosis and conservative management. In: Twomey L, Taylor J, editors. Physical therapy of the low back. 3rd ed. Philadelphia: WB Saunders; 2000. p. 201–47. Triezenberg J. Teaching ethics in physical therapy education: a Delphi study. Journal Physical Therapy Education 1997;11:16–22. van Dieen J, Cholewicki J, Radebold A. Trunk muscle recruitment patterns in patients with low back pain enhance the stability of the lumbar spine. Spine 2003;28:834–41. Vaughan-Williams P, Taylor G, Whittle J. A model framework comparing resources required for activities in the community dental service validated using the Delphi technique. Community Dental Health 1999;16:85–92. WebSurveyor. 2004 Version 3.6, build 114; WebSurveyor Corporation, 1043 Sterling Road, Suite 204, Herndon, VA, USA. Werneke M, Hart D. Categorizing patients with occupational low back pain by use of the Quebec Task Force Classification system versus pain pattern classification procedures: discriminant and predictive validity. Physical Therapy 2004;84:243–54. Who is a Fellow of the American Academy of Orthopaedic Manual Physical Therapists? (FAAOMPT)? Available at: http://www. AAOMPT.org, accessed October 28, 2004.

ARTICLE IN PRESS

Manual Therapy 11 (2006) 22–27 www.elsevier.com/locate/math

Original article

Flexor carpi radialis motoneuron pool in subjects with chronic carpal tunnel syndrome are more excitable than matched control subjects Shapour Jaberzadeha,, Sheila Scutterb a

Department of Physiology, Medical School, University of Adelaide, Adelaide, SA 5005, Australia b School of Physiotherapy, University of South Australia, Adelaide, SA, Australia

Received 20 August 2004; received in revised form 21 December 2004; accepted 16 February 2005

Abstract We compared excitability of the flexor carpi radialis (FCR) motoneuron pool in subjects with and without carpal tunnel syndrome (CTS). The study involved 11 subjects with chronic idiopathic CTS and 11 asymptomatic subjects as controls. The H-reflex and Mresponse of FCR muscle were obtained by stimulating the median nerve in the cubital fossa in the presence of an isometric background contraction using surface stimulating and recording electrodes. There was a significantly higher H-reflex latency and amplitude and H max =M max in CTS subjects (Po0:05). Latency and amplitude of the M-response remained unaffected in CTS group. The results support the hypothesis that central hypersensitivity does occur in chronic CTS. Therefore even in the presence of pathology in peripheral structures central mechanisms should be considered by clinicians. r 2005 Elsevier Ltd. All rights reserved. Keywords: Hypersensitivity; Carpal tunnel syndrome; H-reflex

1. Introduction Median nerve trunk pain and motor responses in the form of antalgic postures and protective movement patterns associated with peripheral nerve injuries have been attributed to peripheral causes such as sensitization of nervi nervorum (Bove and Light, 1995), and possibly excitability of muscle spindles through facilitation of the gamma-system by pain (Johansson and Sojka, 1991). The latter may be supported by retrograde involvement of proximal muscles during the course of carpal tunnel syndrome (CTS) (Newham and Mills, 1999). Earlier suggestion of injury-induced changes in the spinal cord as the basis of hyperalgesia was confirmed by Woolf (1983) who showed that facilitation of the flexion reflex by natural or electrical stimulation can be only explained Corresponding author. Tel.: +61 8 8303 6433; fax: +61 8 8303 3356. E-mail address: [email protected] (S. Jaberzadeh).

1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.02.007

by changes in spinal cord excitability. The effects of tissue or nerve injury on molecular, biochemical and physiological characteristics of the nervous system were further investigated by Dubner (1991). He concluded that pain associated with tissue or nerve injury leads to prolonged functional changes in the nervous system. These changes may relate to previous and current inputs from the injured area (Coderre et al., 1993) or learning processes from increased sensory inputs originating from peripheral tissues (Dubner and Basbaum, 1994). The influence of peripheral tissue pathology on motor performance is clinically viewed as posture and movement abnormalities. This can also be due to activation of a vicious circle of pain and muscle spasm, changes in excitability of reflex circuits (Woolf, 1994) or the function of more complex and integrated motor systems in the spinal cord (Steinmetz et al., 1983; Woolf, 1983, 1994; Patterson and Steinmetz, 1986). While the concept of central sensitization has been proposed, it has not previously been demonstrated in

ARTICLE IN PRESS S. Jaberzadeh, S. Scutter / Manual Therapy 11 (2006) 22–27

subjects with CTS. Therefore the aim of this study was to compare excitability of the flexor carpi radialis (FCR) motoneuron pool in subjects with and without CTS.

2. Method 2.1. Subjects Ethical approval for this study was granted by the Human Research Ethics Committee, University of South Australia. The study involved 11 subjects with chronic idiopathic CTS (3 males, 8 females) with ages ranging from 38 to 72 years (mean 55.45; SD710.59) and 11 matched asymptomatic subjects (3 males, 8 females) with no history of neurological or upper quarter musculoskeletal injury (Table 1) with age ranging from 37 to 71 years (mean 39.6; SD715.5). The diagnosis of CTS was based on clinical history and physical examination according to the diagnostic clinical criteria of the American Academy of Neurology (AAN, 1993), and confirmatory nerve conduction

Table 1 Characteristics of subjects in CTS and matched control group Subjects

Sex

CTS group 1 F 2 F 3 F 4 F 5 M 6 F 7 F 8 M 9 F 10 F 11 M Mean SE

Age (years)

Weight (kg)

Height (cm)

Body mass index

41 65 47 54 72 69 55 59 44 57 22

65.0 78.0 87.5 69.5 77.0 78.5 81.5 78.0 83.0 83.0 60.0

160.0 163.0 167.0 166.5 180.0 170.0 166.0 167.0 177.0 166.0 169.0

0.41 0.48 0.52 0.42 0.43 0.46 0.49 0.47 0.47 0.50 0.36

53.11 4.31

78.73 1.98

168.32 1.74

0.47 0.01

85.5 67.0 82.5 73.0 84.0 80.0 77.5 76.5 81.0 74.0 67.0

164.0 156.0 177.0 168.0 164.0 175.0 164.5 159.0 169.0 166.0 164.0

0.52 0.62 0.49 0.46 0.57 0.46 0.47 0.48 0.48 0.45 0.41

77.09 1.92

166.05 1.86

0.49 0.02

Matched control group 1 F 49 2 F 38 3 M 72 4 F 52 5 F 55 6 M 43 7 F 54 8 F 63 9 M 57 10 F 72 11 F 55 Mean SE

0 3.2

F, M and SE stand for female, male and standard error of measurement, respectively.

23

studies. All our patients had complaints of paraesthesias or numbness in the median nerve distribution of the hand with nocturnal worsening and weakness or clumsiness of the hand for a period of at least 6 months. The matched control subjects were selected from a pool of 26 subjects based on the following criteria: gender, age (73 years), weight (73 kg) and height (75 cm). All subjects were right handed and were tested at the same time of the day. Before measurement of the H-reflex, the upper limb surface temperature was measured at the cubital fossa. Every subject acclimatized to the room temperature (22–24 1C) for at least 1 h before experiments so that there was little variation in upper limb surface temperature between subjects (less than 2 1C). 2.2. H-reflex protocol The subjects were seated upright in a comfortable chair which provided support for the head, neck and body with the elbow joint held firmly at 1351 and the forearm resting horizontally on a table in a supinated position (Fig. 1). During all trials subjects were asked to hold a 1 kg weight and to maintain a constant background isometric contraction of FCR (Jaberzadeh et al., 2004).

Fig. 1. Subject position and location of stimulation, recording and ground electrodes for elicitation of the H-reflex in FCR.

ARTICLE IN PRESS S. Jaberzadeh, S. Scutter / Manual Therapy 11 (2006) 22–27

2.3. Data management and analyses From the averaged record, the peak-to-peak amplitudes of the H-reflex and M-response were determined. Latencies were measured from the displayed stimulus artifact to the start of the evoked action potentials. H max =M max was calculated by dividing peak-to-peak amplitude of the maximum H-reflex to the peak-to-peak amplitude of the maximum M-response. Contractioninduced H-reflexes were recorded in all subjects. A twotailed independent t-test used to determine whether there was a significant difference between means for latency and peak-peak amplitude of H-reflex and Mresponse values and the ratio of H max to M max for CTS and control Groups. P-values of less than 0.05 were considered as significant. All statistical tests were done with SPSS software (SPSS for Windows v.10.0.5, SPSS Inc).

30 Latency (ms)

Five minutes of practice trials familiarized the subjects with the H-reflex stimulation and recording procedures. The H-reflex and M-response were recorded with stimuli increasing in intensity stepwise from below threshold for the H-reflex to supra maximal for the Mresponse. At each stimulus intensity, eight sweeps of surface EMG recordings were automatically averaged. All data were stored and analysed off-line. The apparatus, the stimulation of the median nerve and recording technique for eliciting, and recording of contraction induced FCR H-reflex and M-responses have been described elsewhere (Jaberzadeh et al., 2004).

20

*

10 0 H-reflex Latency

(a)

M-response Latency

6 Amplitude (mV)

24

4 * 2 0

(b)

H-reflex Maximum

M-response

Amplitude

Maximum Amplitude

*

0.6 0.4 0.2 0

Hmax / Mmax Ratio

(c)

Group 1

Group 2

Fig. 2. Comparison of H-reflex and M-response characteristics between group 1 (n ¼ 11) and group 2 (n ¼ 11). (a) H-reflex and Mresponse latency, (b) H-reflex and M-response maximum peak-peak amplitude, and (c) H max =M max (* ¼ significant difference).

3. Results To demonstrate the steadiness of background EMG throughout the experiments, EMG from the beginning of contraction was compared with the EMG at the end of the contraction (test) period, using fast Fourier transformation. The result indicates that there was no FCR fatigue during the contraction period (Jaberzadeh et al., 2004). The result also indicates that there was no difference between age, weight, height and body mass index for CTS and control group. The latency and peak–peak amplitude of H-reflex and M-response of FCR muscle and the ratio of H max to M max for CTS and control groups are shown in Fig. 2. Fig. 1 shows that all values were greater in CTS group. The increase was significant for H-reflex latency and amplitude and the H max =M max (Po0:05) (Table 2).

Table 2 Group 1 and Group 2 mean values and SD for H-reflex latency and amplitude and the H max =M max and comparison of difference between these values Parameters

H-reflex Latency (ms) M-response Latency (ms) H-reflex Amplitude (mV) M-response Amplitude (mV) H max =M max

M SD M SD M SD M SD M SD

Group 1 (n ¼ 11)

Group 2 (n ¼ 11)

t

P

20.34 1.35 3.26 0.31 2.32 0.47 4.42 0.67 0.54 0.08

17.4 1.28 3.01 0.27 1.92 0.41 4.36 0.67 0.44 0.06

4.81

0.00

0.36

0.73

2.11

0.04

0.39

0.7

7.7

0.00

M and SD stand for mean and standard deviation, respectively.

4. Discussion The main findings from this experiment were a significantly longer H-reflex latency, higher H max and

H max =M max and no difference in M-response latency and amplitude in subjects with CTS compared to their matched controls.

ARTICLE IN PRESS S. Jaberzadeh, S. Scutter / Manual Therapy 11 (2006) 22–27

The H-reflex latency depends on Ia afferent conduction time, central delay and efferent conduction time. Prolongation of latency may result from dysfunction in any portion of this loop by both peripheral and central mechanisms. Slowing of median nerve proximal motor conduction in patients with CTS could be considered as an indicator of an additional proximal lesion, ‘‘double crush syndrome’’ (Upton and McComas, 1973). These proximal lesions in the median nerve may increase afferent or efferent conduction time which may be considered as a cause of increased in H-reflex latency in CTS subjects. Two mechanisms may contribute to central delay. First, elicitation of the H-reflex during weak voluntary contraction as occurred in this experiment has been suggested to involve polysynaptic rather than monosynaptic spinal pathways (Burke et al., 1984). Polysynaptic interconnections could contribute to longer latency. Second, latency changes may occur from functional or structural changes with reorganization of elements in the dorsal horn and motoneuron pool. This reorganization of elements may change processing of information in the spinal cord. H-reflex amplitude in the presence of a mild voluntary contraction may be influenced by descending impulses from supraspinal relays (Pereon et al., 1995) or segmental excitatory and inhibitory influences (Capaday and Stein, 1986). At the onset of a voluntary contraction there is a decrease in the level of presynaptic inhibition of the Ia afferents via an interneuronal circuit under descending control (Meunier and Pierrot-Deseillign, 1989) but if the contraction is held at a constant intensity, the level of presynaptic inhibition returns toward resting levels (Meunier and Pierrot-Deseillign, 1989) as does the H-reflex amplitude (Trimble and Harp, 1998). Since a standard method was used in this experiment, differences in H-reflex amplitude between groups are less likely to be affected by descending impulses from supraspinal relays. The amplitude of H-reflex depends on almost every parameter that characterize afferent and motoneuron recruitment (Hilgevoord et al., 1996). Alertness, anxiety, medication, turning of the head, eye closure, duration and intensity of the stimulus and baseline EMG activity of involved muscle are the most important factors which affect amplitude of H-reflex (Oh, 1993). Even stimuli such as loud and unexpected sound may affect the response (Enoka, 1994). In the current study all testing was conducted in a quiet room and these variables were controlled by using a standard protocol for all subjects. Therefore these variables are less likely to account for the H-reflex amplitude increase in CTS group. The H-reflex amplitude may also be increased by upper motor neuron lesions due to increase in central excitability of the motoneurons (Brown, 1984). This

25

variable was also controlled by exclusion of any subject with history of upper motor neuron lesions. Even though the strength of afferent volley of the Ia spindle afferents determine H-reflex amplitude, other afferent fibres, such as Ib fibres from Golgi tendon organ and group II muscle and cutaneous mechanoreceptor nerve fibres, which may be excited by electrical stimuli may also affect the H-reflex amplitude (Brown, 1984). However, since conduction velocities of spindle afferents in all instances are faster than those of other afferents, and they usually follow, not precede, the action of the Ia afferent fibres (Gassel and Diamantopoulos, 1966), stimulation of these fibres is less likely to affect H-reflex amplitude. Increase in excitability of the FCR motoneuron pool in the spinal cord following chronic median nerve injury may explain the larger H-reflex amplitude in CTS subjects compared to their matched controls. During elicitation of the H-reflex in the FCR muscle with selective activation of the group Ia afferents in the median nerve, action potentials are propagated centrally to the spinal cord, where they elicit postsynaptic potentials in the FCR motor neurons. The likelihood that these synaptic potentials will generate action potentials in FCR muscle depends on the size of the synaptic potentials and the level of the membrane potential. The closer the membrane potential is to threshold for action potential generation, the more likely the stimulus is to elicit an action potential. If the membrane potentials of more motor neurons are closer to threshold, then the stimulus will generate action potentials in more motor neurons, and the response will be larger (Hilgevoord et al., 1996). In this regard decrease in the firing threshold of sensory and motor neurons caused by sensitization of nociceptive afferent neurons in the dorsal horn and wide dynamic range (WDR) spinal neurons is the most likely mechanism for the increased H-reflex amplitude in this experiment. Lowering the motoneuron threshold directly results in an increase in maximal H-reflex amplitude (Hilgevoord et al., 1996). Therefore the higher values of H-reflex amplitude in CTS subjects compared to their matched controls may be the result of some central changes in excitability of the FCR motoneuron pool in the spinal cord. Latency and amplitude of the M-response remained unaffected in CTS group. It should be noted that the Mresponse in FCR muscle shows the integrity of the circuit between the site of the stimulus on the median nerve in the cubital fossa and the site of recording over the FCR muscle. Therefore, the M-response primarily tests the integrity of neuromuscular propagation (Enoka and Stuart, 1992). Since the stimulus site on the median nerve and the recording electrodes on FCR were very close (not more than 5–6 cm), it is not surprising that M-response characteristics were not

ARTICLE IN PRESS 26

S. Jaberzadeh, S. Scutter / Manual Therapy 11 (2006) 22–27

different in subjects with CTS compared with their matched controls. During elicitation of M-response, the number of muscle fibres recruited by the stimulus, and the distance between the active muscle fibre and the detection site may affect the amplitude of M-response. In the current experiment the first factor was controlled by using maximal stimulus intensity and the second one was controlled by using a standard protocol. When the electrical stimulus is maximal, the synchronous activation of the muscle fibres in close proximity to the electrodes (about 1–2 cm) represents the summed response of their action potentials (Fuglevand et al., 1992). This may explain why in spite of median nerve neuropathy, the M-response remained unchanged in CTS subjects. These findings indicate hyperexcitability of the FCR motoneuron pool in the spinal cord of CTS subjects. These results agree substantially with those of Girlanda et al. (2000), who reported changes in excitability of the spinal cord following ulnar nerve neuropathy. The authors concluded that a peripheral nerve injury can induce a rearrangement of circuits at the spinal cord level. The question here is how can peripheral nerve injury affect motoneuron excitability? Following peripheral nerve injury, an abnormal barrage of afferent discharge may be sufficient to produce long-term changes in the excitability of the motoneuron pools in the spinal cord. These acute changes might set the scene for the maintenance of sensory–motor disorders both as a result of an ongoing ectopic input, which might induce a state of persistent central sensitization through structural re-organization of the synaptic connections of the dorsal horn and anterior horn cells. In the presence of these central changes the resting state of membrane potentials change to a value closer to threshold for action potential generation (Dubner and Ruda, 1992). Therefore increase in H-reflex amplitude or H max =M max can be due to participation of a larger proportion of motor units in the H-reflex and can be considered as an indication of increased central excitability of the motoneurons.

5. Clinical implications Most forms of treatments for CTS are based on the premise that the source of pain and dysfunction are due to peripheral mechanisms. The basic problems in treating this condition are that usually after the treatment of peripheral cause (such as physiotherapy, surgical decompression of the median nerve in carpal tunnel and use of anti-inflammatory drugs) persistent or residual signs and symptoms in the patients are often present. The findings in this study are significant because it helps to better understand the studies with less than

optimal treatment outcomes for patients with CTS and hence may lead to improved treatment efficacy by better targeting the central as well as the peripheral source of the symptoms. References American Academy of Neurology. Practice parameter for carpal tunnel syndrome (summary statement). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 1993;43:2406–9. Bove GM, Light AR. Unmyelinated nociceptors of rat paraspinal tissues. Journal of Neurophysiology 1995;75:514–8. Brown WF. The physiological and technical basis of electromyography. Boston: Butterworths Publishers; 1984. p. 111–5. Burke D, Gandevia SC, McKeon B. Monosynaptic and oligosynaptic contribution to human ankle jerk and H-reflex. Journal of Neurophysiology 1984;52:435–48. Capaday C, Stein RB. Amplitude modulation of the soleus H-reflex in human during walking and standing. Journal of Neuroscience 1986;6:1308–13. Coderre TJ, Katz J, Vaccarino AL, Melzack R. Contribution of central neuroplasticity to pathological pain: review of clinical and experimental evidence. Pain 1993;52:259–85. Dubner R. Neuronal plasticity and pain following peripheral tissue inflammation or nerve injury. In: Bond MR, Charlton JE, Woolf CJ, editors. Proceedings of the sixth world congress on pain. Amesterdam: Elsevier; 1991. Dubner R, Basbaum A. Spinal cord plasticity following tissue or nerve injury. In: Wall P, Melzack W, editors. Textbook of pain. Edinburgh: Churchill Livingstone; 1994. p. 243–57. Dubner R, Ruda MA. Activity-dependent neuronal plasticity following tissue injury and inflammation. Trends in Neuroscience 1992; 15:96–103. Enoka RM. Neuromechanical basis of kinesiology. 2nd ed. Champaign: Human kinetic; 1994. p. 143–7. Enoka RM, Stuart DG. Neurobiology of muscle fatigue. Journal of Applied Physiology 1992;72:1631–48. Fuglevand AJ, Winter DA, Patla AE, Stashuk D. Detection of motor unit action potentials with surface electrodes: influence of electrode size and spacing. Biological Cybernetics 1992;67:143–54. Gassel MM, Diamantopoulos E. Mechanically and electrically elicited monosynaptic reflexes in man. Journal of Applied Physiology 1966; 21:1053–8. Girlanda P, Quartarone A, Battaglia F, Picciolo G, Sinicropi S. Changes in spinal cord excitability in patients affected by ulnar neuropathy. Neurology 2000;55:975–8. Hilgevoord AAJ, Bour LJ, Koelman JHTM, Ongerboer de Visser BW. The relationship between the soleus H-reflex amplitude and vibratory inhibition in controls and spastic subjects: II. Computer model. Journal of Electromyography and Kinesiology 1996;6: 259–66. Jaberzadeh S, Scutter S, Warden-flood A, Nazeran H. Between-days reliability of H-reflexes in human flexor carpi radialis. Archives of Physical Medicine and Rehabilitation 2004;85:1168–73. Johansson H, Sojka P. Pathophysiological mechanisms involved in genesis and spread of muscular tension in occupational muscle pain and in chronic musculoskeletal pain syndromes: an hypothesis. Medical Hypothesis 1991;35:196–203. Meunier S, Pierrot-Deseillign. Cortical control of prsynaptic inhibition of Ia afferents in humans. Experimental Brain Research 1989; 119:415–26. Newham DJ, Mills KR. Muscles tendons and ligaments. In: Wall PD, Melzack RM, editors. Textbook of pain. 4th ed. Edinburgh: Churchill Livingstone; 1999. p. 517–38.

ARTICLE IN PRESS S. Jaberzadeh, S. Scutter / Manual Therapy 11 (2006) 22–27 Oh SJ. Clinical electromyography, nerve conduction studies. Baltimore: William and Wilkins; 1993. p. 372–82. Patterson MM, Steinmetz JE. Long-lasting alterations of spinal reflexes: a potential basis for somatic dysfunction. Manual Medicine 1986;2:38–42. Pereon Y, Genet R, Guiheneuc P. Facilitation of motor evoked potentials timing of Jendrassik maneuver effects. Muscle & Nerve 1995;18:1427–32. Steinmetz JE, Beggs AL, Lupica CR, Patterson MM. Effects of local anaesthesia on persistence of peripherally induced postural asymmetries in rats. Behavioural Neurosciences 1983;97:921–7.

27

Trimble MH, Harp SS. Post exercise potentiation of the H-reflex in humans. Medicine and Science in Sports and Exercise 1998; 30:933–41. Upton ARM, McComas AJ. The double crush in nerve entrapment syndromes. Lancet 1973;18:359–61. Woolf CJ. Evidence for a central component of post-injury pain hypersensitivity. Nature (London) 1983;306:686–8. Woolf CJ. The dorsal horn: state-dependant sensory processing and the generation of pain. In: Wall P, Melzack M, editors. Textbook of pain. Edinburgh: Churchill Livingstone; 1994. p. 101–12.

ARTICLE IN PRESS

Manual Therapy 11 (2006) 28–39 www.elsevier.com/locate/math

Original article

The inter-examiner reliability of a classification method for non-specific chronic low back pain patients with motor control impairment W. Dankaertsa,b,, P.B. O’Sullivana, L.M. Strakera, A.F. Burnetta, J.S. Skouenc,d a

School of Physiotherapy, Curtin University, Bentley 6102, WA, Australia Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium c The Outpatient Spine Clinic, Haukeland University Hospital, Bergen, Norway d Section of Physiotherapy Science, Department of Public Health and Primary Health Care, Faculty of Medicine, University of Bergen, Norway b

Received 15 June 2004; received in revised form 23 December 2004; accepted 16 February 2005

Abstract The importance of classifying chronic low back pain (LBP) patients into homogeneous sub-groups has recently been emphasized. This paper reports on two studies examining clinicians ability to agree independently on patients’ chronic LBP classification, using a novel classification system (CS) proposed by O’Sullivan. In the first study, a sub-group of 35 patients with non-specific chronic LBP were independently classified by two ‘expert’ clinicians. Almost perfect agreement (kappa-coefficient 0.96; %-of-agreement 97%) was demonstrated. In the second study, 13 clinicians from Australia and Norway were given 25 cases (patients’ subjective information and videotaped functional tests) to classify. Kappa-coefficients (mean 0.61, range 0.47–0.80) and %-of-agreement (mean 70%, range 60–84%) indicated substantial reliability. Increased familiarity with the CS improved reliability. These studies demonstrate the reliability of this multi-dimensional mechanism-based CS and provide essential evidence in a multi-step validation process. A fully validated CS will have significant research and clinical application. r 2005 Elsevier Ltd. All rights reserved. Keywords: Agreement; Classification; Chronic low back pain; Motor control impairment; Reliability

1. Introduction Low back pain (LBP) is one of the most common and costly musculo-skeletal pain syndromes, affecting up to 80% of people at some point during their lifetime (Katz, 2002; van Tulder et al., 2002; Ehrlich, 2003; Woolf and Pfleger, 2003). The re-occurrence rate for LBP is high and these disorders often develop into a chronic fluctuating problem with intermittent flares (Croft et al., 1998; Burton et al., 2004). It has been stated that Corresponding author. School of Physiotherapy Building 408, Curtin University of Technology, GPO Box U1987, Perth, WA 6845, Australia. Tel.: +61 08 9266 3667; fax: +61 08 9266 3699. E-mail address: [email protected] (W. Dankaerts).

1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.02.001

caring for chronic LBP (CLBP), is one of the most difficult and unrewarding problems in clinical medicine (Leclere et al., 1990) as no approach to diagnosis or treatment has been shown to be clearly definitive or effective. One explanation offered for the inability to identify effective treatments is the lack of success in defining subgroups of patients who are most likely to respond to a specific treatment approach (Leboeuf-Yde et al., 1997; Bouter et al., 1998). Indeed, it has been proposed that the ‘LBP-group’ conceals a large heterogeneous group of patients (McKenzie, 1981; Delitto et al., 1995; Spitzer et al., 1995; Borkan et al., 1998; Bouter et al., 1998; O’Sullivan, 2000; Leboeuf-Yde & Manniche, 2001). Any specific treatment applied to a falsely assumed homogenous sample may result in either failure to respond or

ARTICLE IN PRESS W. Dankaerts et al. / Manual Therapy 11 (2006) 28–39

aggravation of the disorder (Binkley et al., 1993; Fritz et al., 2000; Leboeuf-Yde & Manniche, 2001; Fritz et al., 2003). The perceived need to accurately classify LBP into homogenous sub-groups to facilitate treatment to be tailored for specific disorders, led to an international forum on LBP ranking the accurate and reproducible characterization of sub-groups of patients with LBP as the top research priority (Borkan et al., 1998). In general, criteria to classify can be defined as belonging to specific theoretical constructs or dimensions of the domain being classified (Bailey 1994; Ford et al., 2003). The shift from thinking about LBP as a patho-anatomical disorder, to viewing LBP as a multifactorial bio-psycho-social disorder is now well accepted (Borkan et al., 2002). As a consequence of this, the different dimensions relevant to classifying the domain of LBP are patho-antomical, signs and symptoms, psychological and social (Waddell, 1987; Ford et al., 2003). For LBP, several classification systems (CSs) from a multitude of perspectives have been proposed. Recent systematic reviews highlight that the multidimensional nature of LBP is not reflected in most CS (Ford et al., 2003; McCarthy et al., 2004). The authors propose that for non-specific CLBP, there is a special need for a mechanism-based CS acknowledging the bio-psycho-social dimensions of this disorder (Woolf et al., 1998; Ford et al., 2003; O’Sullivan, 2004a). When the mechanism or cause of a disorder is known, as long as it is amenable for treatment, treatment of the cause is usually considered more effective than treating its individual signs and symptoms (Zimny, 2004). Table 1 gives an overview of the more commonly used categories and dimensions used to classify LBP patients and their limitations. It is increasingly clear that unidimensional CS’s have limited clinical utility as do not adequately reflect the nature of LBP nor lead to its effective management. For CLBP there is no validated mechanism-based multi-dimensional CS. The development and testing of new CSs based on a multidimensional construct has been recommended (Riddle, 1998; Borkan et al., 2002; O’Sullivan, 2004a). Recently, O’Sullivan (2000, 2004b) proposed a novel CS based on multiple dimensions for a sub-group of patients with NS-CLBP and clinical signs of motor control impairment (MCI). There is indeed considerable evidence documenting the presence of MCI in subjects with NS-CLBP, although, the nature of the impairment is highly variable (Hodges & Richardson, 1997; O’Sullivan et al., 1997; Hodges and Richardson, 1998; O’Sullivan et al., 1998; Hodges and Richardson, 1999; O’Sullivan, 2000; Sahrmann, 2001) and many mechanisms have been postulated for how pain may alter motor planning (Biedermann et al., 1991; Luoto et al., 1999; Hodges, 2001). O’Sullivan’s (2000, 2004b) CS has been

29

described in detail elsewhere but in brief it proposes (based on very strict inclusion and exclusion criteria) that a sub-group of patients with NS-CLBP exists (Table 2). These patients have impairments in the control of their lumbar spine that expose them to repeated stress and strain, thereby providing a basis for ongoing pain. Five distinct clinical patterns were proposed (Appendix A) based on a specific direction of MCI and the hypothesized mechanism underlying the pain disorder (O’Sullivan 2000, 2004b). Whilst O’Sullivan’s CS appears conceptually coherent, its reliability and validity should be established before its widespread use in clinical practice and research. The validation of a CS is a multi-step process (Woolf et al., 1998; Ford et al., 2003; Fritz et al., 2003; Dankaerts et al., 2004; O’Sullivan, 2004a) within which establishing the inter-examiner reliability is a crucial step. Therefore, the aim of the studies reported in this paper was to determine the inter-examiner reliability of this clinical method of classification for NS-CLBP patients with signs of MCI. The first study aimed to determine the level of agreement between ‘expert’ clinicians. The second study aimed to determine the level of agreement between clinicians from Australia and Norway against the ‘expert’ clinicians and to determine the effect of the level of clinician familiarity with the system on their reliability.

2. Methods Since this paper reports on two studies, the methods are outlined separately. Fig. 1 provides a flow-chart of the overall study design. The studies were conducted from January 2002 till December 2003. Approval to conduct both studies was obtained from the Curtin University of Technology, Human Research Ethics Committee, Perth, Western Australia. 2.1. Study 1 Patients with NS-CLBP were independently assessed by two ‘expert’ clinicians and agreement between their diagnoses determined, based on comprehensive subjective and physical examination. 2.1.1. Patients Patients with a classification of NS-CLBP and MCI seeking physiotherapy treatment were recruited from a private multi-disciplinary orthopaedic clinic in the Perth metropolitan area. After screening and further clinical assessment using strict criteria for inclusion and exclusion (Table 2), 35 patients were selected (17 males and 18 females; mean age 37712.73 years; duration of LBP 5.676.0 years; Revised-Oswestry disability score 37711%; Body Mass Index 23.172.2 kg/m2). All

ARTICLE IN PRESS 30

W. Dankaerts et al. / Manual Therapy 11 (2006) 28–39

Table 1 Different approaches commonly used to classify low back pain (LBP) patients and their limitations Dimension/category Uni-dimensional classification systems Patho-anatomical

Approach

Limitation for NS-CLBP population

Radiological diagnosis (Bernard and Kirkaldy-Willis, 1987)

Majority (up to 85%) is classified ‘non-specific’ as no diagnostic imaging procedure is correlated with LBP (Dillingham, 1995; Deyo and Phillips, 1996; Nachemson, 1999; Pearce, 2000) Abnormal findings in asymptomatic individuals are common (Jensen et al., 1994; Boos and Hodler, 1998; Stadnik et al., 1998; Pfirrmann et al., 1999; Borenstein et al., 2001; Humphreys et al., 2002) No insight into the underlying mechanism responsible for the LBP disorder (may be driven by neurophysiological, bio-mechanical and/or psychosocial factors)

Identify nociceptive source based on diagnostic injections (Bernard and KirkaldyWillis, 1987; Bogduk, 1995; Young et al., 2003) Signs and Symptoms

‘Treatment based’ approach, using a cluster of signs and symptoms to classify LBP (Delitto et al., 1995)

For acute LBP only, a similar approach for chronic LBP has not yet been reported Uni-dimensional approach based only on signs and symptoms has limitations as the basis of a mechanism-based CS

Prognosis

Based on the future outcome of the patient (Engel and von Korff MKaton, 1996; Dionne et al., 1997; Krause et al., 1998)

Of limited use for selection of treatment or management Poor prognosis might simply arise because an appropriate treatment addressing the underlying mechanism behind the pain disorder has not yet been identified or tested

Mechanism-based

Hypothesized mechanism behind the disorder is one of disc derangement (McKenzie, 1981) Sahrmann (2001): a classification approach for LBP consisting of five different categories based on signs and symptoms and the premise that ‘impairments’ in the way people move are the underlying factor of the musculo-skeletal pain and dysfunction

The validity of this approach for NS-CLBP is limited

Quebec Task Force Classification (Spitzer, 1987): based on stage of the disorder (acute, sub-acute or chronic), patho-anatomical diagnosis (specific or non-specific, ‘red’ flags), signs and symptoms (area of pain referral), ‘yellow’ flags and work status (psycho-social)

Designed to assist in making clinical decisions (e.g. surgery or conservative treatment), establishing a prognosis, and evaluating the quality of care for patients with LBP Of limited use in physiotherapy assessment or treatment planning (Padfield et al., 2002). Does not consider the underlying mechanism behind NS-LBP disorders (apart from differentiating somatic referred from radicular pain)

Multi-dimensional classification systems Stage patho-anatomical signs and symptoms psychosocial

patients had the protocol explained to them and provided signed consent prior to entering the study.

2.1.2. Examiners The two examiners were musculo-skeletal physiotherapists. One clinician (PO’S) was the developer of the CS and had 18 years experience with patients with LBP. The other clinician (WD) had 12 years of clinical experience with patients with LBP and extensive training by the developer.

No consideration is given to the stage of the disorder, area of pain, specific versus non-specific LBP, or yellow flags Classification model assumes that all LBP disorders lie within this classification, ignoring the several other dimensions of LBP within the biopsychosocial framework

2.1.3. Procedure Prior to conducting this study, 20 patients participating in a different study conducted by the authors were independently examined and a clinical diagnosis determined by the ‘expert’ clinicians. The aim of this pilot study was to refine the specific criteria for assignment to each of the five sub-categories and to further train WD (O’Sullivan, 2000, 2004b) (Appendix A). With the aid of videotapes of subjects’ postures and movements, the clinicians’ diagnoses were compared and discussed, and operational definitions were refined.

ARTICLE IN PRESS W. Dankaerts et al. / Manual Therapy 11 (2006) 28–39

31

Table 2 Inclusion and exclusion criteria for NSLBP patients with Motor Control Impairmenta Inclusion criteria A history of chronic (43 months) LBP Pain only located to the lower lumbar spine (L4/5 or L5/S1) with minimal radiation Absence of impaired movement of the symptomatic segment in the painful direction of movement or loading (based on clinical joint motion palpation examination) Associated impairments in the control of the motion segment(s) in the provocative movement direction(s) Clear mechanical basis of disorder: specific postural and functional movements that aggravate and ease symptoms; relief of symptoms when reducing the strain to the symptomatic spinal segment in the provocation direction Exclusion criteria More generalized low back pain (beyond L4-5, L5-S1 region) and/or radiating pain Dominant non-organic features (yellow flags) Impaired movement of the symptomatic segment in the painful direction of movement or loading (based on clinical joint motion palpation examination) Based on medical assessment (by general practitioner and/or specialist, including radiological imaging): specific diagnoses for LBP disorder (disc prolapse with radicular pain, severe scoliosis, spondylo-arthrosis, spondylolisthesis, inflammatory or other specific disorders), previous back surgery, and serious causes of LBP (red flag pathology) a

All features within the inclusion criteria had to be present; based on O’Sullivan (2000, 2004b).

Following informed consent, patients were allocated to one of two examiners. The order of testing by the two examiners varied but for practical reasons could not be randomized. A full clinical examination was performed by the first examiner to identify patients with NS-CLBP who had a classification of MCI based on strict inclusion and exclusion criteria (Table 1). The comprehensive history of the disorder involved: screening for yellow and red flags, reviewing medical imaging, questioning the patient regarding symptom provocation and relief. The full physical examination consisted of a series of active and functional movement tests, articular tests to determine mobility and level of symptom provocation, neural tissue examination, and tests for spinal motor control (O’Sullivan, 2000, 2004b). Patients were then sub-classified into one of the five patterns as per O’Sullivan (O’Sullivan, 2000, 2004b). Within a maximum of 1 week (most patients were evaluated by the second examiner within 24 h) the second examiner performed a similar full examination and nominated a classification. The two examiners acted entirely independently and were blind to the other’s classification of the disorder. Assessment sheets were placed in sealed opaque envelopes and filed for later analysis. Patients were asked not to provide the second examiner with any information regarding the first examination process. 2.2. Analysis study 1 Kappa-coefficient and %-of-agreement were calculated to determine the level of agreement between the ‘expert’ clinicians (Portney and Watkins, 2000). The Kappa-coefficient is a reliability statistic that corrects for agreement due to chance (Altman, 1991). Data were analysed using SPSS Version 10.0.

2.3. Study 2 2.3.1. Examiners Thirteen clinicians (physiotherapists and medical doctors) of two geographically separate regions (seven from Western Australia and six from Norway) were invited to participate based on familiarity with the CS. Examiners’ characteristics are displayed in Table 3. The examiners were classified into two sub-groups based on their level of specific training and clinical experience with the CS. All examiners were required to sign a consent form. 2.3.2. Procedure Patients who participated in Study 1 were asked to consent to be videotaped and to complete a self-reported pain questionnaire. If consent was obtained, they were videotaped performing a series of postures and functional movements that represented commonly reported aggravating postures and movements of these patients (O’Sullivan, 2000, 2004b). This included usual posture in standing, forward bending and return, backward bending and return, single leg standing, usual sitting posture, slump posture, erect upright posture and sit-to-stand to sit. Thirty patients classified identically by the two ‘expert’ clinicians (Study 1) gave consent to be videotaped. Of these, 25 patients were randomly selected to fill the previously determined numbers (based on statistical advice) for each of the five patterns. For each of these 25 patients, a case report was written and videotapes were edited in a standard manner. Approximately 1 month prior to the testing day each participating examiner received an instruction package consisting of a synopsis of the study methodology and a comprehensive summary of the study procedure. Three weeks prior to the testing day a clinical seminar was held

ARTICLE IN PRESS 32

W. Dankaerts et al. / Manual Therapy 11 (2006) 28–39

Fig. 1. Flow-chart of study design; MCI ¼ motor control impairment.

by the developer of the CS for all the Western Australian examiners. One week prior to the testing day a revision session was held. For logistical reasons the training for the Norwegian examiners was slightly different. All Norwegian examiners had previously undertaken two clinical workshops based on the CS conducted by the developer. The same instruction package was sent to Norway 3 weeks prior to the testing. A 2-day workshop was held prior to testing. The blinded examiners had to initially determine the classification for each patient based on the case reports

only. In addition, examiners were given the video presentation and were asked to classify the patient based on the combined information. Each examiner placed their assessment booklet in an opaque envelope, which was then sealed prior to further analysis. 2.4. Analysis study 2 Kappa-coefficient and %-of-agreement (Portney and Watkins, 2000) was calculated to determine the level of agreement between the ‘gold standard’ (as determined

ARTICLE IN PRESS W. Dankaerts et al. / Manual Therapy 11 (2006) 28–39

33

Table 3 Characteristics of examiners (Study 2) as per level of familiarity with Classification System (CS)

Specific training in CS Age (years) Clinical experience (years) Speciality

‘Moderate’ familiar (n ¼ 8)

‘Very’ familiar (n ¼ 5)

Clinical education sessions and/or workshops regarding the CS with the developer of the CS 45 (range: 40–54; SD: 7) 20 (range: 10–29; SD: 7) 1 GP/physical medicine 1 MD/clinical neurologist 3 Musculo-skeletal physiotherapists 2 Physiotherapists

Postgraduate training under direct supervision of developer of CS 32 (range: 30–33; SD: 1) 9 (range: 7–11; SD: 2) 4 Musculo-skeletal physiotherapists 1 Sports physiotherapist

Table 4 Results of Studies 1 and 2

Study 1 Study 2

‘Expert’ clinicians (n ¼ 2) All clinicians (n ¼ 13) ‘Moderate familiar’ clinicians (n ¼ 8) ‘Very familiar’ clinicians (n ¼ 5)

SE+PE S S+V S S+V S S+V

Kappa

%-of-agreement

0.96 0.32 0.61 0.28 0.55 0.40 0.71

97% 48% 70% 44% 65% 54% 78%

(0.13–0.54) (0.47–0.80) (0.13–0.37) (0.47–0.64) (0.39–0.54) (0.58–0.80)

(32%–64%). (60%–84%) (32%–52%) (60%–72%) (48%–64%) (68%–84%)

Average Kappa-scores (range) and average %-of-agreement (range) SE+PE ¼ based on a comprehensive subjective and physical examination, S ¼ based on subjective information only (case notes), S+V ¼ based on subjective and video. Guidelines for interpreting the strength of the Kappa statistic: o0: poor; 0.00–0.20: slight; 0.21–0.40: fair; 0.41–0.60: moderate; 0.61–0.80: substantial; 0.81–1.00: almost perfect (based on Altman, 1991).

by the ‘expert’ clinicians) and the other examiners. Agreement was also analysed based on the level of familiarity with the CS, based on subjective information only, and based on subjective information plus the videotaped recordings. Descriptive statistics were used for the analysis of correct classification for each pattern. Data were analysed using SPSS Version 10.0.

3. Results 3.1. Study 1 Based on independent patient examinations ‘expert’ clinicians demonstrated almost perfect agreement (Kappa-coefficient 0.96; %-of-agreement 97%) (Table 4). 3.2. Study 2 The agreement between examiners and ‘expert’ clinicians based on subjective information and video was substantial (Table 3). Agreement was reduced when examiners made a classification decision based only on subjective information, and among those examiners who had less familiarization with the CS (Table 3). Fig. 2a–e shows the correct classification (%) by all examiners for each pattern. All five patterns could be reliably identified, with the Flexion Shifting pattern best

identified (82%), and the Active Extension pattern least correctly identified (62%).

4. Discussion The objective of Studies 1 and 2 was to assess the inter-examiner reliability of a CS for NS-CLBP with MCI as proposed by O’Sullivan (2000, 2004b). Results of Study 1 revealed that there was almost perfect agreement between ‘expert’ clinicians, in identifying and classifying patients with NS-CLBP into specific subgroups of MCI based on a comprehensive clinical examination (Table 4). Results of Study 2 indicate substantial clinical agreement across all five patterns based on combined subjective case reports and video observation of postures and movements. Good interexaminer reliability is an essential first step for a CS to be valid and to be of use, clinically and in research settings (Delitto et al., 1995). The poor reliability when classification was based only on subjective findings was expected. This finding supports that the CS is highly dependent on the assimilation of both the subjective and physical examination (O’Sullivan, 2000, 2004b). Study 2 also aimed to evaluate the importance of specific training in the CS, relative to the ability to accurately apply the CS. The results of this study

ARTICLE IN PRESS Classification per pattern (%)

100 80

(a)

Classification per pattern (%)

W. Dankaerts et al. / Manual Therapy 11 (2006) 28–39

34

correct Flexion Pattern incorrect n=104

68

60 40 20

9

8

11

4

100

(b)

Flexion Shifting Pattern n=39

60 40 20

18 0

0

0

0

0 Flexion Active Passive MultiShifting Extension Extension directional

100

(c) 80

Active Extension Pattern n =78

correct incorrect

62 60 40

20 20

5

9

4

Flexion

100

Classification per pattern (%)

Flexion

Classification per pattern (%)

correct incorrect

82

80

(d)

80

Flexion Active Passive MultiShifting Extension Extension directional

Passive Extension correct incorrect Pattern n =39 77

60 40

20 20

0

0

0

3

0 Flexion Active Passive MultiShifting Extension Extension directional

Classification per pattern (%)

Flexion

Flexion

100

(e) 80

Multi-directional Pattern n =65

Flexion Active Passive MultiShifting Extension Extension directional

correct incorrect 68

60 40 20

14

12 0

6

0 Flexion

Flexion Active Passive MultiShifting Extension Extension directional

Fig. 2. (a–e) Classification per different pattern (in %) by all examiners in Study 2; n ¼ total number of that specific pattern included
13 (total number of examiners).

(Table 4) show a very clear pattern of improved reliability associated with more specific (postgraduate) training. This finding is consistent with Strender et al. (1997) who state that the amount of formal instruction (i.e. continuing education) and specific clinical experience in examination procedures and classification rules is a necessary prerequisite to improving reliability. There appears to be a special need for a mechanismbased CS for NS-CLBP based on a bio-pyscho-social framework (Woolf et al., 1998; McCarthy et al., 2004; O’Sullivan, 2004a; O’Sullivan, 2004b). It is acknowledged that to validate this novel CS as a mechanismbased CS, a multi-step process is required and cannot be based solely on inter-examiner reliability. For this reason a model for clinical research into classification of NS-CLBP has been proposed by the authors (Dankaerts et al., 2004; O’Sullivan, 2004a). This model consists of different stages, each stage dealing with different criteria. Fig. 3 presents a flow-chart summary of the model. This multi-dimensional mechanism-based CS is not an alternative to existing CSs but can be seen as a new development for a sub-group within the NS-CLBP, integrating different aspects of established CSs. For

example, the CS proposed by O’Sullivan fits within the QTFC as it uses several criteria set forward by the QTFC: the patient sample consists of ‘non-specific’, ‘chronic’, ‘LBP patients without radiation below the gluteal folds’, absence of ‘red and dominant yellow flags’ and absence of ‘neurological signs’. The proposed CS by O’Sullivan can be seen as a further sub-classification of Category 1 of the QTFC. Similar to McKenzie’s method (McKenzie, 1981; Donelson, 2001), O’Sullivan’s CS is based on a comprehensive patient assessment. Like Delitto’s (1995) treatment-based CS or McKenzie’s method (McKenzie, 1981), O’Sullivan links a very specific intervention to each of the five patterns. Of particular interest for direct comparison with the proposed multi-dimensional CS is the CS developed by Sahrmann (2001) which appears to be more unidimensional in nature. Both classification models assume MCIs as a possible underlying factor in LBP disorders. But there are some substantial differences in the proposed ways to validate the CS and in the method used to classify the patients. Van Dillen et al. (1998) investigated the reliability (among trained therapists) of the individual tests used in criteria for classification according to Sahrmann (2001). The nature of their study

ARTICLE IN PRESS W. Dankaerts et al. / Manual Therapy 11 (2006) 28–39

35

Fig. 3. Flow-chart of proposed new model for validation of mechanism-based classification system (CS) for NS-CLBP with Motor Control Impairment (MCI). Current study shaded.

design assessed reliability based on individual physical examination items and did not give any insight into the ability of the clinicians to classify the patients into the proposed categories. This reliability study served as a pilot study for a validation study on the CS proposed by Sahrmann (Van Dillen et al., 2003b). According to Bailey (1994), a principal aim of classification is ordering entities into groups with maximum between group heterogeneity and within group homogeneity. In Van Dillen et al. (2003b), the location of symptoms varied from low back only to all kinds of referred locations. All three different stages of LBP disorder were included, without consideration for patho-anatomical findings nor the presence of non-organic signs. The fact that these inclusion criteria consist of several different QTFC categories might have led to a heterogeneous sample. Rather than relying purely on signs and symptoms (Van Dillen et al., 1998, 2003a, b), the current studies used a process of diagnostics to make a clinical determination as to whether the MCI is the driving mechanism behind the disorder or is simply a secondary effect of another process (O’Sullivan, 2004a, b). This

process of diagnostics is described in detail elsewhere (Elvey and O’Sullivan, 2004). In contrast with Van Dillen et al. (1998, 2003b), the authors of the current study place a strong emphasis on the subjective history and pain behaviour. Within the CS it is critical in interpreting how the symptoms (as described by the patient during subjective examination) are influenced by changes in postural alignment and movement. Another purpose of taking and integrating history findings is to determine the presence of dominant non-organic features. Strong evidence exists to suggest that psychosocial factors can be an important component of certain NSLBP disorders (Linton, 2000). Psychological processes (cognition, stress, fear, anxiety and depression) are also known to alter motor behaviour (Hodges and Moseley, 2003) influencing patient’s posture and movement (Hodges and Moseley, 2003). Attempts to ‘normalize’ the movement or MCI in many of these disorders would be inappropriate and ineffective (Elvey and O’Sullivan, 2004; O’Sullivan, 2004a). In Van Dillen et al. (1998, 2003b), no other physical examination was performed to identify other underlying mechanisms of pain response. In contrast, in the current study the patients were firstly

ARTICLE IN PRESS 36

W. Dankaerts et al. / Manual Therapy 11 (2006) 28–39

identified as having an MCI based on a set of characteristics (Table 2). We found it essential to include ‘joint motion palpation’ in Study 1. Firstly, because it was deemed important to identify whether the observed control impairment was linked to the symptomatic level of the patient. Secondly, to identify if the pain disorder is linked to an impairment of ‘movement’ or ‘control’ (Elvey and O’Sullivan, 2004). According to the present authors, in the case of a painful impairment of movement, a treatment (such as manipulative techniques) aiming to promote movement into the painful range is the treatment of choice (Elvey and O’Sullivan, 2004). 4.1. Limitations and recommendations for further studies A limitation of this study was the fact that only the clinicians in Study 1 had to agree on identifying MCI patients from the larger LBP population. Patients in Study 2 must therefore be seen as a selected group that does not fully represent the general population of NSCLBP patients which may be more difficult to classify. Further studies are required to test the ability of clinicians to identify patients with MCI within this NS-CLBP population. The use of ‘expert’ clinicians’ classification as ‘gold standard’ is another limitation of this study. But in the absence of a true criterion standard for MCI diagnosis, this method was justified and has been used by others (Gracovetsky et al., 1995). Because of practical and logistic issues, it was decided to use videotaped recordings of the patients in Study 2. Videotaping has been previously used during reliability studies on visual analysis of gait (Krebs et al., 1985; Eastlack et al., 1991), scapular dysfunction (Kibler et al., 2002) and spinal movements (Fritz et al., 2000). Videotaping has been recommended as an alternative to a test–retest design for assessing inter-examiner reliability with patients who have LBP (Delitto et al., 1992). Both limitations and advantages of videotaping are recognized by the authors. The lack of an actual clinical examination for Study 2 is a limitation and may account for some of the discrepancy in the results between Studies 1 and 2. The advantages of videotaping include: not having to place undue stress on the patient, potentially altering his or her clinical status, while allowing a greater number of participants from geographically distinct regions. In spite of these limitations, the current results support good to high level-of-agreement across all categories based on the methods used. As mentioned above, a multi-step process is required to validate this novel multi-dimensional CS as a mechanism-based classification model. Based on the new proposed model (Fig. 3), several studies have been undertaken to add laboratory and outcome validity to

the CS. A laboratory-based test battery, including EMG and 3D-motion analysis, is currently being employed to further validate the clinical diagnosis, determine motor control differences in pain sub-groups with normative data, and ultimately, provide outcome measures for specific interventions.

5. Conclusions The main aim of these two studies was to investigate the inter-examiner reliability of a CS for NS-CLBP patients with MCI. Substantial to excellent reliability was found depending on the level of familiarity. Further research is required to further validate the proposed CS as a mechanism-based CS. The authors believe that the acceptance and integration of a multidimensional mechanism-based CS for NS-CLBP with MCI could have profound implications leading to the application of specific ‘targeted’ interventions for identified sub-groups, and subsequently enhanced treatment efficacy as suggested by Leboeuf-Yde et al. (1997, 2001).

Acknowledgment This study was carried out whilst the first author (WD) was an International Postgraduate Research Scholar in Australia and was supported financially by the Head of School of Physiotherapy Scholarship, Curtin University of Technology Western Australia. The authors would also like to acknowledge all examiners (CP, DB, LP, LG, JW, RY, MK, JS, KH, LL, KO, KF, AT) who participated in this study. Special thanks to the administrative staff at ‘Body Logic’ for their help in co-ordinating the appointments for patients, Dr. Ritu Gupta for her statistical advice and Marina Wise for the linguistic corrections.

Appendix A The different sub-groups of MCI Patterns and their clinical presentation are briefly described below. Based on O’Sullivan (2000, 2004b) Flexion pattern Definition: MCI of the lumbar spine with a tendency to flexion strain (loss of segmental lordosis) at the symptomatic segment. Flexion pain disorders are associated with functional loss of motor control into flexion resulting in an excessive abnormal flexion strain. Provocative postures/activities: all flexion-related postures (e.g. slouched sitting) and functional activities

ARTICLE IN PRESS W. Dankaerts et al. / Manual Therapy 11 (2006) 28–39

(forward bending, cycling) are commonly reported as being painful. Easing postures/activities: extension postures/activities where the lumbar spine is lordosed (e.g. standing, sitting with a lumbar roll, walking). Posture and movement analysis: tendency to present with a loss of lumbar lordosis during sitting and standing postures. The pelvis is often positioned in posterior pelvic tilt. During all functional tasks the same tendency to have a loss of lordosis at the ‘symptomatic level’ is noted. Forward bending movements commonly reveal a tendency of an early ‘loss of lower lumbar lordosis’ (lumbar curve reversal). Similar loss of lordosis is accentuated in other functional tasks like sitto-stand, squatting and gait. This is associated with an increased lordosis in the upper lumbar and lower thoracic spine. Specific posture and movement control tests: inability/ lack of motor control to anterior rotate pelvis and extend lower lumbar spine independent from thorax during above-mentioned aggravating postures/ movements.

Flexion/lateral shifting pattern Definition: MCI around the lumbar spine with a tendency to flex and laterally shift at the symptomatic segment. Provocative postures/activities: reaching and rotating in one direction in association with flexion postures and / or movements. Easing postures/activities: relief in extended or lordotic postures, stretching to the opposite side from the shift, shift correction (contra-lateral glide from pelvis). Posture and movement analysis: similar to the flexion pattern there is a loss of lumbar segmental lordosis at the affected level with the key feature here an associated lateral shift at the lower lumbar spine level. Minimal precipitation of their spine might deviate into a lateral shift position. E.g.: the lateral shift is accentuated when standing on the foot ipsi-lateral to the shift. Sagittal spinal movements reveal a tendency to laterally deviate during flexion and this is commonly associated with an arc of pain. Tests like ‘sit to stand’ usually reveal a typical flexion pattern presentation (see above) plus a tendency towards lateral trunk shift during the movement with increased weight bearing on the lower limb on the side of the shift. Specific posture and movement control tests: inability/ lack of motor control to anterior rotate pelvis and extend lower lumbar spine independent from thorax during above-mentioned aggravating postures/movements with an associated lateral deviation

37

Active extension pattern Definition: MCI around the lumbar spine with a tendency to hold the lumbar spine actively into extension. Provocative postures/activities: all extension-related postures (standing, erect sitting) and functional activities (carrying out overhead activities, fast walking, running and swimming) are commonly reported as being painful. Also commonly reported as a provocative activity is forward bending (with the key feature here being the tendency to hold the lumbar spine into segmental hyperextension). Easing postures/activities: flexion postures/activities where the lumbar spine is flexed (e.g. crook lying, slouched sitting). Posture and movement analysis: tendency for the lumbar spine to be actively held into segmental hyper-lordosis at the symptomatic segment during upright sitting and standing postures. During all functional tasks such as sit to stand, squatting and forward bending the same tendency to hyper-lordose at the ‘symptomatic segment’ is noted. Forward bending movements commonly reveal increased hip flexion and a tendency of a late ‘loss of lordosis’ (beyond mid range of flexion) or no lumbar curve reversal. Return to neutral from a forward bended position reveals an early hyper-lordosing of the spine at the symptomatic segment. Specific posture and movement control tests: inability/ lack of motor control to initiate a posterior pelvic during above-mentioned aggravating postures/ movements.

Passive extension pattern Definition: MCI around the lumbar spine with a tendency to passively over-extend at the symptomatic segment of the lumbar spine. Provocative postures/activities: similar to the active extension pattern all extension-related postures (standing, erect sitting) and functional activities (carrying out overhead activities, fast walking, running and swimming) are commonly reported as being painful. Easing postures/activities: flexion postures/activities where the lumbar spine is de-lordosed (e.g. crook lying, slouched sitting). Posture and movement analysis: tendency for patients to stand into a sway-back posture (thorax posterior to the pelvis) with a segmental hinging at the symptomatic level. Forward bending is often pain free, but on return to neutral they tend to over-extend at the symptomatic level (hinge into extension) and sway pelvis anterior.

ARTICLE IN PRESS 38

W. Dankaerts et al. / Manual Therapy 11 (2006) 28–39

Specific posture and movement control tests: inability/ lack of motor control to extend the thoraco-lumbar spine above the symptomatic segment with a tendency to hinge into extension at this segment.

Multi-directional pattern Definition: multi-directional MCI around the lumbar spine Provocative postures/activities: multi-directional nature of this pattern often reveals pain all weight bearing postures and functional activities. Easing postures/activities: difficulty to find relieving positions during weight bearing Posture and movement analysis: patient may assume a flexed, extended or laterally shifted spinal posture, and may frequently have to alternate them. Excessive segmental shifting and hinging may be observed in all directions, with associated ‘jerky’ movement patterns and reports of ‘stabbing’ pain on movement in all directions with observable lumbar erector spinae muscle spasm. Specific posture and movement control tests: patients have great difficulty assuming neutral lordotic spinal postures, with over shooting into flexion, extension or lateral shifting postures.

References Altman DG. Practical statistics for medical research. London: Chapman & Hall; 1991. Bailey KD. Typologies and taxonomies: an introduction to classification techniques. Thousand Oaks, California: Sage Publications; 1994. Bernard TN, Kirkaldy-Willis WH. Recognizing specific characteristics of nonspecific low back pain. Clinical Orthopedics 1987;217:266–80. 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. Binkley J, Finch E, Hall J, Black T, Gowland C. Diagnostic classification of patients with low back pain: report on a survey of physical therapy experts. Physical Therapy 1993;73(3):138–50. Bogduk N. The anatomical basis for spinal pain syndromes. Journal of Manipulative and Physiological Therapeutics 1995;18(9):603–5. Boos N, Hodler J. What help and what confusion can imaging provide? Baillieres Clinical Rheumatology 1998;12(1):115–39. Borenstein D.G., O’Mara J.W., Boden S.D., Lauerman W.C., Jacobson A., Platenberg C., Schellinger D., Wiesel S.W., The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects: a seven-year follow-up study. Journal of Bone and Joint Surgery 2001;83(9)A:1306–11. Borkan JM, Koes B, Reis S, Cherkin DC. A report from the Second International Forum for Primary Care Research on Low Back Pain. Reexamining priorities. Spine 1998;23(18):1992–6.

Borkan J, Van Tulder M, Reis S, Schoene ML, Croft P, Hermoni D. Advances in the field of low back pain in primary care: a report from the fourth international forum. Spine 2002;27(5): E128–32. Bouter LM, van Tulder MW, Koes BW. Methodologic issues in low back pain research in primary care. Spine 1998;23(18):2014–20. Burton AK, McClune TD, Clarke RD, Main CJ. Long-term follow-up of patients with low back pain attending for manipulative care: outcomes and predictors. Manual Therapy 2004;9(1):30–5. Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E, Silman AJ. Outcome of low back pain in general practice: a prospective study. British Medical Journal 1998;316(7141):1356–9. Dankaerts W, O’Sullivan P, Burnett A, Straker L. What precedes RCT’s? A new model for clinical research into NSCLBP. Eighth International Federation of Orthopaedic Manipulative Therapists’ Conference, Cape Town, South Africa, 2004. Delitto A, Shulman AD, Rose MJ, Strube MJ, Erhard RE, Bowling RW. Reliability of a clinical examination to classify patients with low back syndrome. Physical Therapy Practice 1992;1:1–9. Delitto A, Erhard RE, Bowling RW. A treatment-based classification approach to low back syndrome: identifying and staging patients for conservative treatment. Physical Therapy 1995;75(6):470–89. Deyo RA, Phillips WR. Low back pain. A primary care challenge. Spine 1996;21(24):2826–32. Dillingham T. Evaluation and management of low back pain: an overview. State of the Art Reviews 1995;9(3):559–74. Dionne CE, Koepsell TD, Von Korff M, Deyo RA, Barlow WE, Checkoway H. Predicting long-term functional limitations among back pain patients in primary care settings. Journal of Clinical Epidemiology 1997;50(1):31–43. Donelson R, editor. Letter to the Editor Spine 2001;26(16):1827–9. Eastlack ME, Arvidson J, Snyder-Mackler L, Danoff JV, McGarvey CL. Interrater reliability of videotaped observational gait-analysis assessments. Physical Therapy 1991;71(6):465–72. Ehrlich GE. Back pain. Journal of Rheumatology 2003(Suppl 67):26–31. Elvey R, O’Sullivan P. A contemporary approach to manual therapy. Grieve’s Modern Manual Therapy. Boyling and Jull, Elsevier 2004:471–94. Engel CC, von Korff MKaton WJ. Back pain in primary care: predictors of high health-care costs. Pain 1996;65(2-3):197–204. Ford J, Story I, McKeenen J. A systematic review on methodology of classification system research for low back pain. Musculoskeletal Physiotherapy Australia 13th Biennial Conference, Sydney, Australia, 2003. Fritz JM, Delitto A, Vignovic M, Busse RG. Interrater reliability of judgments of the centralization phenomenon and status change during movement testing in patients with low back pain. Archives of Physical Medicine and Rehabilitation 2000;81(1):57–61. Fritz JM, Delitto A, Erhard RE. Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain: a randomized clinical trial. Spine 2003;28(13):1363–72. Gracovetsky S, Newman N, Pawlowsky M, Lanzo V, Davey B, Robinson L. A database for estimating normal spinal motion derived from non invasive measurements. Spine 1995;20(9):1036–46. Hodges P, Richardson C. Contraction of the abdominal muscles associated with movement of the lower limb. Physical Therapy 1997;77(2):132–43. Hodges PW. Changes in motor planning of feedforward postural responses of the trunk muscles in low back pain. Experimental Brain Research 2001;141(2):261–6. Hodges PW, Moseley GL. Pain and motor control of the lumbopelvic region: effect and possible mechanisms. Journal of Electromyography and Kinesiology 2003;13(4):361–70.

ARTICLE IN PRESS W. Dankaerts et al. / Manual Therapy 11 (2006) 28–39 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, Richardson CA. Altered trunk muscle recruitment in people with low back pain with upper limb movement at different speeds. Archives of Physical Medicine and Rehabilitation 1999;80(9):1005–12. Humphreys SC, Eck JC, Hodges SD. Neuroimaging in low back pain. American Family Physician 2002;65(11):2299–306. Jensen MC, Kelly AP, Brant-Zawadzki MN. MRI of degenerative disease of the lumbar spine. Magnetic Resonance Quarterly 1994;10(3):173–90. Katz WA. Musculoskeletal pain and its socioeconomic implications. Clinical Rheumatology 2002;21(Suppl 1):S2–4. Kibler WB, Uhl TL, Maddux JW, Brooks PV, Zeller B, McMullen J. Qualitative clinical evaluation of scapular dysfunction: a reliability study. Journal of Shoulder and Elbow Surgery 2002;11(6): 550–6. Krause N, Ragland DR, Fisher JM, Syme SL. Psychosocial job factors, physical workload, and incidence of work-related spinal injury: a 5-year prospective study of urban transit operators. Spine 1998;23(23):2507–16. Krebs DE, Edelstein JE, Fishman S. Reliability of observational kinematic gait analysis. Physical Therapy 1985;65(7):1027–33. Leboeuf-Yde C, Manniche C. Low back pain: time to get off the treadmill. Journal of Manipulative and Physiological Therapeutics 2001;24(1):63–6. Leboeuf-Yde C, Lauritsen JM, Lauritzen T. Why has the search for causes of low back pain largely been nonconclusive? Spine 1997;22(8):877–81. Leclere H, Beaulieu MD, Bordage G, Sindon A, Couillard M. Why are clinical problems difficult? General practitioners’ opinions concerning 24 clinical problems. Canadian Medical Association Journal 1990;143(12):1305–15. Linton SJA. review of psychological risk factors in back and neck pain. Spine 2000;25(9):1148–56. Luoto S, Taimela S, Hurri H, Alaranta H. Mechanisms explaining the association between low back trouble and deficits in information processing. A controlled study with follow-up. Spine 1999;24(3):255–61. McCarthy CJ, Arnall FF, Strimpakos N, Freemont A, Oldham JA. The biopsychosocial classification of non-specific low back pain: a systematic review. Physical Therapy Reviews 2004;9:17–30. McKenzie R. The lumbar spine. mechanical diagnosis and therapy. Waikanae, New Zealand: Spinal Publications; 1981. Nachemson A. Back pain: delimiting the problem in the next millennium. International Journal of Law and Psychiatry 1999;22(5–6):473–90. O’Sullivan PB. Lumbar segmental ‘instability’: clinical presentation and specific stabilizing exercise management. Manual Therapy 2000;5(1):2–12. O’Sullivan P. Invited commentary. Journal of Orthopaedic and Sports Physical Therapy 2004a;34(3):109–10. O’Sullivan P. Clinical instability of the lumbar spine: its pathological basis, diagnosis and conservative management. In: Boyling JD, Jull GA, editors. Modern Manual Therapy. Elsevier 2004b;1: 311–22. O’Sullivan PB, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine 1997;22(24):2959–67.

39

O’Sullivan PB, Twomey L, Allison GT. Altered abdominal muscle recruitment in patients with chronic back pain following a specific exercise intervention. Journal of Orthopaedic and Sports Physical Therapy 1998;27(2):114–24. Padfield B, Chesworth B, Butler R. Use of an outcome measurement system to answer a clinical question: is the Quebec task force classification system useful in an outpatient setting? Physiotherapy Canada Fall 2002:254–60. Pearce JM. Aspects of the failed back syndrome: role of litigation. Spinal Cord 2000;38(2):63–70. Pfirrmann CW, Hodler J, Boos N. Diagnostic assessment in lumbar back pain. II. Imaging and image-guided infiltrations. Schweiz Rundsch Med Prax 1999;88(8):315–21. Portney LG, Watkins MP. Foundations of clinical research: applications to practice. Upper Saddle River, NJ: Pentice Hall; 2000. Riddle DL. Classification and low back pain: a review of the literature and critical analysis of selected systems. Physical Therapy 1998;78(7):708–37. Sahrmann SA. Diagnosis and treatment of movement impairment syndromes. Mosby: St. Louis; 2001. Spitzer WO. Scientific approach to the assessment and management of activity related spinal disorders. Spine 1987;7S:S1–S55. Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, Zeiss E. Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: redefining ‘‘whiplash’’ and its management. Spine 1995;20(8 Suppl):1S–73S. Stadnik TW, Lee RR, Coen HL, Neirynck EC, Buisseret TS, Osteaux MJ. Annular tears and disk herniation: prevalence and contrast enhancement on MR images in the absence of low back pain or sciatica. Radiology 1998;206(1):49–55. Strender LE, Sjoblom A, Sundell K, Ludwig R, Taube A. Interexaminer reliability in physical examination of patients with low back pain. Spine 1997;22(7):814–20. Van Dillen LR, Sahrmann SA, Norton BJ, Caldwell CA, Fleming DA, McDonnell MK, Woolsey NB. Reliability of physical examination items used for classification of patients with low back pain. Physical Therapy 1998;78(9):979–88. Van Dillen LR, Sahrmann SA, Norton BJ, Caldwell CA, McDonnell MK, Bloom N. The effect of modifying patient-preferred spinal movement and alignment during symptom testing in patients with low back pain: a preliminary report. Archives of Physical Medicine and Rehabilitation 2003a;84(3):313–22. Van Dillen LR, Sahrmann SA, Norton BJ, Caldwell CA, McDonnell MK, Bloom NJ. Movement system impairment-based categories for low back pain: stage 1 validation. Journal of Orthopaedic & Sports Physical Therapy 2003b;33(3):126–42. van Tulder M, Koes B, Bombardier C. Low back pain. Best Practice & Research in Clinical Rheumatology 2002;16(5):761–75. Waddell G. 1987 Volvo award in clinical sciences. A new clinical model for the treatment of low-back pain. Spine 1987;12(7):632–44. Woolf AD, Pfleger B. Burden of major musculoskeletal conditions. Bulletin of the World Health Organanization 2003;81(9):646–56. Woolf CJ, Bennett GJ, Doherty M, Dubner R, Kidd B, Koltzenburg M, Lipton R, Loeser JD, Payne R, Torebjork E. Towards a mechanism-based classification of pain? Pain 1998;77(3):227–9. Young S, Aprill C, Laslett M. Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine Journal 2003;3(6):460–5. Zimny NJ. Diagnostic classification and orthopaedic physical therapy practice: what we can learn from medicine. Journal of Orthopaedic & Sports Physical Therapy 2004;34(3):105–9 discussion 110-5.

ARTICLE IN PRESS

Manual Therapy 11 (2006) 40–45 www.elsevier.com/locate/math

Original article

The lumbar multifidus muscle and patterns of pain Jon Cornwalla, A. John Harrisb, Susan R. Mercera, a

Department of Anatomy and Structural Biology, University of Otago, Lindo Ferguson Building, PO Box 913, Dunedin, New Zealand b Department of Physiology, University of Otago, Dunedin, New Zealand Received 10 September 2004; received in revised form 16 December 2004; accepted 16 February 2005

Abstract This paper describes the patterns of pain induced by injecting hypertonic saline into the lumbar multifidus muscle opposite the L5 spinous process in 15 healthy adult volunteers. All subjects experienced local pain while referred pain was reported by 13 subjects in one of two regions of the thigh; anterior (n ¼ 5) or posterior (n ¼ 8). These results confirm that the multifidus muscle may be a source of local and referred pain. Comparison of these maps with pain maps following stimulation of the L4 medial dorsal rami and L4-5 interspinous ligaments shows that pain arising from the band of multifidus innervated by the L4 dorsal ramus has a segmental distribution. In addition patterns of pain arising from multifidus clearly overlap those reported for other lumbar structures. These findings highlight the difficulty of using pain distribution to accurately identify specific lumbar structures as the source of pain. r 2005 Elsevier Ltd. All rights reserved. Keywords: Multifidus; Pain maps; Referred pain

1. Introduction Establishing the source of pain is important if specific interventions for low back pain are to be developed. Sources of chronic low back pain confirmed by controlled studies include the zygapophysial joints (Schwarzer et al., 1994a, b), the intervertebral discs (Schwarzer et al., 1994a, 1995a) and the sacro-iliac joints (Schwarzer et al., 1995b; Maigne et al., 1996). For each of these structures patterns of both local and referred pain have been reported (Mooney and Robertson, 1976; McCall et al., 1979; Fortin et al., 1994a, b; Dreyfuss et al., 1996; Fukui et al., 1997; O’Neill et al., 2002). Patterns of local and referred pain have also been recorded following injection of 6% saline into the lumbar interspinous ligaments (Kellgren, 1939) and interspinous spaces (Feinstein et al., 1954). The lumbar back muscles are another possible source of pain. Kellgren (1938) demonstrated that noxious stimulation by 0.1 to 0.3 cc of 6% saline into the lumbar Corresponding author. Tel.: +61 3 479 7353; fax: +61 3 479 7254.

E-mail address: [email protected] (S.R. Mercer). 1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.02.002

multifidus muscle in at least 3 normal volunteers produced patterns of local and referred pain lasting no more than 5 min. More recently, Bogduk and Munro (1979) confirmed these findings in two experiments. The exact placement of the stimulus within the multifidus muscle was not specified in either of these studies, other than being opposite the L5 spinous process. Clinical evidence of pain arising from back muscles comes from Simons and Travell (1983). These authors stated that the referred pain pattern characteristic of each muscle is often the most valuable single source of information to identify the muscular origin of pain. Confirmation of muscle pain arising from a trigger point is by location of spot tenderness and a taut palpable band, palpation of which elicits a twitch response and distinctive pattern of referred pain (Travell and Simons, 1983). Each lumbar muscle therefore has a specific pattern of local and referred pain that may be used for diagnosis. The lumbar multifidus has a myotomal structure (Macintosh et al., 1986). Haig et al. (1991) have demonstrated that specific placement of EMG needles into each band of multifidus demonstrates electrical

ARTICLE IN PRESS J. Cornwall et al. / Manual Therapy 11 (2006) 40–45

41

recording at a segmental level. A segmental distribution of pain should therefore be observable following stimulation of a band of multifidus. The aim of this study was to determine whether stimulation of the L4 band of the multifidus muscle would produce a specific distribution of pain, and whether this pattern would agree with pain maps produced by stimulating the medial branch of the L4 dorsal rami (Fukui et al., 1997), or the L4-5 interspinous ligaments which are innervated by the interspinous branch of the L4 dorsal ramus (Kellgren, 1939; Bogduk et al., 1982). Clinical ramifications of this study lie in comparing these pain patterns with those resulting from a positive trigger point in multifidus.

2. Methods Fifteen adult volunteers (11 males, 4 females) were recruited through the University of Otago. Criteria for inclusion in the study were that the subjects were skeletally mature (24–45 years of age, mean 32 years) and had no history of musculoskeletal disorders or allergic disease. The study was designed as a double blind randomized trial. Informed consent was gained from all participants, and the Ethics Committee of the University of Otago approved the study. Noxious stimulation was achieved through 0.3 ml intramuscular injection of hypertonic saline (5%) while isotonic saline was used as the placebo. Both the injector and subject were blind to the specific contents of each injection and were unaware of previously described pain maps (Kellgren, 1939; Bogduk and Munro, 1979; McCall et al., 1979; Simons and Travell, 1983; Fukui et al., 1997). One active and one placebo injection were introduced at different stages to each subject. The first injection was randomly assigned to a side. The subsequent injection was introduced to the contralateral side. Each subject lay prone with a small pillow under their pelvis. The L5 spinous process was identified using standard techniques (Spangberg et al., 1990). A 27 gauge needle was inserted level with the L5 spinous process at an angle of 601 ventrally and medially, 2.5 cm lateral to the midline (Fig. 1). The needle was inserted until a solid end feel was noted when it was withdrawn slightly and the agent introduced. An interval of 5 min between injections allowed for subsidence of any pain. Following each injection the subject was asked to describe the intensity and location of any sensations. Pain around the injection site was defined as local pain while pain occurring outside and isolated from the local site was defined as referred pain. Maximum intensity of discomfort or pain was reported using a sliding visual analogue scale (VAS). The location of symptoms was first reported by the subject and confirmed by the investigator lightly tracing on the subject’s skin the

Fig. 1. Diagram of the proposed placement of the needle relative to the multifidus muscle. The needle was inserted lateral to the L5 spinous process, directed at an angle of 601 ventrally and medially and was inserted until a solid end feel was noted, then it was withdrawn slightly. The tip will lie in fibres arising from the L4 spinous process, innervated by the L4 dorsal ramus. (Adapted from Macintosh et al., 1986.)

outline of the area that was deemed uncomfortable or painful. The distribution of pain was then drawn by the investigator on an anatomical map and this map was checked by the subject.

3. Results Apart from cutaneous pain on insertion of the needle no local or referred pain was reported following injections of the placebo. Injections of hypertonic saline caused local pain around the injection site in all subjects and referred pain in 13 of the 15 subjects. Subjects reported either of two patterns of referred pain. Five subjects perceived pain in the anterior thigh while eight subjects felt pain in the posterior thigh. Anteriorly, pain or discomfort radiated from a wide band at the groin tapering inferiorly to a narrow band ending at the knee (Fig. 2A). Posteriorly, pain radiated as a band across the buttock inferiorly ending at the knee (Fig. 2B). The mean score for maximum pain using the VAS was 5.5 (range 2.8, 9.0). The maximum pain scores were not differentiated between the local area of pain or the referred area of pain, but solely as the maximum pain experienced in any region.

4. Discussion The results of this study confirm the previous work of Kellgren (1938) and Bogduk and Munro (1979) on

ARTICLE IN PRESS 42

J. Cornwall et al. / Manual Therapy 11 (2006) 40–45

following stimulation of the medial branch of dorsal rami but only a small subset reported referred pain into the thigh. Localization of pain sensation is thought to rely on activity in the somatosensory cortex (Ploner et al., 2002), with referred pain resulting from activity in adjacent but inappropriate cortical regions (Ramachandran and Rogers-Ramachandran, 2000). The two distinct patterns of pain we observed most likely reflect differences between subjects. However, we cannot dismiss the possibilities that different bands of multifidus were stimulated or that the stimulus spread through adjacent bands and therefore the stimulation was not band specific. The deepest band of multifidus located at the site of stimulation is innervated by L4 with the superjacent band innervated by the medial branch of the L3 dorsal ramus (Fig. 1). The only segmental patterns of pain available for comparison are those described following stimulation of the L3-4 and L4-5 interspinous ligaments (Kellgren, 1939) (Fig. 3) or the medial branch of the lumbar dorsal rami (Fukui et al., 1997) (Fig. 4). We can use this data to establish inferentially whether the distribution observed in this study appears segmental in nature. Comparison with Kellgren (1939) reveals that the observed anterior pattern is in agreement with the Fig. 2. Composite local and referred pain pattern of all 15 subjects: (A) anterior pattern, (B) posterior pattern.

patterns of local lumbar pain and referred pain into the lower extremity following noxious stimulation of the lumbar multifidus muscle. It therefore adds to the currently sparse experimental literature demonstrating that local and referred pain may arise from the multifidus muscle. Although this may appear simplistic there are only two previous studies, each using a small number of subjects, that have experimentally demonstrated the clinical observation that multifidus may be the source of both local and referred pain. The patterns of referred pain were variable. This is not surprising as any pattern of referred pain reflects the intensity of the stimulation and the segmental innervation of the stimulated structure (Kellgren, 1939; Feinstein et al., 1954; Mooney and Robertson, 1976; McCall et al., 1979). Therefore, slightly different positioning of the injection site and different size of the subjects’ muscles might lead to differing patterns of referred pain. In subjects who reported no referred pain it is possible that the injection missed the target muscle and saline may have been injected into the loose areolar and adipose tissue that lies between the lamina and the multifidus muscle (Bogduk et al., 1982). The finding of low back pain in all patients does agree with McCall et al. (1979) where all subjects reported low back pain

Fig. 3. Diagram showing: (A) the distribution of pain arising from injection of the L3-4 innervated by the interspinous branch of L3 dorsal ramus and (B) L4-5 interspinous ligaments innervated by the interspinous branch of L4 in 3 subjects. (Adapted from Kellgren, 1939.)

ARTICLE IN PRESS J. Cornwall et al. / Manual Therapy 11 (2006) 40–45

43

a characteristic pain distribution for each medial branch of the dorsal rami could not be drawn. Fukui et al. (1997) suggest that the primary area of pain for L1 through L4 is the entire low back region. Although all our subjects reported local pain similar to Fukui et al. (1997) a higher proportion of patients in our study also reported referred pain. The anterior and posterior patterns in our study agree with the pain distribution described following L2, L3 and L4 medial branch stimulation by Fukui et al. (1997) (Fig. 4), but due to their style of reporting it is not possible to make finer comparisons. The patterns of referred pain that we observed overlap those described following stimulation of the multifidus muscle opposite the L5 spinous process by Kellgren (1938) and Bogduk and Munro (1979), although they were not identical (Fig. 5). Kellgren (1938) (Fig. 5) described a posterior pattern of referred pain similar in distribution to the posterior pattern reported in this study (Fig. 2). The pattern described by Bogduk and Munro (1979) (Fig. 5) around the iliac crest towards the groin overlapped with the proximal portion of the anterior pattern reported here but did not agree with the distal distribution down the anterior aspect of the thigh.

Fig. 4. Diagram of referred pain distribution: (A) following L4 medial branch stimulation (n ¼ 32), (B) following L3 medial branch stimulation (n ¼ 15), (C) following L2 medial branch stimulation (n ¼ 8). (Adapted from Fukui et al., 1997.)

anterior pattern of L3-4 interspinous ligament while the posterior pattern agrees with the posterior pattern of L4-5 innervated interspinous tissue (Fig. 3). On the basis of this general comparison our stimulation technique appears successful in stimulating the bands of multifidus innervated by the L4 dorsal ramus. It is conceivable that there is an overlap with the L3 pattern suggesting that the stimulus could have spilt over into the L3 innervated band of muscle or been erroneously introduced into the L3 multifidus fascicle. Direct comparison of our results with Fukui et al. (1997) was not possible due to the presentation of his findings and overlap of observed patterns (Fig. 4). Unlike Dwyer et al. (1990) and Aprill et al. (1990), Fukui et al. did not record the specific primary and secondary areas of pain for each stimulation. Therefore

Fig. 5. Diagram of the distribution of referred pain after the injection of 6% saline into multifidus opposite L5. Based on data from Kellgren (1938) (light shading) and Bogduk and Munro (1979) (darker shading).

ARTICLE IN PRESS 44

J. Cornwall et al. / Manual Therapy 11 (2006) 40–45

As neither Kellgren (1939) nor Bogduk and Munro (1979) took account of the myotomal structure of multifidus their work showed only that the multifidus could be a source of pain. They did not provide evidence for a segmental relationship between the source of pain and pattern of referral. If different bands or multiple bands of muscle are stimulated different patterns of pain arise; hence the overlap but not concordance of the pain maps between our study and previous studies (Kellgren, 1939; Bogduk and Munro, 1979). The segmental relationship between the source of pain and pattern of referral must be demonstrated if pain patterns are to be useful in the diagnosis of muscle pain. Of immediate clinical relevance is the comparison between pain patterns observed in our study (Fig. 2) and those from stimulation of the multifidus muscle (Fig. 5) (Kellgren, 1939; Bogduk and Munro, 1979), the lumbar zygapophysial joints (Fig. 6) (McCall et al., 1979; Fukui et al., 1997), the medial branches of lumbar dorsal rami (Fig. 4) (Fukui et al., 1997) and the interspinous ligaments (Fig. 3) (Kellgren, 1939). The clear overlap that exists results from the shared common innervation of these structures (Bogduk, 1994). Inspection of Figs. 2–6 clearly demonstrates that no one pattern of referred pain is pathognemonic for lumbar multifidus. Furthermore, examination of the pain map for trigger points in the lower lumbar multifidus (Travell and

Fig. 7. Diagram of referred pain patterns that arise from a trigger point in the lower lumbar multifidus. (Adapted from Simons and Travell, 1983.)

Simons, 1983) reveals localized pain that may spread down the buttock close to the midline and into the posterior thigh. There is little agreement between this pattern of pain (Fig. 7) and the results of more specific stimulation of the multifidus muscle (Fig. 2). This observation raises questions regarding the specificity of palpation of the multifidus muscle. Palpation opposite L5 is through the overlying skin, superficial fascia, thoracolumbar fascia and erector spinae aponeurosis, all structures innervated by lumbar dorsal ramus.

5. Conclusion

Fig. 6. Diagram of the distribution of referred pain after the injection of 6% saline into the L4-5 zygapophysial joint. Based on data from McCall et al. (1979).

This study confirms two previous experimental studies that lumbar multifidus may be the source of both local and referred pain. Noxious stimulation of the band of multifidus innervated by the L4 dorsal ramus produces patterns of pain that are concordant with pain arising from the medial branch of the L4 dorsal ramus and the L4-5 interspinous ligaments. The results of our study justify a larger study investigating each lumbar level and it will be interesting to see whether more distinct segmental maps may be described. Our results highlight the problems associated with diagnosis based primarily on the distribution of pain.

ARTICLE IN PRESS J. Cornwall et al. / Manual Therapy 11 (2006) 40–45

Acknowledgements The authors gratefully acknowledge the support of the New Zealand Society of Physiotherapists Scholarship Trust Fund and the Lottery Board and Mr Robbie McPhee for the production of the figures. References Aprill C, Dwyer A, Bogduk N. Cervical zygapophyseal joint pain patterns II: a clinical evaluation. Spine 1990;15:458–61. Bogduk N. Lumbar dorsal ramus syndromes. In: Boyling J, Palastanga N, editors. Grieve’s modern manual therapy. 2nd ed. Edinburgh: Churchill Livingstone; 1994. p. 429–40 [chapter 30]. Bogduk N, Munro RR. Experimental low back pain, referred pain and muscle spasm. Journal of Anatomy 1979;128:661. Bogduk N, Wilson AS, Tynan W. The human lumbar dorsal rami. Journal of Anatomy 1982;134:383–97. Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bogduk N. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine 1996;21:2594–602. Dwyer A, Aprill C, Bogduk N. Cervical zygapophyseal joint pain patterns I: a study in normal volunteers. Spine 1990;15:453–7. Feinstein B, Langton JNK, Jameson RM, Schiller F. Experiments on pain referred from deep tissues. Journal of Bone and Joint Surgery 1954;36:981–97. 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 1994a;19:1475–82. Fortin JD, Aprill CN, Ponthieux B, Pier J. Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. Part II: Clinical evaluation. Spine 1994b;19:1483–9. Fukui S, Ohseto K, Shiotani M, Ohno K, Karasawa H, Naganuma Y. Distribution of referred pain from the lumbar zygapophyseal joints and dorsal rami. The Clinical Journal of Pain 1997;13:303–7. Haig AJ, Moffroid M, Henry S, Haugh L, Pope M. A technique for needle localization in paraspinal muscles with cadaveric confirmation. Muscle and Nerve 1991;14:521–6. Kellgren JH. Observations on referred pain arising from muscle. Clinical Science 1938;3:175–90.

45

Kellgren JH. On the distribution of referred pain arising from deep somatic structures with charts of segmental pain areas. Clinical Science 1939;4:35–46. Macintosh JE, Valencia F, Bogduk N, Munro RR. The morphology of the human lumbar multifidus. Clinical Biomechanics 1986;1: 196–204. Maigne J-Y, 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;21:1889–92. McCall IW, Park WM, O’Brien JP. Induced pain referral from posterior lumbar elements in normal subjects. Spine 1979;4: 441–6. Mooney V, Robertson J. The facet syndrome. Clinical Orthopaedics and Related Research 1976;115:149–56. O’Neill CW, Kurgansky ME, Derby R, Ryan DP. Disc stimulation and patterns of referred pain. Spine 2002;27:2776–81. Ploner M, Gross J, Timmermann L, Schnitzler A. Cortical representation of first and second pain sensation in humans. Proceedings of the National Academy of Science USA 2002;99: 12444–8. Ramachandran VS, Rogers-Ramachandran D. Phantom limbs and neural plasticity. Archives of Neurology 2000;57:317–20. Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. The relative contributions of the disc and zygapophyseal joint in chronic low back pain. Spine 1994a;19:801–6. Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. Clinical features of patients with pain stemming from the lumbar zygapophyseal joints. Is the lumbar facet syndrome a clinical entity? Spine 1994b;19:1132–7. Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine 1995a;20: 1878–83. Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine 1995b;20:31–7. Simons DG, Travell JG. Myofascial origins of low back pain. 2 Torso muscles. Postgraduate Medicine 1983;73(2):81–92. Spangberg NL, Anker-Moller E, Justesen TM. The quality of a manual method for the identification of lumbar vertebrae. Ugeskrift for Laeger 1990;152(51):3870–1. Travell JG, Simons DG. Myofascial pain and dysfunction The trigger point manual. London: Williams & Wilkins; 1983. p. 45.

ARTICLE IN PRESS

Manual Therapy 11 (2006) 46–53 www.elsevier.com/locate/math

Original article

Monitoring the change: Current trends in outcome measure usage in physiotherapy Daniel Abramsa,, Megan Davidsonb, Julie Harricka, Peter Harcourta, Maria Zylinskia, Jo Clancyc a

Lifecare Ashwood Sports Medicine Centre; Physiotherapy Consultant, Transport Accident Commission, 222 Exhibition St, Melbourne 3000, Australia b La Trobe University, Victoria 3086, Australia c Victorian Workcover Authority, 222 Exhibition St, Melbourne 3000, Australia Received 16 August 2004; received in revised form 4 January 2005; accepted 16 February 2005

Abstract Physiotherapists have traditionally relied on impairment measures such as range of motion and muscle strength to monitor patient progress. The impact of treatment on patients’ daily activities can be assessed with valid and reliable questionnaires, but the use of standardized questionnaires by physiotherapists appeared to be limited. A range of strategies were implemented that aimed to increase physiotherapists’ use of standardized measures of functional activities. A simple random sample of 300 was drawn from a database of physiotherapy providers to a transport accident scheme, and was surveyed in March and September 2003, with response rates of 51% and 55%, respectively. There was a statistically significant (Po:05) increase in reported use of seven questionnaires and a significant reduction in the perception of barriers that were targeted by the interventions The most frequently utilized tests were a pain rating scale and questionnaires for lumbar and cervical problems. Physiotherapists’ attitudes to outcome measurement were generally positive although there was a small but statistically significant (P ¼ :02) reduction in mean attitude score over the re-test period. Physiotherapists in the population sampled significantly increased their reported use of a range of standardized outcome measures over the re-test period. The trend towards greater objectivity in measuring the progress of rehabilitation can enable physiotherapists to develop improved treatment plans with the patients’ needs at the centre of the equation. r 2005 Elsevier Ltd. All rights reserved. Keywords: Questionnaires; Outcome measures; Compensation

1. Introduction As the emphasis on evidence-based medicine in health services delivery grows (Jette et al., 2003) health professionals are increasingly expected to demonstrate improved treatment outcomes. The World Health Organisation International Classification of Functioning (ICF) conceptualizes dysfunction as impairments, activity limitations and participation restrictions (WHO, 2001). It is now widely accepted that measurement of outcomes should occur across those domains and over the past 10–20 years, patient-report health outcome Corresponding author. Tel.:+61 9664 6057; fax: +61 9656 9358.

1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.02.003

measures have been developed and increasingly used for measuring a wide range of health and rehabilitation outcomes (Garratt et al., 2002). Entry-level professional competencies for physiotherapists include the ability to select relevant, achievable and measurable treatment goals and the use of valid and reliable tests and measures to evaluate the results of treatment (ACOPRA, 2002). Physiotherapists, particularly in orthopaedic practice, have traditionally focused on the measurement of impairments such as pain, range of motion and muscle strength, but have not utilized standardized measures of activity and participation (Jette et al., 1994; Kay et al., 2001; Vanderkooy et al., 1999; van der Valk et al., 1995). Two European

ARTICLE IN PRESS D. Abrams et al. / Manual Therapy 11 (2006) 46–53

surveys of rehabilitation health professionals, including physiotherapists, suggest a pattern across professions, countries and health care settings that the use of standardized measures of function in low back pain rehabilitation is not routine and most assessments are at the impairment level (Haigh et al., 2001; Torenbeek et al., 2001). In 2003, a number of initiatives occurred in Victoria to encourage physiotherapists to use standardized measures of activity and participation. The Australian Physiotherapy Association (APA) adopted a national position statement on treatment justification that restated the professional requirement to measure outcomes using valid and reliable instruments. The Transport Accident Commission (TAC)1 produced a ‘‘Clinical Justification Model’’, a decision algorithm that included a requirement to use standardized outcome measures to assess activities/participation and monitor outcomes for individual patients. A new treatment notification plan was adopted by the TAC that required practitioners to submit standardized or customized outcome measures with all new treatment plans proposed. Flanagan et al. (2003) discussed the use of outcome measures to assess the management of long term patients on a case by case basis. The implementation of the clinical justification model was supported by a series of lectures and education seminars offered by the APA and TAC, educational material (including copies of a range of standardized questionnaires) was made available in hard copy and on the TAC and APA websites, and peer contact was made with physiotherapy treatment providers to assist them implement the clinical justification model. Peer contact was performed by Physiotherapy consultants employed by the TAC, and the results over the corresponding period to this study were internally audited. These strategies aimed to increase the use of standardized measures of activity/participation by physiotherapy providers of services to TAC clients. The primary aim of this study was to survey the use of outcome measures over the 6 month period during which these strategies were implemented. Secondary aims were to determine physiotherapists’ attitudes toward outcomes measurement, and the perceived barriers to their use.

2. Method A longitudinal mailed survey was conducted in March and September 2003. Simple random samples of 300 1

In Victoria, the Transport Accident Commission (TAC) is responsible for the provision of health care services for people injured on the state’s road system, and is governed by the Transport Accident Act, 1986.

47

private practitioners were drawn from the register of 1092 physiotherapists who had treated Transport Accident Commission clients in Victoria in the preceding year. Ethical approval for the study was provided by the Faculty Human Ethics Committee, Faculty of Health Sciences, La Trobe University. A simultaneous internal audit on the use of outcome measures by physiotherapists was conducted by the TAC. A survey instrument was designed to collect information on the type and frequency of use of outcome measures. Possible responses to the question ‘‘In what proportion of cases when the test could be used do you use the test?’’ were: Don’t know the test, Never 0%, Sometimes 1–30% Frequently 31–60% and Always 61–100%. In each section named test(s) appeared first and respondents were invited to nominate other tests. Most of the named tests were either currently available on the TAC website and/or promoted as suitable measures during the workshops conducted during the project. Information on impairment measures and physical assessment was collected in the initial survey questionnaire. Demographic information on age, gender, practice location and post-graduate qualification was collected in September. Barriers to the use of outcome measures were assessed by five statements representing barriers identified in the literature (Beattie and Maher, 1997; Deyo and Patrick, 1989; Kay et al., 2001) or by the authors. Respondents were asked to indicate the extent to which these five factors currently limited their ability or willingness to use validated functional outcome measures:








Time required to administer the tests and measures Lack of training in the use of functional tests and measures Lack of familiarity with functional tests and measures Access to appropriate tests and measures Ability to interpret scores and change in scores

To measure the attitudes of the physiotherapists, a set of 12 statements were generated that related to negative and positive attitudes. The attitude statements (see Appendix A) were based on the literature (Delitto, 1994; Patrick and Deyo, 1989) and the authors’ experience. These statements were finalized after evaluation by 12 academic and clinical physiotherapists who provided feedback on content and wording. A Likerttype agreement scale with five response options for the attitude items was used.

3. Analysis A test of the difference between the proportion of respondents using each test in March and September

ARTICLE IN PRESS 48

D. Abrams et al. / Manual Therapy 11 (2006) 46–53

was calculated (Bland, 1995), and two types of analyses were done. The response categories of Sometimes, Frequently and Always were collapsed for comparison of change in reported use. The second analysis grouped the categories Frequently and Always to examine change in common practice. Differences were not tested where any proportion was less than 10%. For the five items relating to barriers the proportion of respondents selecting ‘‘minor barrier’’ or ‘‘major barrier’’ were combined. The difference in the proportion of respondents reporting the issue as a barrier in March and September was tested, and the difference in the proportion reporting the issue was ‘‘not a barrier’’ was also tested. Attitude scale item responses were scored so that a higher score indicated more positive attitudes. The scalability of the 12 attitude items was explored using item–item, corrected item–total, Cronbach Alpha and Factor Analysis. Items were not included in the summed scale score if item–item were not significant and item–total correlations were less than .30, or if rejection of the item changed the Cronbach alpha from outside to within the range 0.8–0.9 (Streiner and Norman, 1995).

4. Results There were 154 and 164 completed forms received in the March and September surveys, a return rate of 51% and 55%, respectively. The average age was 40.6 years (SD 8.3) and the average time since graduation 17.1 years (SD 8.6). The sample was similar in age to the average age of 38.7 years for Victorian Physiotherapists in 1998. However, there were significantly more rural practitioners (27.4% compared to 17%) and more males (58.5% compared to 27%) (AIHW, 2001).2 A little more than half of the respondents worked in Melbourne and around 9% were from a state other than Victoria. Over 80% of respondents treated more than 15 orthopaedic patients in a typical week but only 4% saw more than 15 neurological patients per week. Around 65% treated between 1 and 5 TAC orthopaedic patients in a typical week, but less than 20% treated any TAC neurological patients. Visits to the physiotherapy resource section of the TAC website increased significantly between March and September from 27% to 48% (Difference 21.6%, 95%CI 10.9–32.3). Reported use of the Pain Rating Scale was high at both survey points and the Quebec Back Pain Disability Scale was low (Fig. 1a, 1b). The 2 In 1998 the proportion of males working in their ‘‘Own/group practice’’ was 35.2%, and in ‘‘Sports centre/clinic’’ 45.7%. The high proportion of males in the current sample reflects the relatively high proportion of males in this sector.

reported use of seven of nine standardized tests of function increased significantly between March and September (Fig. 1c, 1d). Several other named tests were used infrequently, with the majority of the respondents stating they did not know or never used the named test (Fig. 2). The majority of respondents (77.3%) nominated one or more customized assessment techniques. The most frequently nominated techniques (Table 1) can be classed as using time, distance, frequency or weight to measure aspects of various daily activities such as walking, sitting, standing, and lifting. Most respondents indicated this data was collected by patient self-report, although many also indicated they collected data by direct observation for activities such as walking and lifting. Fig. 3 shows the physical assessments that respondents reported they collected frequently or always. Muscle endurance was never measured by 44% and aerobic fitness never measured by 49% of respondents. Sixty-three respondents (41%) also nominated other assessments of physical impairments such as balance, stability, proprioception, sensation, tone, neural tension, muscle length, swelling and movement quality. Of the five barriers to using outcome measures, time required to administer the tests and lack of familiarity with functional tests were nominated by more than 80% of respondents in the March survey. The perception of time as a barrier remained very high in September (Fig. 4a, 4b, but familiarity with tests and access to tests was significantly improved (Fig. 4c, 4d). Ten of 12 items in the Attitudes to Outcomes Measurement scale had significant correlations (Po:05) with most other items and corrected item-total correlations from .39 to .58. Two items (6 and 11) were rejected due to weak and non-significant correlations with other items and with the total score. Cronbach’s alpha for the 10 item scale was .78. Principal components analysis with oblique rotation showed that all 10 items loaded onto a predominant that explained 36.5% of variance. The attitude scale yields a total possible score from 0 to 40 with a higher score indicating more positive attitudes. The total attitude scale score decreased slightly but significantly (P ¼ :02) over the re-test period from 27.1 (SD 4.8) to 25.8 (SD 1.1). The statements most positively endorsed were ‘‘Health professionals should measure the outcomes of their treatment’’ and ‘‘Health professionals should monitor patient progress using reliable and valid tools’’. More than 90% of respondents agreed with these statements at both survey points. Approximately, one-third of respondents at each survey point agreed with the statements ‘‘I do not think it is appropriate for the TAC/APA to tell me what to measure and how to report patient status’’.

ARTICLE IN PRESS D. Abrams et al. / Manual Therapy 11 (2006) 46–53

49

Fig. 1. (a) proportion reporting use of instruments sometimes, frequently or always; (b) frequently or always; (c and d) difference in proportion using instruments in March and September.

Fig. 2. Least known tests. FABQ ¼ Fear Avoidance Beliefs Questionnaire, DRAM ¼ Distress and Risk Assessment Method, FIM ¼ Functional Independence Measure, Barthel ¼ Barthel Index, MAS ¼ Motor Assessment Scale, SF-36 ¼ SF-36 Health Survey.

5. Discussion The results showed that the use of outcome measures amongst TAC physiotherapy providers had increased

significantly over the period. This was confirmed by findings of the TACs internal audit over the same period. During this audit, physiotherapy consultants contacted physiotherapy treatment providers to discuss

ARTICLE IN PRESS D. Abrams et al. / Manual Therapy 11 (2006) 46–53

50 Table 1 Customized measures of activity Activity

Nominated by n (%) respondents

Measurement test or concept

Sitting Walking

71 (46%) 70 (45%)

Lifting Standing Sleeping ADLs Sit to stand Work Driving Steps/stairs

27 (18%) 23 (15%) 13 (8%) 12 (8%) 10 (6.5%) 8 (5%) 7 (4.5%) 5 (3%)

‘‘endurance’’ ‘‘time’’ ‘‘tolerance’’ ‘‘duration’’ ‘‘distance’’ ‘‘tolerance’’ ‘‘time’’ ‘‘duration’’ ‘‘test’’ ‘‘10 m walk time’’ ‘‘6 min walk’’ ‘‘12 min walk’’ ‘‘20 min walk test’’ ‘‘10 m step’’ ‘‘tolerance’’ ‘‘max repeated’’ ‘‘ability’’ ‘‘amount’’ ‘‘repetitions’’ ‘‘capacity’’ ‘‘kgs’’ ‘‘endurance’’ ‘‘time’’ ‘‘tolerance’’ ‘‘duration’’ ‘‘pattern’’ ‘‘disturbance’’ ‘‘times woken’’

‘‘tolerance’’ ‘‘hours per day’’ ‘‘time’’ ‘‘endurance’’ ‘‘tolerance’’ ‘‘distance’’ ‘‘time’’ ‘‘number of’’ ‘‘number in 2 min’’ ‘‘step test’’ ‘‘time taken and safety’’

Fig. 3. Physical assessment.

Fig. 4. (a) Proportion rating as minor or major barrier, (b) proportion rating as not a barrier, (b and c) difference in proportion rating as minor or major barrier, and not a barrier, in March and September.

ARTICLE IN PRESS D. Abrams et al. / Manual Therapy 11 (2006) 46–53

the use of outcome measures in assisting with treatment plans. An increase in the usage of outcome measures was found, rising from 30% in March to 66% in September. Significant increases in reported usage were observed for all of the outcome measures promoted by the TAC and the APA. Increased use of these indices reflected the respondents’ predominantly orthopaedic caseload. Limited use was made of neurological and daily activity measures. This result reflects the type of patient seen by the surveyed physiotherapists, most of whom treated few or no patients with a neurological injury. Only one other study has surveyed change over time in the reported usage of outcome measures. Canadian physiotherapists were surveyed in 1992 (Cole et al., 1994) and 1998 (Kay et al., 2001) with little change in the proportion of physiotherapists using ‘‘published measurement scales’’ from 41% to 43%, despite the publication of a battery of rehabilitation instruments (Cole et al., 1994) and introductory outcome measures workshops. These relatively ‘‘passive’’ approaches used alone are known to be ineffective and unlikely to change practitioner behaviour (Grimshaw et al., 2001). In contrast to the significant increase in reported usage of the questionnaires promoted to physiotherapists by the TAC and the APA, there was no significant increase in the use of a number of other questionnaires of relevance to orthopaedic patients, notably the FABQ, DRAM and SF-36, in the current study. Outcome measures were used more frequently for lower back and neck conditions than for limb dysfunction. The high prevalence of lower back and neck pathology in the general community may account for their high comparative use (AIHW, 2002). The greatest change in respondents’ behaviour concerning these clinical tools was in the increase in percentage that used them regularly. Usage of the Oswestry and the NDI was high. Amongst those physiotherapy respondents who knew of these questionnaires, the percentage who did not use them more than halved. Upper and lower limb outcome measures showed the greatest increase in uptake, along with a patient-specific measure. Shoulder-specific questionnaire usage also rose. The Patient Specific Functional Scale (PSFS) rose 20% in usage from an initial base of 36%. Despite this, over 25% of physiotherapists remained unfamiliar with this measure. Patient specific measures are useful because they cover areas that can be missed by questionnaires with set content. They also help to address practitioner concerns about instrument sensitivity. Therapists tended to use customized measures as a means of recording patient-specific measurements with the majority of practitioners in the March survey recording functional progress in terms of time, distance, weight or frequency. Therapists may not appreciate that customized patient assessment using unstandar-

51

dized methods are likely to have poor reproducibility (Waddell et al., 1982). The barriers of test familiarity and access both improved significantly and this is consistent with the education and access aspects of the intervention. In September, more than half the respondents still considered four of the five barriers to be a minor or major barrier. The perception that time was a barrier remained high. It might be expected that as familiarity to the measures improved, the perception that time was a barrier to use would diminish, but this did not occur. Clearly there is more to be done to reduce the barriers to using standardized outcome measures in physiotherapy practice. Physiotherapists’ attitudes to the use of outcome measures were generally positive. While reported use of standardized instruments significantly improved, the attitude score was a little less positive at post-test. In this study, the interventions targeted and achieved behaviour change, not attitude change. Further study is needed to explore the relationship between behaviour change and attitudes. This study is the first to report on the use of standardized outcome measures by Australian Physiotherapists in private practice. A limitation of the study was the lack of a control group, and therefore no causal relationship has been established for the increase in use of outcome measures. Nevertheless, the interventions undertaken during this period included practitioner education workshops, distribution of literature on the use of measures, an APA position statement, ready access to information on the TAC website and direct practitioner contact from colleagues on the use of standardized outcome measures. The mandatory use of outcome measures with all new treatment plans submitted to the TAC is presumed to be an important influence on the change in behaviour observed. This is consistent with the findings by Grimshaw and colleagues (2001) where provider-directed active and multifaceted interventions were found to be capable of creating a change in clinical practice. Little evidence was found that passive approaches such as the distribution of educational material and clinical guidelines alone would influence provider practice. Two random samples were taken from the same sampling frame and although the data were treated as independent there was some overlap in the samples. The response rate was a little over 50%, but this rose to 65% when undelivered surveys were discounted. A return rate of around 50% is typical of physiotherapy surveys (Jette et al., 2003). The extent to which the results are generalizable is unclear. Physiotherapists who were using standardized outcome measures may have been more likely to complete and return the surveys. Social desirability bias may also have resulted in over-reporting of the use of standardized outcome measures by those

ARTICLE IN PRESS D. Abrams et al. / Manual Therapy 11 (2006) 46–53

52

who did complete the surveys. The data is therefore likely to overestimate the proportion of physiotherapists using these tools. An unavoidable limitation of surveys of behaviour is that the data relates to reported rather than actual behaviour. However, the internal audit findings of the Transport Accident Commission provides confirmation that the use of outcome measures, at least for TAC patients, increased over the same period.

6. Conclusion This study found a significant increase in the use of a number of standardized outcome measures by physiotherapists over a 6 month period. The changes observed were likely influenced by active education initiatives, professional support, and peak body position statements. Mandatory reporting of outcome measures, implemented by TAC during the period and monitored by peer review, also played a key role. Most of the physiotherapists surveyed supported the use of valid and reliable instruments, although a minority did not think it was appropriate for either the APA or the TAC to tell them how to report on patient status. The majority of those surveyed collected customized measures, but fewer standardized their assessment by using the PSFS. Further education initiatives into the specificity and standardization of the measurements taken may not only improve the quality of the information collected by physiotherapists, but also help to guide treatment choices in accordance with the patients’ needs.

Appendix A Attitude to outcome measurement scale items 1) Health professionals should measure the outcomes of their treatment. 2) Functional outcome tests and measures are unpopular with clients. 3) It is not necessary to measure functional outcomes. 4) The use of validated outcome measures is clinically helpful in an increasingly medico-legal environment. 5) There is no need to change from the ways that we have always used to assess patients. 6) Patient-report measures are not very reliable. 7) Health professionals should monitor patient progress using reliable and valid tools. 8) I do not think it is appropriate for the APA to tell me what to measure and how to report patient status. 9) Validated outcome measures can encourage a focus on functional outcomes.

10) Available tests are inappropriate for the type of patients that I treat. 11) Patients can be unexpectedly candid when selfcompleting assessment questionnaires. 12) I do not think it is appropriate for the TAC to tell me what to measure and how to report patient status. Response options: strongly agree, agree, neither agree nor disagree, disagree, strongly disagree. Items 6 and 11 were not included in the final scale because of low and non-significant correlations with other items and with the total scale score. References ACOPRA. Australian physiotherapy competency standards. Brisbane: ACOPRA; 2002. AIHW. Physiotherapy Labour Force 1998. Canberra: Australian Institute of Health and Welfare; 2001. Beattie P, Maher C. The role of functional status questionnaires for low back pain. Australian Journal of Physiotherapy 1997;43(1): 29–38. Bland M. An Introduction to Medical Statistics. Oxford: Oxford University Press; 1995. Cole B, Finch E, Gowland C, Mayo N. Physical Rehabilitation Outcome Measures. Toronto: Canadian Physiotherapy Association; 1994. Delitto A. Are measures of function and disability important in low back care? Physical Therapy 1994;74(5):452–62. Deyo RA, Patrick DL. Barriers to the use of health status measures in clinical investigation, patient care, and policy research. Medical Care 1989;27(3 Suppl):S254–68. Flanagan T, Coburn P, Harcourt P, Zylinski M, Jull G. Justifying the on-going physiotherapy management of long-term patients. Manual Therapy 2003;8(4):254–6. Garratt A, Schmidt L, Mackintosh A, Fitzpatrick R. Quality of life measurement: bibliographic study of patient assessed health outcome measures. BMJ 2002;324(7351):1417. Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L, Grilli R, Harvey E, Oxman A, O’Brien MA. Changing provider behavior: An overview of systematic reviews of interventions. Medical Care 2001;39(8 Suppl 2):II2–II45. Haigh R, Tennant A, Biering SF, Grimby G, Marincek C, Phillips S, Ring H, Tesio L, Thonnard J. The use of outcome measures in physical medicine and rehabilitation within Europe. Journal of Rehabilitation Medicine 2001;33(6):273–8. Jette AM, Smith K, Haley SM, Davis KD. Physical therapy episodes of care for patients with low back pain. Physical Therapy 1994;74(2):101–10. Jette DU, Bacon K, Batty C, Carlson M, Ferland A, Hemingway RD, Hill JC, Ogilvie L, Volk D. Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Physical Therapy 2003;83(9):786–805. Kay TM, Myers AM, Huijbregts MPJ. How far have we come since 1992? A comparative survey of physiotherapists’ use of outcome measures. Physiotherapy Canada 2001(Fall):268–75. Patrick DL, Deyo RA. Generic and disease-specific measures in assessing health status and quality of life. Medical Care 1989;27(3 Suppl):S217–32. Streiner DL, Norman GR. Health Measurement Scales. A Practical Guide to their Development and Use. Oxford: Oxford University Press; 1995.

ARTICLE IN PRESS D. Abrams et al. / Manual Therapy 11 (2006) 46–53 Torenbeek M, Caulfield B, Garrett M, Van Harten W. Current use of outcome measures for stroke and low back pain rehabilitation in five European countries: first results of the across project. International Journal of Rehabilitation Research 2001;24(2): 95–101. Vanderkooy J, Bach B, Gross A. A clinical effort toward maximizing evidence-based practice. Physiotherapy Canada 1999;51(4): 273–9.

53

van der Valk RWA, Dekker J, van Baar ME. Physical therapy for patients with low back pain. Physiotherapy 1995;81(6):345–51. Waddell G, Main CJ, Morris EW, Venner RM, Rae PS, Sharmy SH, Galloway H. Normality and reliability in the clinical assessment of backache. British Medical Journal Clinical Research Edition 1982;284(6328):1519–23. WHO. International Classification of Functioning, Disability and Health. Geneva: World Health Organization; 2001.

ARTICLE IN PRESS

Manual Therapy 11 (2006) 54–60 www.elsevier.com/locate/math

Original article

The response of the transverse abdominis and internal oblique muscles to different postures Anne-Marie Ainscough-Potts, Matthew C Morrissey, Duncan Critchley Division of Applied Biomedical Research, Guy’s, King’s and St. Thomas’ School of Biomedical Sciences, Guy’s Campus, 3.19 Shepherd’s House, London SE1 1UL, UK Received 21 June 2004; received in revised form 23 February 2005; accepted 10 March 2005

Abstract The purpose of this study was to consider how the deep abdominal muscles responded to alterations in seated stability. The thickness of the right transverse abdominis (TrA) and internal oblique (IO) muscles were measured with ultrasound imaging in 30 healthy human subjects (mean age 27.7, years 22 females) in supine lying, relaxed sitting on a chair with both feet on the ground, relaxed sitting on a gym ball with both feet on the ground and sitting on a gym ball lifting the left foot off the floor. Measurements were taken at the end of both inspiration and expiration. The results showed that muscle thickness expressed as a percentage of the actual muscle thickness in supine lying did not differ between relaxed sitting on a chair and sitting on a gym ball for either muscle (P ¼ 0:01220:054) where Bonferroni corrected P-value for significance ¼ 0.002. Raising the foot off the floor produced a significant increase in thickness for TrA and IO, when compared with the other seated postures (Po0:001). It was also found that both muscles were thicker at the end of expiration (Po0:001) which has also been established by other authors. These findings suggest that both deep abdominal muscles respond in the same way to postural changes. It also demonstrates that these muscles are automatically targeted by significantly decreasing the base of support, but in normal subjects sitting on a gym ball is not sufficient to increase their activity. r 2005 Elsevier Ltd. All rights reserved. Keywords: Abdominal muscles; Ultrasound scanning; Posture

1. Introduction Treating low back pain is a complex activity and the British Association of Chartered Physiotherapists in Manipulation (1996) gave an overview of the options that may be considered. This group concluded that there was a place for supervised exercises for patients with chronic low back pain. Currently, there is interest in strengthening the deep abdominals, which are thought to help protect the lower spine and prevent recurrence of pain (Hides et al., 2001, Richardson et al., 1999). Corresponding author. Tel.: +44 207 848 6319; fax: +44 207 848 6325.

1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.03.007

Clinicians attempt to strengthen these muscles by offering specific challenges to the body that elicit their contraction. Investigations by Hodges and Richardson (1996 and 1998), using fine wire EMG, found that the transverse abdominis (TrA) became active in normal subjects prior to limb movement. However, when back pain was present they found the activity of TrA was delayed. They concluded that the early activation of TrA may be a protective mechanism for the lumbar spine, which is lost when patients have back pain. Norris (1995a) also suggested that the active muscular system should be addressed, and highlights the need to address the deep abdominals that are

ARTICLE IN PRESS A.-M. Ainscough-Potts et al. / Manual Therapy 11 (2006) 54–60

stabilizers, as well as the superficial ones that act as prime movers. Attempts have been made by clinicians to target the deep abdominal muscles with exercises such as abdominal hollowing and Richardson and Jull (1995) advocated four-point kneeling as the easiest method of activating TrA. In designing a rehabilitation programme for TrA, many physiotherapists have noted that it can be difficult to elicit a contraction using starting positions and verbal instructions alone and have been looking for possible ways of triggering an automatic response. Many authors have advocated sitting on a large inflated gym ball as a rehabilitation tool. Lewis and Hawke (1983) advocated sitting on a gym ball to help re-educate pelvic rocking whereas Scott et al. (1983) suggested that this would improve joint position sense, balance and posture. Carriere (1999) proposed that using the gym ball might improve proprioception. Norris (1995b) advocated using a gym ball as part of a spinal rehabilitation programme to trigger abdominal muscle activity. Gym balls are frequently employed in clinical practice with the aim of facilitating deep abdominal muscle activity; however, there has been little research to support their use in this way. Fine wire EMG is an invasive procedure, so there has been a development towards using real time ultrasound scanning for measurements of abdominal muscle activity, where changes in muscle thickness are believed to be indicative of relative muscle activity levels. Misuri et al. (1997) used real time ultrasound measurements of the abdominal muscles, and found an increase in thickness during expiration, when the muscles were actively contracting. Bunce et al. (2002) also found that ultrasound was a reliable tool for measuring changes in TrA muscle thickness between supine lying, standing and walking. McMeeken et al. (2004) compared needle EMG recordings of TrA contraction with real time ultrasound changes in thickness and found there was a good correlation at all levels of activity. Hodges et al. (2003) used surface and fine wire EMG recording and compared the response with real time ultrasound thickness changes in the abdominal muscles. They found that at submaximal contractions there was a good correlation in TrA and internal oblique (IO). In another study using ultrasound, Critchley and Coutts (2002) found that TrA changes in thickness during abdominal hollowing in four-point kneeling. These findings help support the use of their non-invasive technique to measure abdominal muscle thickness and estimate relative muscle activity. The purpose of this study was to evaluate possible changes in the thickness of the right TrA and IO in different positions, standardized as a percentage of the muscle thickness found in supine lying. The postures investigated were relaxed sitting on a chair, sitting on a

55

gym ball and sitting on the same gym ball raising the left foot off the ground.

2. Method 2.1. Subjects Thirty healthy subjects (22 females and 8 males) ranging in age from 18 to 50 with a mean (standard deviation (SD)) age of 27.7 (8.6) were recruited from physiotherapy students and staff from King’s College London. Their height had a mean (SD) of 1.706 m (89.9 m) and a body mass mean (SD) of 67.2 Kg/m2 (12.4 Kg/m2). All subjects completed a questionnaire that recorded their age, gender, height, weight, levels of physical activity and a brief history of any previous back problems. Subjects had no history of low back pain in the past 6 months. Two females had suffered previous back pain. One had post-natal back pain 12 years ago which received mobilizations and the second had pain after lifting a box, which lasted 3 days, and then recovered spontaneously. Four males had previous problems. One had right sciatica 12 years ago, and left sciatica 6 years ago now resolved. Three others mentioned that they had previous back problems that spontaneously recovered and required no treatment. Women who were pregnant or thought they might have been pregnant at the time were excluded from the study. Ethics approval was gained from the Guy’s Hospital Research Ethics Committee and informed written consent was received from all subjects prior to data collection. 2.2. Equipment A portable real time ultrasound scanner (Aloka 55D900 ultrasound monitor Aloka Co. Ltd., Tokyo, Japan) was used to measure muscle thickness of TrA and IO on the right side of the abdominal wall in B-mode with a 7.5 MHz linear head, and a connected screen that showed the image. By using the callipers measures of muscle thickness were obtained in millimetres. The scanner was calibrated approximately every 7 days. The calipers readings are compared with a standard distance through water (Cardiff Test Tool; Diagnostic Sonar Ltd., Livingstone, Scotland) to ensure reliable and accurate readings. 2.3. Testing postures The positions used for the recordings were (a) supine lying with arms folded out of the way (Fig. 1), (b) sitting comfortably in a chair 43 cm high (with no arm rests), supported against a back rest, with arms folded; hands

ARTICLE IN PRESS 56

A.-M. Ainscough-Potts et al. / Manual Therapy 11 (2006) 54–60

Fig. 1. Supine lying.

Fig. 3. Relaxed sitting on gym ball, both feet on the ground.

thickness at the end of inspiration and expiration, usually no more than 2 min. The subjects were requested to adopt each of the experimental positions in a random order using a random square Latin table. 2.4. Ultrasound measurement of muscle thickness

Fig. 2. Relaxed sitting on chair, both feet on the ground.

gently resting on the opposite shoulders and the feet together on the floor (Fig. 2), (c) sitting comfortably with a straight back on a 65 cm in diameter gymnasium ball, with arms folded and gently resting as above and feet together on the floor (Fig. 3) and (d) the same ball sitting position as (c) but lifting the left foot off the floor by approximately 10 cm (Fig. 4). When sitting on the ball, a 70 kg person reduced the ball height to 43 cm as measured using a tape measure—the same as the seat height of the chair. Each position was held long enough for the examiner to have a clear picture of the muscle

The thickness of both muscles were measured on the right side. The abdominal wall was exposed and the linear head, covered with conducting gel, was placed on the skin halfway between the anterior superior iliac spine and the lower rib cage in the anterior axillary line (Strohl et al., 1981) where the three deep abdominal layers could be readily identified. Initially, supine lying was used to familiarize the examiner with the individual subject’s muscle topography. However, no recording was made of the muscle thickness (Fig. 1). The recording of the muscle thickness in supine lying was taken at the time when that posture was measured during the randomized presentation of the postures. The scan site was not marked on the skin but a knowledge of the local muscle topography was used to return to the same place as the position of the muscle was expected to alter between lying and sitting. The curser points measured the muscle thickness between the fascial bands.

ARTICLE IN PRESS A.-M. Ainscough-Potts et al. / Manual Therapy 11 (2006) 54–60

Fig. 4. Sitting on a gym ball, lifting the left foot.

2.5. Analysis The data was analysed using the SPSS statistical software version 11.50 (SPSS Inc. 233 South Wacker Drive, 11th Floor, Chicargo, IL 60606-6307). Statistical significance was set at P ¼ 0:05. Paired t-tests were used to detect any differences between inspiration and expiration for the TrA and IO muscles, as well as thickness differences between the muscles. t-Tests were used on the data from both muscles at the end of both inspiration and expiration to detect differences in response between the different postures. Intrarater reliability was tested using the method described by Rankin and Stokes (1998) using intraclass correlation coefficients (ICC). Two results of muscle thickness (in millimetres) from ten subjects, in each of the postures, during both respiratory states, were used to calculate the ICCs.

57

Possible order effects were evaluated and no statistically significant effects were noted (range of P-values ¼ 0.98–0.99). Table 1 shows the means, standard deviations and ranges of the muscle thickness recorded in millimetres for both muscles at the end of inspiration and expiration in each of the four experimental positions. These data demonstrate the wide range of abdominal muscle thickness that exists in a normal population. Inspiration was compared with expiration and there was a significant difference (Po0:001) for both muscles with the muscles being larger in size during expiration. Table 2 shows the results of significance tests when the difference in thickness is expressed as a percentage of the individual muscle thickness in lying. For both muscles in both respiratory states there is no statistically significant difference when relaxed sitting is compared with sitting on the gym ball (P ¼ 0:01220:054). When either relaxed sitting or sitting on the gym ball was compared with sitting on the gym ball and lifting the left leg off the ground there was a significant increase in muscle thickness (Po0:001). Fig. 5 depicts the mean (SD) of the results for each muscle when the experimental posture was expressed as a percentage of the thickness of the individual’s muscle in lying as a way of standardizing the results. The large standard deviations indicate that some people have a decrease in thickness between lying and relaxed sitting and lying and sitting on the gym ball, but not between lying and sitting on the gym ball and raising the left foot off the floor. Fig. 6 uses the standardized results and shows the means (SD) of comparing the different experimental positions. A Bonferroni correction of dividing the significance of 0.05 by the number of postural observations (24) was carried out on the data in order to avoid reporting false positive results and setting the significance to Po0:002. This was in line with the recommendations of Portney and Watkins (2000). Sitting on the gym ball was not statistically significant when compared with relaxed sitting in either respiratory state (P ¼ 0:01220:054). Sitting on the gym ball, and lifting the contra-lateral foot off the ground, was statistically significant when compared to sitting, relaxed sitting or sitting on the gym ball in both respiratory states (Po0:001) and  indicates a statistical significant difference in Table 2.

4. Discussion 3. Results For each respiratory state and in each of the postures, two results for ten subjects gave ICC results between 0.97 and 0.99. The remainder of the all the results were calculated from the mean of three observations.

The results showed that both muscles, in both respiratory states, acted in the same way. Using the normalized data relaxed sitting in the chair showed no significant difference when compared with sitting on the gym ball but a significant increase in thickness was

ARTICLE IN PRESS 58

A.-M. Ainscough-Potts et al. / Manual Therapy 11 (2006) 54–60

Table 1 Muscle thickness in the different postures (N ¼ 30) Position

Muscle and respiratory state

Mean

SD

Range min–max

Lying

TrA inspiration TrA expiration IO inspiration IO expiration

3.98 4.23 9.05 9.62

0.91 0.99 2.95 3.1

2.63–7.10 2.7–7.27 5.03–15.93 5.10–16.27

Relaxed sitting

TrA inspiration TrA expiration IO inspiration IO expiration

4.43 4.83 9.44 10.04

1.31 1.46 2.82 2.98

2.23–8.03 2.23–8.90 5.47–16.27 5.83–17.37

Sitting on the gym ball

TrA inspiration TrA expiration IO inspiration IO expiration

4.77 5.10 10.18 10.71

1.56 1.70 3.5 3.58

1.67–7.40 1.73–8.27 5.67–18.70 5.67–19.57

Sitting on the gym ball with the left foot raised approx 10 cm off the floor

TrA inspiration TrA expiration IO inspiration IO expiration

6.32 6.71 12.58 13.12

2.01 2.07 3.97 3.97

2.57–10.30 2.53–10.20 5.93–21.50 6.37–21.0

All measurements are in millimetres. Table 2 t-Test results of the effects of different postures when abdominal muscle thickness is expressed as a percentage of the thickness of the muscle in lying (P ¼ 0:002) Transverse abdominis muscle percentage difference Mean difference (SD) between postures 1 and 2

P-value

Transverse abdominis muscle percentage difference During inspiration Sitting on a gym ball Relaxed sitting On the gym foot raised Relaxed sitting On the gym foot raised Sitting on a gym ball

8.34 (22.72) 47.95 (35.07) 39.6 (31.23)

0.054 0.001* 0.001*

During expiration Sitting on a gym ball On the gym foot raised On the gym foot raised

Relaxed sitting Relaxed sitting Sitting on a gym ball

5.45 (23.87) 44.82 (35.79) 39.37(26.59)

0.221 0.001* 0.001*

Internal oblique muscle percentage difference During inspiration Sitting on a gym ball On the gym foot raised On the gym foot raised

Relaxed sitting Relaxed sitting Sitting on a gym ball

6.96 (14.15) 35.31 (20.72) 28.34 (19.42)

0.012 0.001* 0.001*

During expiration Sitting on a gym ball On the gym foot raised On the gym foot raised

Relaxed sitting Relaxed sitting Sitting on a gym ball

6.13 (13.22) 33.5 (21.43) 27.37 (22.67)

0.017 0.001* 0.001*

Posture 1

Posture 2

*Statistically significant difference (using Bonferroni correction of 0.05/24 P ¼ :002).

found when the subjects sat on the gym ball and raised their left foot. The results of the raw data were expressed as a percentage of the recordings taken in supine lying, the method used previously by Critchley and Coutts (2002) and McMeeken et al. (2004). This normalized the data, so t-tests could be used to compare differences between the means and identify whether significant differences

existed between the postures. These are shown in Fig. 5. The experimental positions of relaxed sitting and sitting on the gym ball, A and B, show large standard deviations which fall below zero in all cases imply that some subjects decrease their muscle recruitment when sitting in a chair or just sitting on a gym ball. The results when they sat on the gym ball and raised the left leg (C) still show large standard deviations but they do not go

ARTICLE IN PRESS A.-M. Ainscough-Potts et al. / Manual Therapy 11 (2006) 54–60

Fig. 5. Posture result means (SD) represented as a percentage of the thickness in lying (mm).

Fig. 6. Comparisons of the different percentage postures with means (SD) with  indicating Po0:002.

below zero, which suggests that this posture is most likely to increase activity in both muscles. Table 2 and Fig. 6 give the results of the comparisons of the mean differences between the postures. They show that there is little difference between relaxed sitting and just sitting on the gym ball, but when these two postures are compared with sitting on the gym ball and raising the left leg, there is a significant difference in thickness in both muscles demonstrating that there is an increase in activity. From observing the data in Table 1, it is clear that there is a general trend for the muscles to increase in thickness as stability of the postures gradually decreases, during both respiratory states. These results reinforce the proposal by Richardson et al. (1999) that a progression for improving the activity of IO and TrA was to decrease the stability of the base of support, and saw sitting on a gym ball as an ‘advanced posture’ compared with crook lying, due to the inherent instability of this position.

59

However, when the data from this study was normalized there was no significant difference found between relaxed sitting and sitting on a gym ball in normal subjects. The results of this current study suggest that, in normal subjects, as postures become less stable, the inner abdominal muscles TrA and IO respond in the same way during both respiratory states. Relaxed sitting in a chair and sitting on a gym ball produced a similar response from the TrA and IO, and comparisons of the means show no statistical significance. As the muscles responded in a similar way, the study demonstrates that sitting on a gym ball is not sufficient to trigger a reaction in TrA alone. When the two seated postures are compared with sitting and lifting the contra-lateral foot off the floor, the increase in thickness in both muscles is statistically significant, and happens without conscious effort. Once again, both muscles responded so they do not appear to work independently during these activities. However, this study does not take into account any feed forward mechanism that might be occurring in the TrA, which has been found by Hodges and Richardson (1996 and 1998). In their studies they found that TrA became active in anticipation of activities of limb movements, and may act as a brace stabilizer of the low back prior to activities. Both the TrA and IO muscles in all the positions were found to be thicker at the end of expiration, as compared to inspiration with P ¼ 0:001 This agrees with the findings of De Troyer et al. (1990) who found TrA was thicker at the end of expiration and Misuri et al. (1997) who found an increase in both muscles. So this current study confirms the contribution that these muscles make towards the respiratory process. These interpretations presuppose that an increase in thickness represents activity in the deep abdominal muscles. This is the case in low-level (o20% maximum voluntary contraction) static effort (Hodges et al., 2003) and for concentric contraction at all levels of effort in TrA (McMeeken et al., 2004). The most demanding posture in the present study, lifting a single foot, is likely to involve low-level static contraction of the deep abdominal muscles which increases confidence in the validity of these results. The present investigation reports changes in muscle thickness in both deep abdominal muscles at one imaging point only. Recent anatomical studies (Urquhart et al., 2005) have described morphological and hence possible functional subdivisions within TrA and OI. The possibility of such a functional subdivision is supported by the differences in thickness change between lying and standing seen in different parts of OI (Beith et al., 2001). Further investigations of muscle change in thickness in different portions of the deep abdominal muscles might clarify their functional role and ultrasound lends itself

ARTICLE IN PRESS 60

A.-M. Ainscough-Potts et al. / Manual Therapy 11 (2006) 54–60

well to making such multiple measures quickly and simply. Clinicians wishing to activate the deep abdominal muscles need to consider a choice of starting position that induces instability, but this study suggests that both TrA and IO respond in the same way to alterations in postural demands, rather than acting independently.

5. Conclusion Sitting on a gym ball with the feet supported is not enough to trigger a significant increase in right-sided deep abdominal muscle thickness, indicating stronger contraction, than relaxed supported sitting. In this study the left foot needed to be raised which indicates a further decrease in stability was required to produce statistical significance at a subconscious level. It would be of interest for further studies to compare the effects of the training using the gym ball, on the possible change in size of the muscles.

References British Association of Chartered Physiotherapists in Manipulation. Back pain management. The evidence for physiotherapy. Chartered Society of Physiotherapy 1996:11–7. Beith ID, Critchley DJ, Copeman E, Newham DJ. Changes in thickness of the left and right human abdominal muscles in standing and lying. Journal of Physiology 2001;531:147P. Bunce SM, Moore AP, Hough AD. M-mode ultrasound: a reliable measure of transverse abdominis thickness? Clinical Biomechanics 2002;17:315–7. Carriere B. The ‘Swiss Ball’ physiotherapy 1999;83(10):552–61. Critchley DJ, Coutts FJ. Abdominal muscle function in chronic low back pain. Physiotherapy 2002;68(6):322–31. De Troyer A, Estenne M, Ninane V, Van Gansbeke D, Goirini M. Transverse abdominus muscle function in humans. Journal of Applied Physiology 1990;68:1010–6.

Hides JA, Jull GA, Richardson CA. Long term effects of specific stabilizing exercises for first-episode back pain. Spine 2001; 26(11):243–8. Hodges PW, Richardson CA. Inefficient muscular stabilization of the lumbar spine associated with low back pain. Spine 1996;21(22): 2640–50. Hodges PW, Richardson CA. Delayed postural contraction of transverse abdominis in low back pain associated with movements of the lower limb. Journal of Spinal Disorders 1998;11(1):46–56. Hodges PW, Pengel LHM, Herbert RD, Gandevia SC. Measurement of muscle contraction with ultrasound imaging. Muscle and Nerve 2003;27:682–92. Lewis FMK, Hawke JR. Orthopaedic treatments—1. The spine. Physiotherapy 1983;69(3):76–7. McMeeken JM, Beith ID, Newham DJ, Milligan P, Critchley DJ. The relationship between EMG and change in thickness of transverses abdominis. Clinical Biomechanics 2004;19:337–42. Misuri G, Colagrande S, Gorini M, Iandelli I, Mancini M, Duranti, Scano G. In vivo ultrasound assessment of respiratory function of abdominal muscles in normal subjects. European Respiratory Journal 1997;10:2861–7. Norris CM. Spinal stabilisation 3. Stabilisation mechanisms of the lumbar spine. Physiotherapy 1995a;81(2):72–8. Norris CM. Spinal stabiliation 5. An exercise programme to enhance lumbar stabilisation. Physiotherapy 1995b;81(3):138–46. Portney LG, Watkins MP. Foundations of clinical research. Application to practice. 2nd ed. Englwood Cliffs, NJ: Prentice Hall; 2000. p. 461–6 [chapter 21]. Rankin G, Stokes M. Reliability of assessment tools in rehabilitation: an illustration of appropriate statistical analysis. Clinical Rehabilitation 1998;12:187–99. Richardson C, Jull G. Muscle control–pain control. What exercises would you prescribe? Manual Therapy 1995;1:2–10. Richardson C, Jull G, Hodges P, Hides J. Therapeutic exercise for spinal segmental stabilization in low back pain. New York, NY: Churchill Livingstone; 1999. p. 153–4 [chapter 10]. Scott JJ, Pruce SPD, Wilson DJ. Orthopaedic Treatments—2. The upper and lower limbs. Physiotherapy 1983;69(3):78–9. Strohl KP, Mead J, Bankett RB, Loring SH, Kosch PC. Regional differences in abdominal muscle activity during various manoeuvres in humans. Journal of Applied Physiology 1981;51:1471–8. Urquhart DM, Barker PJ, Hodges PW, Story IH, Briggs CA. Regional morphology of the transversus abdominis and obliuus internus and externus abdominis muscles. Clinical Biomechanics 2005; 20:233–41.

ARTICLE IN PRESS

Manual Therapy 11 (2006) 61–68 www.elsevier.com/locate/math

Original article

Test–retest reliability of cervicocephalic kinesthetic sensibility in three cardinal planes$ H.-Y. Leea, C.-C. Tengb, H.-M. Chaib, S.-F. Wangb, a

Institute of Occupational Medicine and Industrial Hygiene, College of Public Health, National Taiwan University, 1453R, No.1 Ren-Ai Road Section 1, Taipei, 100, Taiwan b Graduate Institute and School of Physical Therapy, College of Medicine, National Taiwan University and Hospital, 1453R, No.1 Ren-Ai Road Section 1, Taipei, 100, Taiwan Received 29 August 2003; received in revised form 26 February 2005; accepted 10 March 2005

Abstract The test–retest reliability of both the head-to-neutral head position (NHP) and head-to-target repositioning tests in three cardinal planes has been examined in this study. Twenty young adults underwent both head repositioning tests and retests with 10 min rest intervals. Root mean square error (RMSE, total error), constant error (CE, directional bias), variable error (VE, variability), and standard error of measurement (SEM) were calculated from the position data recorded by an ultrasound-based motion analysis system. Intra-class correlation coefficients (ICC) were used to examine reliability. The results showed fair to excellent reliability of RMSE during head-to-NHP (ICC ¼ 0.45–0.80) and head-to-target tests (ICC ¼ 0.42–0.90), except during the head-to-NHP test (ICC ¼ 0.29) from a head extended position. Low reliability of VE associated with the neck motion toward left side bending indicated a direction-dependent effect. The SEM of RMSE (0.7–2.61), CE (0.3–4.01) and VE (0.4–1.51) indicated an acceptable range of error. The present study indicated acceptable and reliable RMSE measurements with a motion analysis system in healthy young adults. Furthermore, examining the CE and VE could contribute to the interpretation of whether the subject performed the reposition tests with directional bias and repositioning variability, respectively. r 2005 Elsevier Ltd. All rights reserved. Keywords: Head repositioning; Proprioception; Kinaesthesia; Reliability

1. Introduction Cervicocephalic kinesthetic sensibility, the ability to judge the head position without visual or vestibular assistance, has recently gained increasing attention for the diagnosis and treatment of cervical dysfunction (Revel et al., 1991; Revel et al., 1994, Loudon et al., 1997). Both biomechanical and neurophysiologic evi$ The Human Ethic Committee of College of Medicine, National Taiwan University has approved the protocol of the study. This study was supported by grants DOH88-HR-823, NHRI-GT-EX89E823C, and NSC 92-2320-B-002-109. Corresponding author. Tel.: +886 2 3123456 x7558; fax: +886 2 23313598. E-mail address: [email protected] (S.-F. Wang).

1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.03.008

dence has indicated its pivotal role in coordinating the movement of the head, trunk and the extremities (Ghez and Krakauer, 2000; Shumway-Cook and Woollacott, 2001). Dysfunction of kinesthetic sensibility characterized by increased error during repositioning tests was strongly associated with chronic neck pain (Revel et al., 1991; Revel et al., 1994; Loudon et al., 1997). No direct evidence illustrated the role of decreased proprioception of the cervical spine in the process of cervical spine joint degeneration. However, this has been documented for the knee joint (Lephart et al., 1997). In order to investigate the relationship of decreased cervical spine proprioception to cervical spine degeneration, a reliable measurement of cervicocephalic kinesthetic sensibility is necessary.

ARTICLE IN PRESS 62

H.-Y. Lee et al. / Manual Therapy 11 (2006) 61–68

Kinesthetic sensibility has been defined and measured by repositioning errors during joint repositioning tests for many major joints in the extremities (Barrack et al., 1983; Barrett et al., 1991). Despite some studies on cervicocephalic kinesthetic sensibility (Revel et al., 1991; Loudon et al., 1997), no general agreement has been reached on how to perform the head repositioning test. Revel et al. (1991) proposed the head repositioning test by having the blindfolded subject actively move his/her head through full range of motion in either the transverse or sagittal plane and then return the head to a subjective neutral head position (NHP). This methodology has been adopted in several studies investigating cervicocephalic kinesthetic sensibility (Revel et al., 1994; Heikkila and Astrom, 1996; Heikkila and Wenngren, 1998; Rix and Bagust, 2001). This is known as the head-to-NHP repositioning test (head-to-NHP). In contrast, Loudon et al. (1997) proposed a passive–active target repositioning test. This is a two-step test performed by passively positioning the head of subject in a pre-determined position, and then by having the subject actively match his/her head to the pre-determined position from the NHP position. This is the head-to-target repositioning test (head-totarget). Only a few studies have dealt with the test–retest reliability of the head repositioning tests (Revel et al., 1991; Loudon et al., 1997; Christensen and Nilsson, 1999; Kristjansson et al., 2001). Comparison of the results of these studies was impossible due to different methodologies in experimental procedure or data analysis. Measuring the repositioning ability expressed by absolute error (AE) in the transverse plane, Kristjansson et al. (2001) found that the reliability of the head-to-NHP and head-to-target repositioning test could be ranked from fair to good (intra-class correlation coefficients; ICC ¼ 0.69–0.82). Although Revel et al. (1991) noted that inter-rater reliability was acceptable in the sagittal and transverse planes, they did not report the ICC values. Besides using AE to indicate the reposition error, the repositioning error has been expressed as constant error (CE), variable error (VE) (Brumagne et al., 1999), and root mean square error (RMSE) (Schmidt and Lee, 1999). Among them, the RMSE is the true mathematical combination of CE and VE (that is, the total error, see Appendix). Therefore, if the VE is relatively small, the RMSE will be nearly identical to the absolute value of CE which is often indicated by AE. High values of CE and VE were interpreted as the subject performing the repositioning tests with directional bias and repositioning variability, respectively (Brumagne et al., 1999). Thus, two repositioning tests, which expressed by CE, VE, and RMSE, seemed to be a suitable method to comprehensively address the issue of cervicocephalic kinesthetic sensibility.

Repositioning ability is determined primarily by the function of the muscle spindles of the contracting muscles (Gandevia et al., 1992). Furthermore, different cervical joints (White and Panjabi, 1990) and muscles (Vitti et al., 1973; Mayoux-Benhamou et al., 1997) are involved in performing neck motions in the three cardinal planes. Whether the repositioning tests in all of the three cardinal planes would demonstrate acceptable reliability remained unclear. This study, therefore, examined the reproducibility of repositioning errors in three cardinal planes based on both head-to-NHP (Revel et al., 1991; Revel et al., 1994) and head-to-target tests (Loudon et al., 1997).

2. Method 2.1. Subjects Twenty young adults were recruited from a local university. The subjects with the following history were not included: (1) cervical trauma, (2) seeking any form of medical treatment for cervical pain within the last three months, (3) neurological and vestibular impairment demonstrated by motor weakness, numbness, vertigo, dizziness, or motor imbalance. Written consent was obtained from all subjects before entering the study and ethical clearance was granted by the institutional Review Board of the National Taiwan University Hospital. 2.2. Instrumentation The ultrasound-based motion analysis system, CMS 70P (Zebris system, Medizintecknik GmbH, Tubingen Germany), was used to measure the head position in the three cardinal planes as described in previous studies (Wang et al., 2002, 2003, 2005). Two sets of ultrasound triple markers, one mounted on a head attachment (H) and another on a shoulder (S), were arranged to detect real-time cervical motions via three miniature ultrasound transmitters (U in Fig. 1). The transducer sensor stand (T) consisted of three integrated microphones (M) that recorded the ultrasound waves with the sampling frequency of each sound wave at 25 Hz. The cervical motion was processed automatically by the Win-data 2.11 software, using the principle of coordinate transformation to calculate the desired angle of the local coordinates (Wang et al., 2005). Acceptable test–retest reliability for the measurement of cervical range of motion (ROM) using ultrasoundbased motion analysis system has been demonstrated in previous experiments performed in our laboratory

ARTICLE IN PRESS H.-Y. Lee et al. / Manual Therapy 11 (2006) 61–68

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

(Wang et al., 2002, 2003, 2005) and in other studies (Castro et al., 2000; Dvir and Prushansky 2000). 2.3. Procedure After verbally describing the test procedure, the subject was asked to sit upright on a chair with his/her feet on the floor and to look straight ahead. His/her trunk was fastened to the back of a chair using a Velcro strap as described in the previous studies (Wang et al., 2002, 2003, 2005). The rater adjusted the head triple markers to ensure that the plane of head triple markers was parallel to the sagittal plane of head movement. The whole test procedure was divided into three parts: (1) determining the NHP, (2) determining the target position, and (3) performing the head-to-NHP and head-to-target repositioning tests. The NHP was determined by asking the subject to maintain his/her head in the neutral position as sitting upright comfortably and looking straight ahead. The motion analysis system was re-calibrated so that the NHP was defined as 01 for each subject. The subject was then asked to recognize this position as his/her NHP. This position was the target for the head-to-NHP repositioning test and the baseline for the head-to-target repositioning test. The reliability of movement behaviour is influenced by multiple factors, including muscle length, speed of

63

movement and subject’s cooperation during the tests (Schmidt and Lee, 1999). All of these factors were carefully controlled during the reliability testing. The maximum ROMs in each direction of the three cardinal planes were measured first. The target position was defined as 65% of the maximum ROM for each movement of the subject. Sixty-five percent of maximum ROM was used as the target position because this position puts the neck muscles in a slightly lengthened position and avoids excessive stretch of the soft tissue of the neck. To familiarize the subject with the target position in each direction, the rater moved the subject’s head passively at a speed below 351/s until the pre-determined target position was reached. The movement speed was controlled by the rater using the real-time display of the neck angle of the motion analysis system. The control in the movement speed eliminates excessive stimulation to the vestibular system during high speed of head motions (Goebel et al., 1994). The subjects were permitted to concentrate on this position for 2–3 s. Once the recognition of the target position was established, the head-to-NHP tests and the headto-target repositioning tests were performed. The head-to-NHP test was carried out first to have the subject move his/her head from the target position back to the NHP. After staying in the NHP for 2–3 s, the subject performed the head-to-target repositioning test immediately by moving his/her head back to the target position. The subject was then asked to relocate his/ her head to the pre-determined target position and rest 2–3 s for another trial. The whole trial was completed with the subjects’ eyes closed in order to eliminate the influence of visual inputs. Both the head repositioning tests were performed in six directions of cervical motion (flexion/extension, left/rightward rotation, and left/rightward side-bending) in a sequence with a 1-min interval between directions. Three trials were collected for each direction. The entire procedure was repeated by the same rater after a 10-min interval.

2.4. Data analysis The predetermined (target and NHP) and repositioning angles were developed through the off-line analysis with Windata 2.11 software of the motion analysis system. The mathematical formulas of the CE, VE, and RMSE for repositioning errors are defined below: Define: E ij ¼ X ij
T ij , i ¼ 1; . . . ; n; j ¼ 1; . . . ; m, where n ¼ 20 denotes the subject number, m ¼ 3 denotes the trial number and X ij and T ij denote the reposition angle of ith subject in jth trial, and the

ARTICLE IN PRESS H.-Y. Lee et al. / Manual Therapy 11 (2006) 61–68

64

target position angle of ith subject in jth trial, respectively. Define (1)

CE2 ¼

1 n

n X i¼1

1 2 E¯ i ; where CEi ¼ E¯ i ¼ m

m X

E ij ,

j¼1

n m 1X 1X VE 2i ; where VE2i ¼ ðE ij
E¯ i Þ2 , n i¼1 m j¼1

(2)

VE2 ¼

(3)

RMSE2 ¼

n m 1X 1X RMSE2i ; where RMSE2i ¼ E2 . n i¼1 m j¼1 ij

The ICC (1, 3) was used to test the intra-rater reliability of the RMSE, CE, and VE. The standard error of measurement (SEM) indicates the error using the same metric as the measure (Roebroeck et al., 1993) and is expressed by the product of standard deviation and square root of (1
ICC) (Portney and Watkins, 1993). According to Fleiss’ classification (Fleiss, 1986), an ICC value above 0.75 indicates excellent reliability, values between 0.40 and 0.75 are fair to good, and values below 0.40 indicate poor reliability. SPSS for Window 10.0 (SPSS Inc., Chicago, USA) was used for the statistical analysis.

3. Results Table 1 presents the basic information and maximum cervical range of the participants. The participants consisted of 11 men and 9 women between the ages of 18 and 30 years (21.973.9). There was no significant difference between different genders in maximum cervical range in all directions.

Table 1 Basic data of the young participants (n ¼ 20) Mean7SD Gender Male (n) Female (n) Age, y/o

11 9 21.973.9

Maximum cervical range (deg) Flexion Extension Rotation to right Rotation to left Side-bending to right Side-bending to left

53.0711.5 75.4716.5 65.178.0 63.478.2 38.475.9 39.575.9

3.1. Head-to-NHP repositioning test 3.1.1. RMSE The repositioning error expressed by RMSE for the head-to-NHP tests ranged from 2.871.81 to 6.572.61 (Table 2, RMS). The reliability of RMSE for the head-to-NHP tests was ranked as fair to excellent (ICC ¼ 0.53–0.80) except that poor reliability was noted for the head-to-NHP test from a head extended position (ICC ¼ 0.29). The SEM of RMSE during head-to-NHP tests ranged from 1.21 to 2.61. 3.1.2. CE The CE for the head-to-NHP tests ranged from 1.573.41 to 5.274.01 (Table 2, CE) For the CE during head-to-NHP tests, a fair to excellent reliability was found for all cervical motions (ICC ¼ 0.54–0.84), except for the one from an extended head (ICC ¼ 0.38). The SEM of CE during head-to-NHP tests ranged from 0.31 to 3.71. 3.1.3. VE The repositioning errors expressed by VE during head-to-NHP tests ranged from 0.970.61 to 2.471.61 (Table 2, VE). For the head-to-NHP tests from the head flexed, leftward rotated, and leftward side-bended positions, a fair to excellent reliability of VE was demonstrated (ICC ¼ 0.55–0.83). But, interestingly, for the motion from the opposite directions, such as from head extended, right rotated, and right side-bended positions, the reliability of VE was poor. The SEM of VE during head-to-NHP tests ranged from 0.41 to 1.51. 3.2. Head-to-target repositioning test 3.2.1. RMSE The repositioning errors expressed by RMSE for the head-to-target tests ranged from 1.471.01 to 3.172.71 (Table 3, RMS). The reliability of RMSE for the headto-target tests in all six directions in the three cardinal planes was fair to excellent (ICC ¼ 0.42–0.90, Table 3, see RMSE). The SEM of RMSE for the head-to-target tests ranged from 0.71 to 1.51 (see Table 3, RMSE). 3.2.2. CE The repositioning error expressed by CE during headto-target tests ranged from
1.474.81 to 0.874.51 (Table 3, CE). For head-to-target tests during flexion/ extension and left/rightward rotation, the reliability of CE was fair to excellent (ICC ¼ 0.72–0.83, see Table 3, CE). But for the reliability of CE in the frontal plane, the ICC was poor. The SEM of CE during head-totarget tests ranged from 2.01 to 4.01 (Table 3, CE).

ARTICLE IN PRESS H.-Y. Lee et al. / Manual Therapy 11 (2006) 61–68

65

Table 2 Test–retest reliability (ICC) of the head-to-NHP repositioning tests in three cardinal planes of the cervical spine expressed by RMSE, CE, and VE Parameter

Pre-determined positions

Test (Mean7SD)

Retest (deg)

SEM (deg)

ICC

RMSE

Flexed Extended R rotated L rotated R side-bended L side-bended

4.472.2 6.572.6 4.972.7 5.273.1 2.871.8 3.171.6

5.172.9 5.473.6 4.172.6 5.173.8 3.272.3 3.272.0

1.5 2.6 2.0 1.5 1.4 1.2

0.65 0.29 0.45 0.80 0.53 0.58

CE

Flexed Extended R rotated L rotated R side-bended L side-bended

2.573.0 5.274.0 3.773.8 2.073.7 2.073.4 3.170.7

2.474.7 2.575.3 2.173.4 2.573.7 1.573.4 3.570.8

2.2 3.7. 2.4 2.5 1.8 0.3

0.68 0.38 0.54 0.54 0.71 0.84

VE

Flexed Extended R rotated L rotated R side-bended L side-bended

1.671.3 2.471.6 1.771.1 1.571.3 1.170.6 0.970.7

1.470.9 1.871.3 1.670.9 1.771.0 1.170.7 0.970.6

0.6 1.5 0.9 0.5 0.6 0.4

0.71
0.03 0.19 0.83 0.03 0.55

CE, constant error; VE, variable error; RMSE, root mean square error; SEM, Standard error of measurement, C.I., confidence interval; R, Right; L, Left. For CE means, the positive value means overshooting.

Table 3 Test-retest reliability (ICC) of the head-to-target repositioning tests in three cardinal planes of the cervical spine expressed by RMSE, CE, and VE Parameter

Head-to-target

Test (Mean7SD)

Retest (deg)

SEM (deg)

ICC

RMSE

Flexion Extension R rotation L rotation R side-bending L side-bending

2.772.1 3.172.2 2.471.9 3.072.3 2.071.8 1.471.0

2.572.0 3.072.3 2.872.1 3.172.7 1.971.2 2.171.8

0.8 0.7 1.3 1.5 1.1 0.9

0.83 0.90 0.56 0.66 0.42 0.57

CE

Flexion Extension R rotation L rotation R side-bending L side-bending

0.574.7 0.874.5
0.674.4
0.874.3 0.574.5 0.372.7


0.074.5 0.675.0 0.574.9
1.474.8
0.673.0
0.473.8

1.9 2.5 2.1 2.0 3.7 4.0

0.83 0.72 0.80 0.81 0.01
0.48

VE

Flexion Extension R rotation L rotation R side-bending L side-bending

1.470.9 1.971.0 1.670.9 2.271.3 1.070.7 0.870.5

1.470.9 2.071.6 1.871.3 1.370.8 1.170.8 1.170.6

0.7 0.9 1.2 1.0 0.5 0.8

0.44 0.52
0.17 0.15 0.49
0.97

CE, constant error; VE, variable error; RMSE, root mean square error, SEM, Standard error of measurement; C.I., confidence interval. R, Right; L, Left. For CE, the positive value means overshooting.

3.2.3. VE The repositioning errors expressed by VE during head-to-target tests ranged from 0.87 0.51 to 2.271.31 (Table 3, VE). The reliability of VE was fair during repositioning toward flexion, extension, and right side-

bending (ICC ¼ 0.44, 0.52 and 0.49, respectively, see Table 3, VE), except poor ICC of VE during head-totarget tests toward left rotation, right rotation, and left side-bending. The SEM of VE during head-to-target tests ranged from 0.51 to 1.21 (see Table 3, VE).

ARTICLE IN PRESS 66

H.-Y. Lee et al. / Manual Therapy 11 (2006) 61–68

4. Discussion The present results reveal that the majority of the head-to-NHP tests and head-to-target tests in the three cardinal planes are reliable when the positioning errors are expressed as RMSE except from head extension to the neutral position. Thus, the RMSE (or its nearly identical value of AE) was a reliable method to measure reposition errors. Although, the reliability of CE and VE in only some planes and direction are acceptable, the value of CE and VE could determine whether the subject was performing with consistent directional bias or repositioning variability, respectively (Brumagne et al., 1999). Describing the errors using AE alone might result in no significant difference among groups. It has been reported that healthy adults tended to overshoot NHP from the flexed position to NHP, in contrast to the tendency to undershoot from the extended position to NHP (Revel et al., 1991); while patients with cervical or lumbar pain tended to overshoot the target during flexion/extension (Blouin et al., 1995; Lam et al., 1999; Loudon et al., 1997; Revel et al., 1991). Thus, the error of head-to-NHP tests from the extended position between groups is likely not to be different if the AE was the only measurement. Asymmetry in variability (expressed by VE) of repositioning errors between the right and left-sidebending was shown during head repositioning tests. In this study, poor reliability of VE indicated that the variability of the repositioning errors among trials was high during neck motion toward left side-bending. Lack of consistency during repeated repositioning toward the left/right sides in the frontal plane was also found by Swinkels and Dolan (1998) in a study of the lumbar repositioning test. They attributed this phenomenon to the effect related to side dominance. Further studies are required to investigate the relationship of hand dominance and the head repositioning test. The reduced reliability for the repositioning errors in the frontal planes during head-to-target tests might be attributed to the increased coupling movements, which introduced variation during action in the frontal plane (Feipel et al., 1999). Higher reliability was found for the head-to-target tests in the sagittal plane (ICC ¼ 0.83–0.90) in comparison to those in the frontal plane (ICC ¼ 0.42–0.57) in the lumbar region (Gill and Callaghan, 1998; Swinkels and Dolan, 1998; Lam et al., 1999). Nevertheless, the reliability of RMSE in the frontal planes during head-to-NHP tests was fair to excellent. Thus, the movement control during head-totarget tests appeared to differ from its reciprocal motions during head-to-NHP in the frontal plane. The value of ICC in isolation does not provide any indication of the magnitude of disagreement between measurements, and therefore should be complemented

by a standard deviation of differences (Rankin and Stokes, 1998) or SEM (Eliasziw et al., 1994). ICC is the index calculated by ratio of variance of interest divided by the sum of variance of interest and measurement error (Fleiss, 1986). While examining the raw data of VE, we found that within-mean square variation (WMS) is close to or greater than the between-mean square variation (BMS). Thus, the ICC would not be a good index to examine the reliability of VE. In contrast, the small value of standard error of measurement (SEM) could indicate acceptable reliability. Accordingly, Table 3 presents the SEM values. Indeed, herein the SEM of RMSE (0.7–2.61), CE (0.3–4.01) and VE (0.4–1.51) were in a small range, indicating an acceptable range of error. Based on the assumption that repositioning ability is determined by the function of muscle spindles of the contracting muscles (Gandevia et al., 1992), one could interpret the difference in the test–retest reliability of the head-to-NHP and head-to-target repositioning tests as different repositioning ability of muscle groups that were used to perform these two repositioning tests (Vitti et al., 1973; Mayoux-Benhamou et al., 1997; Vasavada et al., 1998; White and Panjabi, 1990) For example, by calculating the force generation capacity of cervical muscles during different motions, Vasavada et al. (1998) found that some muscles (the semispinalis capitis and the longissimus capitis) might participate more for the head motion toward NHP in the transverse plane, but less for the head motion away from NHP. Vitti et al. (1973) demonstrated that longus colli was activated during rotation to the NHP, whereas both longus colli and SCM were co-activated during rotation from NHP toward the maximal range. Further investigation is required to determine whether the poor repositioning reliability from extended position indicates various movement strategies adapted by individual or proprioceptive changes of neck flexors in asymptomatic young adults.

5. Conclusion This study demonstrates that the RMSE was reliable in the majority of head-to-NHP tests and head-to-target tests in the three cardinal planes. Examining the CE and VE could provide further information about the attribution of the measurement errors in the directional bias and the repositioning variability, respectively.

Acknowledgements The authors would like to thank the financial support from Department of Health and National Health Research Institute of the Republic of China, Taiwan under Contract No. DOH88-HR-823 and

ARTICLE IN PRESS H.-Y. Lee et al. / Manual Therapy 11 (2006) 61–68

NHRI-GT-EX89E823C, and National Science Foundation under Contract No. NSC 92-2320-B-002-109. The statistical consultation from Dr. Jen-Jen Lin is highly appreciated.

Appendix Define: E ij ¼ X ij
T ij , i ¼ 1; . . . ; n; j ¼ 1; . . . ; m, where n ¼ 20 denotes the subject number, m ¼ 3 denotes the trial number and X ij and T ij denote the reposition angle of ith subject in jth trial and target position angle of ith subject in jth trial, respectively. Define n m 1X 1X 2 (1) CE2 ¼ E ij , E¯ i ; where CEi ¼ E¯ i ¼ n i¼1 m j¼1 n m 1X 1X VE 2i ; where VE2i ¼ ðE ij
E¯ i Þ2 , n i¼1 m j¼1

(2)

VE2 ¼

(3)

RMSE2 ¼

n m 1X 1X RMSE2i ; where RMSE2i ¼ E2 . n i¼1 m j¼1 ij

Claim: RMSE2 ¼ CE2 þ VE2 . Proof. RMSE2 ¼

n X m 1 X E2 nm i¼1 j¼1 ij

¼

n X m 1 X ðE ij
E¯ i þ E¯ i Þ2 nm i¼1 j¼1

¼

n X m h i 1 X 2 ðE ij
E¯ i Þ2 þ E¯ i þ 2E¯ i ðE ij
E¯ i Þ nm i¼1 j¼1

¼

n X m n 1 X 1X 2 ðE ij
E¯ i Þ2 þ E¯ nm i¼1 j¼1 n i¼1 i

¼

n n 1X 1X 2 VE 2i þ E¯ , n i¼1 n i¼1 i

where n X m n m X 1 X 1 X ðE ij
E¯ i Þ ¼ 0. E¯ i ðE ij
E¯ i Þ ¼ E¯ i nm i¼1 j¼1 nm i¼1 j¼1

&. References Barrack RL, Skinner HB, Cook SD, Haddad Jr RJ. Effect of articular disease and total knee arthroplasty on knee joint-position sense. Journal of Neurophysiology 1983;50:684–7.

67

Barrett DS, Cobb AG, Bentley G. Joint proprioception in normal, osteoarthritic and replaced knees. Journal of Bone & Joint Surgery—British Volume 1991;73:53–6. Blouin J, Vercher JL, Gauthier GM, Paillard J, Bard C, Lamarre Y. Perception of passive whole-body rotations in the absence of neck and body proprioception. Journal of Neurophysiology 1995;74:2216–9. Brumagne S, Lysens R, Swinnen S, Verschueren S. Effect of paraspinal muscle vibration on position sense of the lumbosacral spine. Spine 1999;24:1328–31. Castro WH, Sautmann A, Schilgen M, Sautmann M. Noninvasive three-dimensional analysis of cervical spine motion in normal subjects in relation to age and sex. An experimental examination. Spine 2000;25:443–9. Christensen HW, Nilsson N. The ability to reproduce the neutral zero position of the head. Journal of Manipulative and Physiological Therapeutics 1999;22:26–8. Dvir Z, Prushansky T. Reproducibility and instrument validity of a new ultrasonography-based system for measuring cervical spine kinematics. Clinical Biomechanics 2000;15:658–64. Eliasziw M, Young SL, Woodbury MG, Fryday-Field K. Statistical methodology for the concurrent assessment of interrater and intrarater reliability: using goniometric measurements as an example. Physical Therapy 1994;74:777–88. Feipel V, Rondelet B, Le Pallec J, Rooze M. Normal global motion of the cervical spine: an electrogoniometric study. Clinical Biomechanics 1999;14:462–70. Fleiss JL. Reliability of measurement. In: The design and analysis of clinical experiments. New York: Wiley; 1986. p. 1–32 [Chapter 1]. Gandevia SC, McCloskey DI, Burke D. Kinaesthetic signals and muscle contraction. Trends in Neurosciences 1992;15:62–5. Ghez C, Krakauer J. The organization of movement. In: Kandel ER, Schwartz JH, Jessell TM, editors. Principles of neural science. 2000. p. 653–73. Goebel JA, Hanson JM, Fishel DG. Age-related modulation of the vestibulo-ocular reflex using real and imaginary targets. Journal of Vestibular Research 1994;4:269–75. Gill KP, Callaghan MJ. The measurement of lumbar proprioception in individuals with and without low back pain. Spine 1998;23: 371–7. Heikkila H, Astrom PG. Cervicocephalic kinesthetic sensibility in patients with whiplash injury. Scandinavian Journal of Rehabilitation Medicine 1996;28:133–8. Heikkila HV, Wenngren BI. Cervicocephalic kinesthetic sensibility, active range of cervical motion, and oculomotor function in patients with whiplash injury. Archives of Physical Medicine and Rehabilitation 1998;79:1089–94. Kristjansson E, Dall’Alba P, Jull G. Cervicocephalic kinaesthesia: reliability of a new test approach. Physiotherapy Research Internal 2001;6:224–35. Lam SS, Jull G, Treleaven J. Lumbar spine kinesthesia in patients with low back pain. Journal of Orthopaedic and Sports Physical Therapy 1999;29:294–9. Lephart SM, Pincivero DM, Giraldo JL, Fu FH. The role of proprioception in the management and rehabilitation of athletic injuries. American Journal of Sports Medicine 1997;25:130–7. Loudon JK, Ruhl M, Field E. Ability to reproduce head position after whiplash injury. Spine 1997;22:865–8. Mayoux-Benhamou MA, Revel M, Vallee C. Selective electromyography of dorsal neck muscles in humans. Experimental Brain Research 1997;113:353–60. Portney LG, Watkins MP. Statistical measures of reliability. In: Portney LG, Watkins MP, editors. Foundations of clinical research. Applications to practice. Norwalk, Conn: Appleton & Lange; 1993. p. 505–28.

ARTICLE IN PRESS 68

H.-Y. Lee et al. / Manual Therapy 11 (2006) 61–68

Rankin G, Stokes M. Reliability of assessment tools in rehabilitation: an illustration of appropriate statistical analyses. Clinical Rehabilitation 1998;12:187–99. Revel M, Andre-Deshays C, Minguet M. Cervicocephalic kinesthetic sensibility in patients with cervical pain. Archives of Physical Medicine and Rehabilitation 1991;72:288–91. Revel M, Minguet M, Gregoy P, Vaillant J, Manuel JL. Changes in cervicocephalic kinesthesia after a proprioceptive rehabilitation program in patients with neck pain: a randomized controlled study. Archives of Physical Medicine and Rehabilitation 1994;75:895–9. Rix GD, Bagust J. Cervicocephalic kinesthetic sensibility in patients with chronic, nontraumatic cervical spine pain. Archives of Physical Medicine and Rehabilitation 2001;82:911–9. Roebroeck ME, Harlaar J, Lankhorst GJ. The application of generalizability theory to reliability assessment: an illustration using isometric force measurements. Physical Therapy 1993;73:386–95. Schmidt RA, Lee TD. Methodology for studying motor performance. In: Schmidt RA, Lee TD, editors. Motor control and learning: a behavioral emphasis. New York: Human Kinetics; 1999. p. 15–40. Shumway-Cook A, Woollacott MH. Normal reach, grasp, and manipulation. In: Shumway-Cook A, Woollacott MH, editors.

Motor control: theory and practical applications. Philadelphia: Lippincott, Williams & Wilkins; 2001. p. 447–70. Swinkels A, Dolan P. Regional assessment of joint position sense in the spine. Spine 1998;23:590–7. Vasavada AN, Li S, Delp SL. Influence of muscle morphometry and moment arms on the moment-generating capacity of human neck muscles. Spine 1998;23:412–22. Vitti M, Fujiwara M, Basmanjian JM, Iida M. The integrated roles of longus colli and sternocleidomastoid muscles: an electromyographic study. Anatomical Record 1973;177:471–84. Wang S-F, Chai H-M, Lu T-W. Comparison of ranges of cervical motion measured by gravity-based goniometry and ultrasoundbased motion analysis system. Formosan Journal of Physical Therapy 2002;27:124–30. Wang S-F, Teng C-C, Chai H-M. Intra-rater reliability of measurement of cervical range of motion using ultrasound-based motion analysis system. Formosan Journal of Physical Therapy 2003;28:181–8. Wang S-F, Teng C-C, Lin K-H. Measurement of cervical range of motion pattern during cyclic neck movement by ultrasound-based motion system. Manual Therapy 2005;10:68–72. White AA, Panjabi MM. Clinical biomechanics of the spine. 2nd ed. Philadelphia: J.B. Lippincott; 1990.

ARTICLE IN PRESS

Manual Therapy 11 (2006) 69–77 www.elsevier.com/locate/math

Original article

Diagnostic value of five clinical tests in patellofemoral pain syndrome$ Jo Nijsa,b,, Catherine Van Geela, Cindy Van der auweraa, Bart Van de Veldea a

Division Musculoskeletal Physiotherapy, Department of Health Sciences, Hogeschool Antwerpen, Belgium Department of Human Physiology, Faculty of Physical Education and Physical Therapy, Vrije Universiteit Brussel (VUB), Brussel – Belgium

b

Abstract The current study is aimed at examining the validity of five clinical patellofemoral tests used in the diagnosis of patellofemoral pain syndrome (PFPS). Forty-five knee patients were divided into either the PFPS or the non-PFPS group, based on the fulfilment of the diagnostic criteria for PFPS. An investigator, blinded to the group assignment, performed the vastus medialis coordination test, patellar apprehension test, Waldron’s test, Clarke’s test, and the eccentric step test. The positive likelihood ratio was 2.26 for both the vastus medialis coordination test and the patellar apprehension test. For the eccentric step test, the positive likelihood ratio was 2.34. A positive outcome on either the vastus medialis coordination test, the patellar apprehension test, or the eccentric step test increases the probability of PFPS to a small, but sometimes important, degree. For the remaining tests, the positive likelihood ratios were below the threshold value of 2, indicating that given a positive test result, the probability that the patient has PFPS is altered to a small, and rarely important degree. The negative likelihood ratios for all tests exceeded the threshold value of 0.5, suggestive of clinically irrelevant information. These data question the validity of clinical tests for the diagnosis of PFPS. r 2005 Elsevier Ltd. All rights reserved. Keywords: Diagnosis; Patellofemoral; Patellofemoral pain syndrome; Validity

1. Introduction In the absence of other pathology, anterior or retropatellar pain which exacerbates during sustained sitting, kneeling, ascending or descending stairs, and squatting is defined as patellofemoral pain syndrome (PFPS). The aetiology of PFPS has not been delineated, but appears to be multifactorial. Abnormal tracking of the patella, possibly inducing pain and abnormal tissue stresses, has frequently been proposed as a contributing factor to PFPS (Baker et al., 2002). A delayed onset of $ The first three authors contributed equally to the present manuscript. Corresponding author. Tel.: +32 2 477 4604; fax: +32 2 477 4607. Department of Human Physiology, Faculty of Physical Education and Physical Therapy, Vrije Universiteit Brussel (VUB), MFYS/Sportgeneeskunde, VUB KRO gebouw –1, Laarbeeklaan 101, 1090 Brussel – Belgium E-mail address: [email protected] (J. Nijs).

1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.04.002

the vastus medialis obliquus in relation to the vastus lateralis, as observed in PFPS subjects (Cowan et al., 2001, 2002, Tang et al., 2001), might account for the abnormal patellar tracking. Apart from a neuromuscular imbalance of the vastii, other theories for the origin of PFPS have been proposed (and are able to explain maltracking of the patella): tightness of the lateral knee retinaculum, hamstrings, iliotibial band, and gastrocnemius; overpronation of the subtalar joint (Tang et al., 2001), reduced proprioceptive information (Baker et al., 2002), and the depth of the trochlear groove (Powers, 2000). Regarding the conservative treatment strategies, Bizzini et al. (2003) concluded from their systematic literature review that quadriceps strengthening, acupuncture, the use of a resistive brace, and the combination of exercises with patellar taping and biofeedback are effective in decreasing pain and improve functioning in PFPS patients. In their review article, Thome´e et al. (1999) suggested that standardized information and

ARTICLE IN PRESS 70

J. Nijs et al. / Manual Therapy 11 (2006) 69–77

adjusted physical activity (i.e. avoiding pain-causing activities etc.) will suffice for many PFPS patients having mild symptoms, while chronic PFPS subjects (knee pain duration of at least six months) require a specific training programme. However, at least three systematic reviews addressing the effectiveness of physical interventions in PFPS indicate that the evidence is limited and that high quality randomized controlled clinical trials are required (Zomerdijk et al., 1998; Crossley et al., 2001; Bizzini et al., 2003). Physical examination is essential in the diagnosis of any medical condition, especially in musculoskeletal disorders (Malanga et al., 2003). However, in order to draw appropriate conclusions from the findings of the physical examination, it is important that clinicians are aware of the significance of the test results (i.e. the diagnostic value of each test). A positive vastus medialis coordination test has been suggested as an indicator of dysfunction of the vastus medialis obliquus muscle which may result in pain (Souza, 1997), pain or crepitus during Waldron’s test has been proposed as a sign of patellofemoral pain disorders (Martens et al., 1995; Souza, 1997). Likewise, both the patellofemoral grinding test and the eccentric step test have been suggested to be indicative of PFPS (Souza, 1997; Selfe et al., 2001a; Malanga et al., 2003). However, the scientific examinations of several clinical tests of patellar position and mobility have yet to prove them reliable (Watson et al., 2001), and Malanga et al., (2003) concluded from their literature review that studies documenting the sensitivity or specificity of the patellofemoral grinding test in the diagnosis of PFPS are essentially lacking. Apart from one study reporting that the eccentric step test produced knee pain in 57 of 77 PFPS patients (74%) (Selfe et al., 2001a), we are unaware of data addressing the scientific value of clinical tests in the diagnosis of PFPS. A study examining the validity of the vastus medialis coordination test, patellar apprehension test, Waldron’s test, and Clarke’s test in the diagnosis of PFPS in knee pain patients was therefore warranted. A number of self-assessment questionnaires, which are aimed at assessing functionality in PFPS patients, have been reported in the scientific literature, but their psychometric properties have not been addressed adequately (Bennell et al., 2002). Still, Selfe et al. (2001a) constructed the Modified Functional Index Questionnaire (MFIQ), and examined its reliability and clinical sensitivity in PFPS patients (Selfe et al., 2001b). An English questionnaire, however, cannot be applied to subjects having Dutch as their native language (i.e. to PFPS patients in the Flemish part of Belgium or in the Netherlands). We therefore translated the original MFIQ into Dutch, and examined some of the psychometric properties of the Dutch version of the MFIQ.

2. Purpose The primary aim of the current study was to examine the validity of five clinical patellofemoral tests (the vastus medialis coordination test, patellar apprehension test, Waldron’s test, Clarke’s test, and the eccentric step test) used in the diagnosis of PFPS in knee pain patients. Secondly, this study aimed at translating an existing English self-assessment questionnaire for assessing functionality in PFPS-patients into Dutch, and examining some of the psychometric properties (the diseasespecificity, the internal consistency, and the convergent validity) of the scores obtained with this new assessment-tool in PFPS-patients.

3. Methods 3.1. Subjects and study design A sample of convenience of 45 knee patients was recruited from private practices and outpatient clinics (multicentre trial). Prior to study participation, all patients were given both oral and written information regarding the nature and purpose of the study. All subjects had to give written informed consent in order to be included in the study. The rights of the subjects were protected, implicating that the patient was allowed to withdraw at any time if the pain became unbearable. Subjects were included for the trial if they experienced knee pain, if they were referred by a physician for physical therapy (Ng and Cheng, 2002), if they were independent ambulators in the community (Watson et al., 2001), and if they had not undergone knee surgery (Cowan et al. 2001; Ng and Cheng, 2002; Laprade and Culham, 2002; Brechter and Powers, 2002). Including patients with scars from knee surgery would prohibit a blinded assessment. Next, all included patients were divided into either the PFPS or the non-PFPS group, based on the fulfilment of the diagnostic criteria for PFPS. The criteria used for the diagnosis of PFPS were based on those used in other PFPS studies: patients (1) were diagnosed as a PFPS case by a medical doctor (Bennell et al., 2002; Ng and Cheng, 2002), (2) had anterior or retropatellar knee pain (Bennell et al., 2002; Brechter and Powers, 2002; Cowan et al., 2001; Watson et al., 2001); (3) reported that at least two of the following activities exacerbated their symptoms: prolonged sitting, ascending or descending stairs, squatting, kneeling (Lepa¨lla¨ et al., 1998; Bennell et al., 2002; Cowan et al., 2001; Tang et al., 2001; Watson et al., 2001; Brechter and Powers, 2002; Cowan et al., 2002; Thome´e et al., 2002); and (4) were not allowed to show clinical evidence of a current knee condition other than PFPS (Lepa¨lla¨ et al., 1998; Bennell et al., 2002; Cowan et al., 2001; Watson et al., 2001; Cowan et al., 2002;

ARTICLE IN PRESS J. Nijs et al. / Manual Therapy 11 (2006) 69–77

Laprade and Culham, 2002; Thome´e et al., 2002). Subjects not fulfilling all four requirements listed above were assigned to the control group (non-PFPS knee patients), on the premise that they did not fulfil the first three requirements either. Patients fulfilling the first three criteria, and having evidence of a current knee condition other than PFPS were considered ‘co-morbid PFPS-patients’. Since the primary aim of this study was to examine the diagnostic value of patellofemoral tests, co-morbid PFPS patients were excluded from the trial. In occurrence, Malanga et al. (2003) indicated that the pathologic changes in one structure may alter the examination outcome of a different structure. Therefore, prior to data collection, all subjects entering the study underwent a structured and standardized clinical examination, in order to rule out any condition other than PFPS (bursitis, tendonitis, damage to the articular cartilage, tears of the menisci, ligaments or joint capsule, patellar subluxation or dislocation, etc.). The clinical examination comprised of history taking, review of the medical records, inspection, and a set of standard orthopaedic tests (patellar ballottement test, assessment of both active and passive joint range of motion, palpation of the knee joint—including the detection of abnormal temperature, varus/valgus stress tests, Lachman’s test, anterior and posterior drawer test, pivot shift test, McMurray’s test for both the medial and the lateral meniscus, Apley’s test, and muscle testing of the knee) (Winkel and Aufdenkampe, 1994; Reider, 1999). The patellar ballottement test was performed with the patient lying supine and the knee extended. In this position, the examiner pushed the patella posteriorly with two fingers using a quick motion. In the case of a large effusion, the patella descends to the patella and is felt to strike it with a distinct impact (Reider, 1999). Reviewing the medical records of the study participants, it was noted that specialized diagnostic imaging techniques were used in 34 of 45 patients. One imaging technique (magnetic resonance imaging, computer tomography, radiographs, radioisotope scan or ultrasound scanning) was used in 18 cases, while up to 5 different imaging techniques were used in the remaining 16 subjects. All subjects were screened according to the in- and exclusion criteria by the same investigator, in order to determine study eligibility and group assignment (PFPS group or control group). Next, the patients were asked to fill in a set of self-reported measures: three visual analogue scales (VAS for pain at rest, pain during movement, and pain at night), and the Dutch version of the Modified Functional Index Questionnaire (MFIQDV). A detailed description of the MFIQ-DV is given in the ‘Self-assessment tools’-section. Afterwards, a second investigator, blinded to the group assignment, performed a battery of patellofemoral tests in the following order: the vastus medialis coordination test, patellar

71

apprehension test, Waldron’s test (phase 1 and 2), Clarke’s test, and the eccentric step test. 3.2. Self-assessment tools Visual analogue scales (VAS—100 mm) for pain at rest, pain during movement, and pain at night, were used. The pain scores obtained with the VAS are believed to be reliable (Jensen et al., 1986; HarmsRingdahl et al., 1986) and sensitive to change (Jensen et al., 1986). Using a time interval of 2 days in a sample of 24 PFPS patients, the test-retest reliability coefficients (intraclass correlation coefficients) ranged between 0.77 and 0.79 (Bennell et al., 2002). Selfe et al. (2001a) constructed the MFIQ. The Cronbach Alpha coefficient for internal consistency was 0.83 in a sample of 77 patients with PFPS (Selfe et al. 2001a). Assessing the test-retest reliability of the MFIQ total scores it was found that the 95% confidence interval (CI) was 7 11.2 (SD75.47) (Selfe et al., 2001b). A change of 10 points in the overall score on the MFIQ was considered clinically sensitive (Selfe et al., 2001b). In order to make the MFIQ an appropriate questionnaire for the assessment of functionality in Dutch-language PFPS patients, the first and the third author independently translated the English version of the MFIQ into Dutch. Afterwards, both translations were compared and combined into one version (the Modified Functional Index Questionnaire-Dutch Version or MFIQDV1). The MFIQ-DV contains ten closed-ended questions, using both three-point (the first two questions) and four-point (questions three–ten) Likert scales. For counting the total scores obtained with the MFIQ-DV, the scoring system as described by Selfe et al. (2001a) was used. This scoring system indicates that higher scores are suggestive of more severe problems. In order to exclude investigator bias, all study subjects were asked to complete the questionnaire independently. Patients with bilateral symptoms were asked to complete the questionnaires for their most symptomatic leg only. 3.3. Clinical tests 3.3.1. Vastus medialis coordination test The vastus medialis coordination test was performed and interpreted as described by Souza (1997). The patient lay supine, and the examiner placed his/her fist under the subject’s knee and asked the patient to extend the knee slowly without pressing down or lifting away from the examiner’s fist (Fig. 1). The patients were instructed to achieve full extension. The test was considered positive when a lack of coordinated full extension was evident, i.e. when the patient either had difficulty smoothly accomplishing extension or recruited 1

The MFIQ-DV can be obtained from the corresponding author.

ARTICLE IN PRESS 72

J. Nijs et al. / Manual Therapy 11 (2006) 69–77

either the extensors or flexors of the hip to accomplish extension. Souza (1997) suggested that a positive test may be an indicator of dysfunction of the vastus medialis obliquus muscle which may result in patellar pain. 3.3.2. Patellar apprehension test The patellar apprehension test, also referred to as the Fairbanks apprehension test, was performed with the patient lying supine and relaxed (Reider, 1999). The examiner used one hand to push the patient’s patella as lateral as possible, in order to obtain a lateral patellar glide (Fig. 2). Starting with the knee flexed at 301, the examiner grasped the leg at the ankle/heel with the other hand and performed a slow, combined flexion in the knee and hip (Reider, 1999; Malanga, et al., 2003). This lateral glide was sustained throughout the test. The test was considered positive when it reproduced the patient’s pain or when apprehension was present. The apprehension can manifest itself in a number of ways, ranging

Fig. 1. Vastus medialis coordination test.

Fig. 2. Patellar apprehension test.

from verbal expressions of anxiety over grabbing the knee to involuntary quadriceps muscle contractions (to prevent further knee flexion) (Reider, 1999; Souza, 1997; Malanga, et al., 2003). 3.3.3. Waldron’s test (phase I and II) For phase I of Waldron’s test, with the patient lying supine and the examiner pressed the patella against the femur while simultaneously performing a passive knee flexion with the other hand (Reider, 1999). Crepitus and pain during a particular part of the range of motion are considered signs of patellofemoral pain disorders (Souza, 1997; Martens et al., 1995). For phase II, the standing patient was asked to perform a slow, full squat, again with the examiner performing a gentle compression of the patella against the femur. As was the case in Waldron’s test phase I, pain and crepitus were of interest for interpreting the test. 3.3.4. Clarke’s test (or patellofemoral grinding test) Clarke’s test was performed with the patient lying supine with both knees supported by a knee pad, in order to create a sufficient amount of knee flexion and consequent articulation of the patella in the patellofemoral joint. Performing the test in full extension might even cause false-positive findings, due to pinching of the suprapatellar pouch (Souza, 1997). While the patient was relaxed, the examiner pressed the patella distally (with the hand on the superior border of the patella) and then asked the patient to contract the quadriceps muscle (Souza, 1997; Malanga et al., 2003). If the patient’s pain was reproduced during test performance, then the test was considered positive. A positive Clarke’s test has been suggested to be indicative for patellofemoral disorders (Souza, 1997; Malanga et al., 2003). 3.3.5. Eccentric step test For the eccentric step test, the patients wore shorts and performed the testing in bare feet (Fig. 3). The step was made of a stool 15 cm high. Selfe et al. (2001a), in an attempt to standardize the height of the step against the anthropometric differences between study participants, adjusted the step height to 50% of the length of the tibia. Selfe et al., (2001a) found that the eccentric step test produced knee pain in 57 of 77 PFPS patients (74%). The step was manufactured by wood, and a layer of non-slip rubber was placed on top of the wood to prevent slipping of the subjects while performing the test. Selfe et al. (2001ab) used video equipment to quantify the eccentric step test. Due to the time consuming and expensive nature of this procedure, the video equipment was deemed inappropriate for clinical purposes and consequently not used in the present investigation. Apart from the step height and the video analysis, the eccentric step test was performed as described by Selfe et al. (2001a). Briefly, each study

ARTICLE IN PRESS J. Nijs et al. / Manual Therapy 11 (2006) 69–77

73

The disease specificity of the MFIQ-DV scores was assessed by examining the differences in both the total and the item scores between the PFPS and the nonPFPS groups (Mann–Whitney U test). Cronbach’s alpha reliability coefficients were calculated as a measure for estimating the internal consistency of the item scores of the MFIQ-DV. Spearman Rank correlation coefficients were calculated for the convergent validity analysis (the total scores obtained with the MFIQ-DV versus the visual analogue scales). The level of significance was set at 0.05. To examine the diagnostic value of the patellofemoral tests, the positive and negative likelihood ratios were calculated and interpreted as described by Fritz and Wainner (2001). Likelihood ratios are considered the best statistics for summarizing the usefulness of a diagnostic test; sensitivity and specificity work in the opposite direction of clinical decision making, while predictive values are highly dependent on the prevalence of the condition of interest in the sample (Fritz and Wainner, 2001). Since likelihood ratios are ratios of probabilities, they can be treated as risk ratios for the purposes of calculating CI (Deeks and Altman, 2004). The 95% CI for the likelihood ratios were calculated as described by Kirkwood and Sterne (2003, p. 155–156). Fig. 3. Eccentric step test.

4. Results participant was given a standard demonstration of the test followed by standardized verbal instructions: ‘stand on the step, put your hands on your hips, and step down from the step as slowly and as smoothly as you can’. Patients were asked to keep their hands on their hips throughout the test performance. After each patient performed the test with one leg, the procedure was repeated using the other leg. A warm-up or practice attempt was not allowed. The eccentric step test was considered positive when the patients reported knee pain during the test performance. 3.4. Statistics All data were analysed using SPSS 11.0 r for Windows (SPSS Inc. Headquarters, 233 s. Wacker Drive, 11th floor, Chicago, Illinois 60606, USA). The following descriptive statistics were obtained: mean and standard deviation (SD) for age and knee pain duration, frequencies and percentages for gender distribution and the number of left knees affected, and median and interquartile range for the total scores obtained with the MFIQ-DV. To examine the differences between the PFPS and the non-PFPS group, both the Fisher exact test (for gender distribution) and the Mann–Whitney U test (knee pain duration, age, and the visual analogue scales) were used.

Of the 45 knee patients enrolled, one had undergone knee surgery and was therefore excluded. Five additional patients (seven knees) were classified as co-morbid PFPS patients and were consequently excluded. Of the remaining 39 study participants (59 symptomatic knees), 20 patients were classified in the PFPS group (31 knees), and the remaining 19 in the control group (non-PFPS sample—28 knees). The control group comprised of four patients with a grade II injury of the medial collateral ligament (one of which had a comorbid shin splints or periostitis), one patient with a iliotibial band friction syndrome, one with osteoarthritis of the knee, two with an injury of the anterior cruciate ligament, three with a meniscus tear (two of the medial meniscus and one of the lateral meniscus), one with a stress fracture, one with severe knee instability, one with severe overloading of the muscles of the lower extremities, two with tendonitis of the Quadriceps tendon, one with a contusion of the knee, one with an injury of the M. Popliteus, and one with both an injured joint capsule and several injured knee ligaments. The demographic features of both the PFPS and the non-PFPS group are presented in Table 1. No statistically significant differences in age (Mann–Whitney U ¼ 185; 5; p ¼ 0:899), knee pain duration (U ¼ 121; p ¼ 0:052), or gender distribution (p ¼ 0:320) were found between the two groups.

ARTICLE IN PRESS J. Nijs et al. / Manual Therapy 11 (2006) 69–77

74

Regarding the self-reported measures, both the descriptive statistics and the comparisons between the PFPS and the non-PFPS group are presented in Table 2. No statistically significant differences in pain intensity at night (VAS night: Mann–Whitney U ¼ 175; p ¼ 0:595), at rest (VAS rest: U ¼ 154; p ¼ 0:271), or during movement (VAS movement: U ¼ 178:5; p ¼ 0:746) were found between the PFPS and the non-PFPS group. Regarding the disease specificity for the scores obtained with the MFIQ-DV, neither the total scores (Mann–Whitney U ¼ 159; p ¼ 0:382), nor any of the individual item scores (data not shown) showed a statistically significant difference between the two groups. The Cronbach Alpha coefficient was 0.71 for the PFPS patients and 0.80 for the non-PFPS subjects. Furthermore, the convergent validity analysis revealed statistically significant associations between the total scores obtained with the MFIQ-DV and the visual analogue scales for pain during movement in both the PFPS patients (rho ¼ 0:41; p ¼ 0:020) and the non-PFPS subjects (rho ¼ 0:50; p ¼ 0:007). In the latter group, there was a statistically significant correlation between the pain intensity at rest and the MFIQ-DV overall scores (rho ¼ 0:422; p ¼ 0:025). All Spearman Rank correlation coefficients and corresponding p-values are displayed in Table 3. The outcome of the clinical tests for both groups is presented in Table 4. The positive likelihood ratio was 2.26 for both the vastus medialis coordination test and the patellar apprehension test. For the eccentric step test, the positive likelihood ratio was 2.34. For the remaining tests, the positive likelihood ratios were below

Table 1 Demographic features of both the PFPS (n ¼ 20) and the non-PFPS group (n ¼ 19)

PFPS Non-PFPS a

age (years 7SDa)

number of females (%)

knee pain duration (months7 SD)

number of left knees affected (%)

31.0715.2 26.578.5

9 (45.0) 5 (26.3)

45.1755.2 35.1758.9

17 (54.8) 14 (50.0)

standard deviation.

the threshold value of 2 (Table 5). For all five tests, the negative likelihood ratios were above the threshold value of 0.5.

5. Discussion This study provided new insight into the scientific value of five clinical tests for the diagnosis of PFPS in knee pain patients. It was shown that the positive likelihood ratio was 2.26 for both the vastus medialis coordination test and the patellar apprehension test, and 2.34 for the eccentric step test. A likelihood ratio of 1 indicates that the test result does nothing to change the odds favouring the condition of interest. A positive likelihood ratio indicates a shift in odds favouring the condition of interest (i.e. PFPS) when the test is positive. A larger positive likelihood ratio is therefore desirable. A positive likelihood ratio within the range of 2–5, as is the case for the vastus medialis coordination test, the patellar apprehension test, and the eccentric step test, is considered to generate small, but sometimes important, shifts in probability (Jaeschke et al., 1994). Thus, a positive outcome on either the vastus medialis coordination test, the patellar apprehension test, or the eccentric step test in a knee pain patient increases the probability of PFPS to a small, but sometimes important degree. Still, the intraobserver and the interobserver reliability of these tests remain to be established. Given the subjective interpretation of the vastus medialis coordination test, the examination of the intraobserver and interobserver reliability of this test is highly recommended. For the remaining tests, the positive likelihood ratios were below the threshold value of 2, indicating that given a positive test result, the probability that the knee pain patient has PFPS is altered to a small, and rarely important degree. Negative likelihood ratios indicate a change in odds favouring the condition given a negative test result. Consequently, a small negative likelihood ratio will identify the test that is useful for ruling out PFPS when negative (Fritz and Wainner, 2001). The negative likelihood ratios for all tests exceeded the threshold value of 0.5 (Jaeschke et al. 1994), suggestive of clinically irrelevant information. Indeed, negative likelihood ratios within the range of

Table 2 Descriptive statistics of the self-reported measures taken from 20 PFPS and 19 non-PFPS patients

PFPS Non-PFPS a

VASa rest Mean7SDb; [range]

VASa movement Mean7SD; [range]

VASa night Mean7SD; [range]

MFIQ-DV Median; IQRc [range]

20.5728.2 [0.0;83.0] 18.4727.9 [0.0;87.0]

51.2723.9 [8.0;98.0] 51.2732.5 [0.0;100.0]

8.6720.5 [0.0;77.0] 12.6724.5 [0.0;94.0]

32.5; 23.8 [15;65] 35.0; 11.3 [5;55]

visual analogue scale for pain at rest, during movement, and at night, standard deviation, c interquartile range. b

ARTICLE IN PRESS J. Nijs et al. / Manual Therapy 11 (2006) 69–77

0.5–1 alter the probability to a small, and rarely important degree (Jaeschke et al., 1994). Selfe et al. (2001a) reported that the eccentric step test produced knee pain in 57 of 77 PFPS patients (74%). In the present study, we were unable to confirm these results: the eccentric step test provoked pain in 13 of 31 PFPS knees (41%). The eccentric step test was performed in the same way as described by Selfe et al. (2001a), subject to a different step height (15 cm in our study versus an adjusted step height to 50% of the length of the tibia in the Selfe et al. trial). The mean step height used in the Selfe et al. (2001a) was not reported. In another study by Selfe (2000) using identical

Table 3 Convergent validity of the MFIQ-DV in PFPS (n ¼ 20) and non-PFPS (n ¼ 19) patients: correlation analyses between the MFIQ-DV total scores and visual analogue scales PFPS Patient

non-PFPS Patient

MFIQ-DV rhob (p-value) MFIQ-DV rho (p-value)
0.21 (0.208) VASa rest VASa movement 0.42 (0.020)
0.08 (0.671) VASa night

0.42 (0.025) 0.50 (0.007) 0.36 (0.060)

a visual analogue scale for pain at rest, during movement, and at night, b Spearman Rank correlation coefficient.

Table 4 Outcome on the clinical tests in the PFPS (n ¼ 20; 31 symptomatic knees) and non-PFPS patients (n ¼ 19; 28 knees) Test

PFPS

Non-PFPS

Vastus medialis coordination test positive Patellar apprehension test positive Waldron’s test phase I positive Waldron’s test phase II positive Clarke’s test positive Eccentric step test positive

5 10 14 7 15 13

4 9 6 7 5

(16.1%) (32.3%) (45.2%) (22.6%) (48.4%) (41.9%)

2 (7.1%) (14.3%) (32.1%) (21.4%) (25.0%) (17.9%)

75

methodology to adjust the height of the step, a modal step height of 22 cm (range 20–26) was reported. Despite the fact that the latter study addressed healthy subjects, it can be assumed that the step height used in the Selfe et al. (2001a) study on PFPS subjects was higher compared to our fixed step height. This might explain the discrepancy between the present data and those reported by Selfe et al. (2001a), and suggests a relationship between step height and painful responses. The patellar apprehension test is performed primarily to test the knee for patellar dislocation (Malanga et al. 2003; Reider, 1999; Souza, 1997) and not for diagnosing PFPS. It should be noted, therefore, that the high amount of patients presenting with a positive patellar apprehension test, as seen in our sample, was not due to the classical apprehension sign but due to pain provocation during test performance. One study reported a sensitivity of 39% of the patellar apprehension test for the diagnosis of patellar dislocation (Sallay et al., 1996). From their literature review, Malange et al. (2003) concluded that no studies document the validity of Clarke’s test for the diagnosis of PFPS. In addition, we are unaware of data documenting the validity of the vastus medialis coordination test, Waldron’s test, and the patellar apprehension test for the diagnosis of PFPS in knee pain patients. Consequently, we claim these data to be the first documenting the validity of these clinical tests for the diagnosis of PFPS in knee pain patients. This study provided preliminary evidence supporting the internal consistency and validity of the Dutch version of the MFIQ, a self-assessment tool for evaluating functionality in PFPS patients. The Cronbach Alpha coefficient was 0.71 for the PFPS patients and 0.80 for the non-PFPS subjects. For interpreting Cronbach’s Alpha coefficient, 0.80 is considered the threshold value for sufficient internal consistency of the different items included in the questionnaire (Dijkers et al. 2002). Since shorter questionnaires are known to be less reliable (Selfe et al. 2001b), we claim that even the value of 0.71 supports the internal consistency of the Dutch MFIQ. The convergent validity analysis revealed statistically significant associations between the total

Table 5 Validity of five clinical tests for the diagnosis of PFPS in knee patients. Test

+LRa

95%CIb


LRc

95%CI

Vastus medialis coordination test Patellar apprehension test Waldron’s test phase I Waldron’s test phase II Clarke’s test Eccentric step test

2.26 2.26 1.41 1.05 1.94 2.34

1.88 2.09 0.62 0.98 1.05 1.88

0.90 0.79 0.81 0.99 0.69 0.71

0.57 0.83 0.36 0.92 0.37 0.57

a

Postive likelihood ratio, 95% CI, c Negative likelihood ratio. b

to to to to to to

2.92 2.45 3.20 1.13 3.59 2.92

to to to to to to

0.88 0.98 1.84 1.06 1.28 0.88

ARTICLE IN PRESS 76

J. Nijs et al. / Manual Therapy 11 (2006) 69–77

scores obtained with the MFIQ-DV and the visual analogue scales for pain during movement in both the PFPS patients and the non-PFPS subjects. These results support the convergent validity of the total scores obtained with the MFIQ-DV in both PFPS and nonPFPS knee patients. Neither the total scores obtained with the MFIQ-DV, nor any of the individual item scores indicated a statistically significant difference between the PFPS and the non-PFPS knee pain patients. Thus, the disease specificity of the MFIQ-DV for PFPS patients is questionable. It is concluded that these data support the internal consistency and the convergent validity of the scores obtained with the MFIQ-DV in both PFPS and non-PFPS patients. Before the use of the MFIQ-DV in clinical practice and research settings can be advised, however, the test-retest reliability, content validity, responsiveness, and other forms of validity should be examined. These results should be interpreted with some caution. First, some of the tests of interest in the present investigation are manual tests during which the tester applies a force to the patella. It is difficult to quantify and to standardize the amount of force used, this issue requires further investigation. Second, this sample was not randomly selected. Still, most reports on PFPS studied a sample of convenience (e.g. Bennell et al., 2002, Watson et al., 2001; Brechter and Powers, 2002; Thome´e et al., 2002). A high number of rehabilitation centres and private practices for physiotherapy were contacted for the subjects’ recruitment. Since PFPS patients were the topic of interest in the present study, physiotherapists might have primarily referred patients with suspected PFPS for study participation. This might have introduced selection bias into the trial, as evidenced by the high number of PFPS patients in this sample of knee pain patients (20 of 39% or 51%), which is distinctive from previously reported epidemiological data suggesting that between 25% and 40% of knee patients have PFPS (Brody and Thein, 1998; Powers, 1998; Wilk et al., 1998). Still, since likelihood ratios are independent of the prevalence of the condition of interest in the sample (Fritz and Wainner, 2001), this is unlikely to have biased these results. Third, the testers were senior physical therapy students. At the time the study took place, they were holders of a bachelor degree in physical therapy and completed their final year of the master program in physical therapy. These students received a significant amount of training prior to the study. Still, their skills may not be reflective of most experienced physical therapists and medical doctors who currently use these tests. On the other hand, from a study examining the intertester reliability of clinical tests of the sacroiliac joint it was concluded that the years of experience did not affect the reliability (Potter and Rothstein, 1985). Fourth, physical examination tests are generally not performed in isolation, but together with

the interview, inspection and several other tests. Consequently, the data presented here are somewhat artificial. Finally, the order of the tests performed should have been randomized. There may have been cumulative increases in pain. To test for this cumulative effect it would have been of interest to obtain a VAS from each subject after each test was performed. Even with the order of the tests randomized, this would enable to identify bias related to cumulative increases in pain.

6. Conclusion These data question the validity of Waldron’s test phase I, Waldron’s test phase II, and Clarke’s test in the diagnosis of PFPS. In patients presenting with knee pain, a positive outcome on either the vastus medialis coordination test, the patellar apprehension test, or the eccentric step test increases the probability of PFPS to a small, but sometimes important degree. Furthermore, the present report provided evidence supporting the internal consistency, and the convergent validity of the scores obtained with the MFIQ-DV in both PFPS and non-PFPS knee pain patients. The disease specificity of the MFIQ-DV for PFPS patients is questionable.

Acknowledgements The authors would like to thank all the study participants, and all the physicians and physiotherapists who assisted with subject recruitment. Special thanks to Katrien Vanherberghen, who holds a master degree in physical therapy and has English as her native language, for editing the final version of the manuscript. The authors are grateful to Rene´ Nijs (PhD, statistician) for his advice on the statistical analysis. References Baker V, Bennell K, Stillman B, Cowan S, Crossley K. Abnormal knee joint position sense in individuals with patellofemoral pain syndrome. Journal of Orthopaedic Research 2002;20:208–14. Bennell K, Bartam S, Crossley K, Green S. Outcome measures in patellofemoral pain syndrome: test retest reliability and interrelationships. Physical Therapy in Sport 2002;1:32–41. Bizzini M, Childs CJD, Piva SR, Delitto A. Systematic review of the quality of randomised controlled trials for patellofemoral pain syndrome. Journal of Orthopaedic and Sports Physical Therapy 2003;33:4–20. Brechter JH, Powers CM. Patellofemoral joint stress during stair ascent and descent in persons with and without patellofemoral pain. Gait and Posture 2002;16:115–23. Brody LT, Thein JM. Nonoperative treatment for patellofemoral pain. Journal of Orthopaedic Sports Physical Therapy 1998;28:336–44. Cowan SM, Bennell KL, Hodges PW, Crossley KM, McConnell J. Delayed onset of electromyographic activity of vastus medialis

ARTICLE IN PRESS J. Nijs et al. / Manual Therapy 11 (2006) 69–77 obliquus relative to vastus lateralis in subjects with patellofemoral pain syndrome. Archives of Physical Medicine and Rehabilitation 2001;82:183–9. Cowan SM, Hodges PW, Bennell KL, Crossley KM. Altered vastii recruitment when people with patellofemoral pain syndrome complete a postural task. Archives of Physical Medicine and Rehabilitation 2002;83:989–95. Crossley K, Bennell K, Green S, McConnell J. A systematic review of physical interventions for patellofemoral pain syndrome. Clinical Journal of Sports Medicine 2001;11:103–10. Deeks JJ, Altman DG. Diagnostic tests 4: likelihood ratios. British Medical Journal 2004;329:168–9. Dijkers MPJM, Kropp GC, Esper RM, Yavuzer G, Cullen N, Bakdalieh Y. Reporting on reliability and validity of outcome measures in medical rehabilitation research. Disability and Rehabilitation 2002;24:819–27. Fritz JM, Wainner RS. Examining diagnostic tests: an evidence-based perspective. Physical Therapy 2001;81:1546–64. Harms-Ringdahl K, Carlsson AM. Ekholm JRaustorp A, Svensson T, Toresson HG. Pain assessment with different intensity scales in response to loading joint structures. Pain 1986;27:401–12. Jaeschke R, Guyatt GH, Sackett DL. Users’ guides to the medical literature, III: how to use an article about a diagnostic test, B: What are the results and will they help me in caring for my patients? Journal of the American Medical Association 1994;271:703–7. Jensen MD, Koroly P, Braver S. The measurement of clinical pain intensity: a comparison of six methods. Pain 1986;27:117–26. Kirkwood BR, Sterne JAC. Comparing two proportions. In: Kirkwood BR, Sterne JAC, editors. Essential medical statistics. Oxford: Blackwell Science; 2003. p. 148–64. Lepa¨lla¨ J, Kannus P, Natri A, Sieva¨nen H, Ja¨rvinen M, Vuori I. Bone mineral density in the chronic patellofemoral pain syndrome. Calcified Tissue International 1998;62:548–53. Malanga GA, Andrus S, Nadler SF, McLean J. Physical examination of the knee: a review of the original test description and scientific validity of common orthopedic tests. Archives of Physical Medicine and Rehabilitation 2003;84:592–603. Martens M, Winkel D, Wyffels P. Orthopedische geneeskunde, onderzoek, diagnostiek en behandeling van de extremiteiten. Houten/Diegem: Bohn Stafleu Van Loghum; 1995. p. 343. Ng GYF, Cheng JMF. The effects of patellar taping on pain and neuromuscular performance in subjects with patellofemoral pain syndrome. Clinical Rehabilitation 2002;16:821–7. Potter NA, Rothstein JM. Intertester reliability for selected clinical tests of the sacroiliac joint. Physical Therapy 1985;65: 1671–5.

77

Powers CM. Patellar kinematics, part II: The influence of the depth of the trochlear groove in subjects with and without patellofemoral pain. Physical Therapy 2000;80:965–73. Powers CM Rehabilitation of patellofemoral joint disorders: a critical review. Journal of Orthopaedic Sports Physical Therapy 1998;28:345–54. Reider B. The knee. In: Reider B, editor. The orthopaedic physical examination. Philadelphia: WB Saunders Company; 1999. p. 201–48. Sallay PI, Poggi J, Speer KP, Garrett WE. Acute dislocation of the patella. A correlative pathoanatomic study. American Journal of Sports Medicine 1996;24:52–60. Selfe J. Peak 5 motion analysis of an eccentric step test performed by 100 normal subjects. Physiotherapy 2000;86:241–7. Selfe J, Harper L, Pedersen I, Breen-Turner, Waring J. Four outcome measures for patellofemoral joint problems. Part 1. Development and validity. Physiotherapy 2001a;87:507–15. Selfe J, Harper L, Pedersen I, Breen-Turner, Waring J. Four outcome measures for patellofemoral joint problems. Part 2. Reliability and clinical sensitivity. Physiotherapy 2001;87:516–22. Souza TA. The knee. In: Hyde TE, Gengenbach MS, editors. Conservative management of sport injuries. Maryland: Williams & Wilkins; 1997. p. 394–5. Tang SFT, Chen C-K, Hsu R, Chou S-W, Hong W-H, Lew HL. Vastus medialis obliquus and vastus lateralis activity in open and closed kinetic chain exercises in patients with patellofemoral pain syndrome: an electromyographic study. Archives of Physical Medicine and Rehabilitation 2001;82:1441–5. Thome´e R, Augustsson J, Karlsson J. Patellofemoral pain syndrome – a review of current issues. Sports Medicine 1999;28:245–62. Thome´e P, Thome´e R, Karlsson J. Patellofemoral pain syndrome : pain, coping strategies and degree of well-being. Scandinavian Journal of Medicine and Science in Sports 2002;12:276–81. Watson CJ, Leddy HM, Dynjan TD, Parham JL. Reliability of the lateral pull test and tilt test to assess patellar alignment in subjects with symptomatic knees: student raters. Journal of Orthopaedic and Sports Physical Therapy 2001;31:368–74. Wilk KE, Mangine RE, Davies GJ, Malone TR. Patellofemoral disorders: a classification system and clinical guidelines for nonoperative rehabilitation. Journal of Orthopaedic Sports Physical Therapy 1998;31:368–74. Winkel D, Aufdenkampe G. Orthopedische geneeskunde en manuele therapie. Deel 1: Extremiteiten. Houten/diegem: Bohn Stafleu Van Loghum; 1994. p. 149–202. Zomerdijk TE, Beetsma AJ, Dekker J, van Wijck R, van Horn JR. Conservatieve behandeling van het patellofemoraal pijnsyndroom — Een systematisch literatuuronderzoek. Nederlands Tijdschrift voor Fysiotherapie 1998;108:95–102.

ARTICLE IN PRESS

Manual Therapy 11 (2006) 78–82 www.elsevier.com/locate/math

Case report

Sternocleidomastoid muscle imbalance in a patient with recurrent headache Michael T. Cibulka Jefferson County Rehabilitation & Sports Clinic, 1330 YMCA Drive, Suite 1200, Festus, MO 63028, USA Received 21 April 2004; received in revised form 24 November 2004; accepted 5 January 2005

Keywords: Headache; Physical therapy; Upper cervical spine

1. Introduction

2. Examination

Headache is a common complaint seen by physical therapists. Headache that develops from the upper cervical spine has been called cervicogenic headache (Bogduk, 1992; Nilsson et al., 1997; Biondi, 2001). The three upper cervical spine joints (atlanto-occipital, atlanto-axial, and C2/3) are often associated with headache (Bogduk, 1992; Dvorak and Walchli, 1997; Jull, 1997; Bogduk, 2001). Besides problems of upper cervical joint mobility, problems related to the muscles of the cervical spine have also been linked to cervicogenic headache (Jull, 1997; Jull et al., 1999). Muscle impairment of the sternocleidomastoid (SCM), the anterior scalene (AS) and the deep cervical flexor muscles (longus capitus and colli and rectus capitus anterior) has also been found to be associated with neck pain and cervical osteoarthritis (Gogia and Sabbahi, 1994; Barton and Hayes, 1996; Jull et al., 2002; Falla et al., 2004). The author has noticed that patients with cervicogenic headache often have imbalances in muscle length and strength between the left and right SCM and AS muscles. This case report describes the evaluation and treatment of a patient with cervicogenic type headache who also showed left to right imbalance between the SCM muscles and restricted upper cervical spine motion.

2.1. History

Tel.: +1 636 931 7600; fax: +1 636 931 8808.

E-mail address: [email protected]. 1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.01.006

2.1.1. General demographics The patient was a 38-year-old female with a 12-month history of recurrent headache. The headaches developed over the right supra-orbital region, along both temples (right worse than left) as well as in the left and right (right worse than left) sub-occipital region. The patient had a history of right-sided neck pain that developed after being rear ended in a moving vehicle accident 2 years previously. Since her car accident she had neck pain at least three times in between now and then but no report of headache until the last 12 months. The initial whiplash neck pain was treated by physical therapy, which included moist heat, cervical traction, mobilization, and exercises to reduce forward head posture (chin tuck exercises). After the physical therapy she reports that she had only minor neck pain. 2.1.2. Current conditions/chief complaints Her chief complaint was recurrent headaches, which would last usually until she had taken some medication (two capsules of 200 mg Motrin gelcaps). The pain usually started as stiffness in the sub-occipital region which later spread to the right temple and then to the right and later left supra-orbital region. No complaint of vertigo, jaw or dental pain was given. 2.1.3. Functional status and activity level The headaches did not usually interfere with her job or activities of daily living but when she developed a

ARTICLE IN PRESS M.T. Cibulka / Manual Therapy 11 (2006) 78–82

79

headache she had to take her medicine right away or the headache would often intensify and the medicine would not work as well. Headaches often came on for no apparent reason. However, she did note that sitting longer that 2 or 3 h at a time could precipitate a headache.

Testing the antero-lateral neck flexors (SCM and AS) by side-bending the head as far as possible and then rotating to the opposite side showed reduced length of the left when compared to the right side. This test showed the left SCM and AS were shorter in length than the right side.

2.2. Test and measures

2.2.5. Joint mobility Specific joint mobility of the cervical spine was tested, although the inter-tester reliability of testing specific joint mobility has been shown to be fair to moderate (Kappa coefficients 0.28–0.43) (Smedmark et al., 2000). In a study of patients with headache Jull et al. (1997) found high intra-tester reliability in finding cervical dysfunction. The atlanto-occipital joint was assessed using the method described by Bourdillon and Day (1987). On passive motion testing the author noticed that right side bending motion appeared less than left side bending at the atlanto-occipital joint. Assessment of the atlanto-axial joint was performed using a method described by Bourdillon and Day (1987). Assessment of the atlanto-axial joints showed less right rotation than left rotation observed visually by 201. After the upper cervical joints were tested the lower cervical joints were testing using a side gliding technique. Movement of right side gliding was found diminished at C2/3 but not with left side gliding. Movement appeared symmetrical for segments from C3/4 to C6/7. Also, no pain was created nor did the ‘‘end feels’’ appear different from side to side.

2.2.1. Pain Current headache pain was rated as 1 out of 10 on a Likert like 0–10 scale where 0 is no pain and 10 is the worst pain possible. Worst pain on the VAS scale was rated as 7 out of 10 while the best was 0 of ten, when she did not have a headache. The neck pain questionnaire was also given because the patient had neck pain. The neck pain questionnaire is a self reported patient response outcome measure designed to determine patient response on 10 different items for pain and function (Vernon and Mior, 1991). The neck pain questionnaire score was 12%, with a 4 out of 5 on the headache subsection. The patient reported that she developed headaches about 17 days of the month. 2.2.2. Posture and alignment When standing in a comfortable upright stance with the feet placed shoulder’s width apart no forward head posture or thoracic kyphosis was noted from a lateral view. From an anterior/posterior view the head was held in a position of 101 of left lateral flexion. However, no obvious torticollis was observed in the cervical spine. Examination in sitting showed that she did display some forward head posture. Examination of her jaw showed a normal angle class I occlusion with normal centric position of her teeth on full occlusion. She had no missing teeth except for her Wisdom teeth. 2.2.3. Palpation Palpation of the muscles of the cervical spine showed tenderness only in the right SCM muscle when compared to the left. Also, the right SCM muscle appeared to be smaller in circumference than the left SCM muscle when palpating with the thumb and index finger. 2.2.4. Range of motion Active cervical range of motion was measured with the cervical range of motion (CROM) goniometer. The reliability of the CROM has shown to be high (Youdas et al., 1992). Left and right active shoulder range of motion was full, with 1751 of abduction and flexion, 90 of external rotation and 601 of left internal rotation and 551 of right internal rotation (Norkin and White, 1995). Muscle length tests of the pectoralis major and latissimus dorsi, as described by Kendall et al., were symmetrical and normal in length (Kendall et al., 1952).

2.2.6. Muscle performance Manual muscle testing was performed according to the method of Kendall et al. (1993). Testing the left and right shoulders of the right abductor, right shoulder flexor, and right external rotator muscles, all displayed Normal muscle grades. Manual muscle testing of the SCM and AS muscles showed weakness on the right, a Good Minus muscle grade (Kendall et al., 1993). Testing the anterior head and neck flexor muscles (longus capitus and colli and rectus capitus anterior aided by the SCM, AS, and hyoid muscles) was performed supine as described by Kendall et al. (1993). Resistance was applied to the chin and resistance was placed in the direction of head. Backward bending was attempted to test the ability of the anterior neck flexor muscles (longus capitus and colli and rectus capitus anterior) to maintain the head in chin tucked or flexed position. No weakness of the anterior neck flexors was noted suggesting a Normal muscle grade. Although some studies suggest that manual muscle testing scores have questionable reliability, (Frese et al., 1987; Wadsworth et al., 1987) others suggest that they can be used for detecting substantial weakness. Florence et al. found the manual muscle testing intrarater reliability for individual muscles range from kw ¼ .80 to .99 (Cohen’s

ARTICLE IN PRESS 80

M.T. Cibulka / Manual Therapy 11 (2006) 78–82

weighted Kappa) in patients with neuromuscular impairments (Florence et al., 1992). Bohannon (1999) found that manual muscle tests grades correlated well with hand held dynamometry scores in 50 patients suggesting that they measure the same variable-strength. 2.2.7. Special tests A Sharp-Purser test was performed as well as the extension-rotation test to assess the possibility of atlanto-axial ligamentous laxity or vertebral artery occlusion. Uitvlugt and Gndenbaum (1988) showed that the Sharp-Purser test is a useful clinical examination to diagnose atlanto-axial instability (sensitivity 88%; specificity 96%). The extension-rotation test, like other vertebral artery tests, has been shown to have excellent specificity but poor sensitivity (Cote et al., 1996). Both tests were negative.

3. Diagnosis and prognosis The diagnosis of this patient was cervicogenic headache with limited upper cervical mobility (decreased right side bending at the atlanto-occipital and C2/3 joint and decreased left rotation at the atlanto-axial joint) and SCM/AS neck flexor muscle imbalance (weakness of the right SCM and diminished length of the left SCM). The prognosis was only ‘‘Fair’’ due to the fact that she had had little success with previous treatments and that the headache was a recurrent problem.

4. Intervention The goals of the intervention included diminishing/ eliminating headache, restoring mobility to the upper cervical spine joints, and restoring muscle balance (muscle length and strength) to the cervical spine SCM and AS muscles. The treatment on day one included manual therapy of the cervical spine using a technique (Nicholas, 1974) to increase motion between the second and third cervical vertebrae (C2/3) in side-bending right. Before the manipulative technique was performed moist heat was applied to her cervical spine for twenty minutes to relax the patient. The manipulative technique was then performed. Briefly, the patient lies supine; the therapist holds the patient’s occiput with the left hand and with the right hand using the radial aspect of the MCP joint of the index finger engages the right articular pillar of C3. The patient’s neck is side bent right by pushing with the right hand medially into C3 and then rotated left until all the motion is taken up. Once the slack is taken up a sudden medial movement on C3 pillar was given. A resultant audible ‘‘pop’’ was heard. After the treatment to the patients C2/3 segment she reported no increase or

decrease in headache pain or did she have any other symptom. Nothing in the history or physical examination suggested any contra-indications to using this technique. On the second visit the patient reported some relief in headache intensity on the next day (worst pain was only a 5 out of 10 compared to 7 out of 10 previously) and was again assessed for upper cervical mobility. Again the C2/3 joint range was found diminished when compared to the left side. Treatment again was with a manipulative technique to the C2/3 joint and she was taught a home stretching exercise of the left SCM. Briefly she was asked to stretch 3–4 times daily by lying supine with her head in neutral. By grasping her head with her right hand over her head she pulled her head into right side bending until a gentle stretch was felt in the left SCM. Stretch was held for 30 s or until the sensation of stretch in the left SCM disappeared. Four stretch repetitions were performed each time. On the third visit (one week) she again completed the Likert pain scale and Neck Pain Questionnaire scores before therapy. Her worst pain score was 3 out of 10 while her Neck Pain score was 6%. On the third visit low load exercises were started to increase the strength and endurance of the right SCM and AS muscles. The patient was instructed to lie supine with shoulders flexed and elbows bent to 901. The patient was then instructed to lift the left ear toward her chest (sternum) in the same way Kendall describes the SCM muscle tests (Kendall et al., 1993). Each time she lifted her head she held the head up for two counts and then slowly lowered the head down. The patient was instructed to exercise the right SCM muscle until she felt fatigue in the right SCM muscle but not pain or an increase in headache. The onset of fatigue was the stopping point of the exercise. The patient started with two sets of 8 and built up to two sets of 25 by her last day, two weeks from the initial evaluation (6th visit). After two weeks the Likert pain score for the worst pain possible was 2 out of 10 and her Neck Pain Questionnaire score was 2%. No limitations in mobility were noted in her upper cervical spine with Normal right SCM/AS muscle grades. Muscle length of the left and right SCM were symmetrical. Physical therapy was discontinued. A month later the patient came by for a re-evaluation and reported no complaint of recurrent headache. Muscle grades and muscle length of the SCM were normal as was the mobility in the upper cervical spine.

5. Discussion The treatment of cervicogenic headache has been described by many clinicians (Dreyfuss et al., 1994; Hurwitz et al., 1996; Jull, 1997; Pollmann et al., 1997; Bove and Nilsson, 1998; Biondi, 2000, 2001; Bronfort

ARTICLE IN PRESS M.T. Cibulka / Manual Therapy 11 (2006) 78–82

et al., 2001; Gross et al., 2002). Many of the treatments include joint mobilization/manipulation, based on studies that suggest that limited mobility of the upper cervical joints can create headache (Hurwitz et al., 1996; Nilsson et al., 1997; Jull et al., 2002). Another treatment approach for patients with headache is strengthening the muscles of the cervical spine (Jull, 1997; Jull et al., 2002). Although only a few randomized controlled trials have been performed, studies suggest that strengthening the deep anterior cervical muscles of the cervical spine is effective in helping patients with cervicogenic headache (Gross et al., 2002; Jull et al., 2002; Stanton and Jull, 2003). So far no studies have described the treatment of SCM weakness in patients with unilateral neck pain and headache. Studies have shown the relationship between the SCM and unilateral neck pain and headache. Barton and Hayes (1996) found SCM muscle weakness in patients with unilateral neck pain and headache. Falla et al. (2004) found neck flexor (SCM and AS) fatigue is side specific in patients with unilateral neck pain. Gogia and Sabbahi (1994) reported higher fatigue of the upper trapezius and SCM muscles in patients with osteoarthritis of the cervical spine. This case report describes the successful treatment of the SCM muscle imbalance in a patient with unilateral neck pain and headache. As a group the sternocleidomastoid muscles and the anterior scalene muscles flex the cervical spine. Individually the SCM and AS side-bend the cervical spine and head to the same side and rotate the head and cervical spine to the opposite side (Kendall et al., 1993). The finding of limited active right side-bending and limited left rotation is consistent in a patient with a weak right sternocleidomastoid muscle (Kendall et al., 1993). The patient also showed limited passive length of the left SCM. Often when a muscle is weak its antagonist will display diminished muscle length (Kendall et al., 1952). Mobility tests of the upper cervical spine were also consistent with the muscle length and strength findings of the SCM muscles. In this case limited right atlantooccipital and C2/3 right side bending and limited left atlanto-axial rotation correlate with finding a weak right SCM/AS and short left SCM/AS. Thus the agreement between finding limited mobility of the upper cervical spine in the same direction one would expect weakness of the right SCM give credibility in the evaluation of this patient. The reason why the right SCM muscle in this patient was weak is unknown. The patient gave a history of having a motor vehicle accident previously. In a motor vehicle accident the neck is often whip-lashed and the cervical muscles are often involved (Kumar et al., 2002; Kumar et al., 2004a, b). Macnab found that in flexionextension injuries from motor vehicle accidents, the SCM and longus colli muscles sustain extensive injury (Macnab, 1971). More recently Kumar et al. (2002, 2004) found that the SCM muscles are the most

81

common muscles involved in a low velocity rear-end accident. The SCM is not only the longest muscle of the cervical spine but also the muscle furthest away from the neutral axis during bending. During normal bending the greatest tensile forces develop in those tissues that are furthest from the neutral axis on the convex side (Popov, 1976). Thus the cervical muscles located the furthest away from the neutral axis of bending appear most susceptible to injury. Although the accident happened a few years ago the possibility exists that the previous motor vehicle accident weakened her right SCM muscle is a credible notion. Future studies that specifically examine the effect a motor vehicle accident has on the SCM and AS muscles would be an interesting study. The episodic symptoms of headache create finding an appropriate outcome measure important. The outcome measure that was chosen to assess headache was not ideal. The patient’s chief complaint was not neck pain but headache. The neck pain questionnaire is not well suited for headache. Of the 10 subsections of the neck pain questionnaire only three were filled out on the initial evaluation. The Headache subsection was rated 4 out of 5 (highest), Pain Intensity was rated 1 out of 5, while reading was rated 1 out of 5. All of the other subsections were rated 0 out of 6, including driving, sleeping, recreation, lifting, personal care, work, and concentration. The neck pain questionnaire score was initially only 12%, which appears low. A problem with any outcome questionnaire is capturing meaningful and useful data. When a patient exhibits a headache they are often incapacitated at that particular time. However, when they don’t have a headache they are usually fine and are without symptoms. Therefore, unless the patient has a headache at the time they are filling out the neck pain questionnaire, the neck pain questionnaire may not be very useful or sensitive of an outcome measure. It has been suggested (Jull, 1997; Jull et al., 2002) that anterior neck flexor weakness is related to cervicogenic headache. Jull et al. (2002) suggest that poor activation levels and endurance capacity of the deep and postural supporting muscles of the neck may develop in patients with headache. The same authors have shown that manipulative therapy combined with endurance exercises for the anterior neck flexor muscles diminished cervicogenic headache (Jull et al., 2002). In this case report the deep anterior neck flexors were tested for isometric strength but not for endurance as described by Jull et al. (1999) because at the time this case was written the author did not know this method of testing. Examining the relationship between the anterior neck flexors and the SCM and AS in future studies would be interesting. The effectiveness of treating headache with this intervention cannot be proven in a case report. However, an essential role of a case report is to provide a framework for new concepts and ideas that may

ARTICLE IN PRESS 82

M.T. Cibulka / Manual Therapy 11 (2006) 78–82

stimulate new research. This case report describes a patient with recurrent headache that was treated by mobilizing the upper cervical spine and also restoring symmetry to the left and right SCM and AS muscles. References Barton P, Hayes KC. Neck flexor muscle strength, efficiency, and relaxation times in normal subjects and subjects with unilateral neck pain and headache. Archives of Physical Medicine and Rehabilitation 1996;77(7):680–7. Biondi DM. Cervicogenic headache: mechanisms, evaluation, and treatment strategies. Journal of the American Osteopathic Association 2000;100(9 Suppl):S7–S14. Biondi DM. Cervicogenic headache: diagnostic evaluation and treatment strategies. Current Pain and Headache Reports 2001; 5(4):361–8. Bogduk N. The anatomical basis for cervicogenic headache. Journal of Manipulative and Physiological Therapeutics 1992;15(1):67–70. Bogduk N. Cervicogenic headache: anatomic basis and pathophysiologic mechanisms. Current Pain and Headache Reports 2001; 5(4):382–6. Bohannon RW. Intertester reliability of hand-held dynamometry: a concise summary of published research. Perceptual and Motor Skills 1999;88(3 Pt 1):899–902. Bourdillon J, Day E. Spinal Manipulation. London: William Heinemann Medical Books; 1987. Bove G, Nilsson N. Spinal manipulation in the treatment of episodic tension-type headache: a randomized controlled trial. Journal of American Medical Association 1998;280(18):1576–9. Bronfort G, Assendelft WJ, Evans R, Haas M, Bouter L. Efficacy of spinal manipulation for chronic headache: a systematic review. Journal of Manipulative and Physiological Therapeutics 2001; 24(7):457–66. Cote P, Kreitz BG, Cassidy JD, Thiel H. The validity of the extensionrotation test as a clinical screening procedure before neck manipulation: a secondary analysis. Journal of Manipulative and Physiological Therapeutics 1996;19(3):159–64. Dreyfuss P, Rogers J, Dreyer S, Fletcher D. Atlanto-occipital joint pain. A report of three cases and description of an intra-articular joint block technique. Regional Anesthesia 1994;19(5):344–51. Dvorak J, Walchli B. Headache in cervical syndrome. Therapia Hungarica 1997;54(2):94–7. Falla D, Jull G, Rainoldi A, Merletti R. Neck flexor muscle fatigue is side specific in patients with unilateral neck pain. European Journal of Pain 2004;8(1):71–7. Florence JM, Pandya S, King WM, Robison JD, Baty J, Miller JP, Schierbecker J, Signore LC. Intrarater reliability of manual muscle test (Medical Research Council scale) grades in Duchenne’s muscular dystrophy. Physical Therapy 1992;72(2):115–22 discussion 122–6. Frese E, Brown M, Norton BJ. Clinical reliability of manual muscle testing. Middle trapezius and gluteus medius muscles. Physical Therapy 1987;67(7):1072–6. Gogia PP, Sabbahi MA. Electromyographic analysis of neck muscle fatigue in patients with osteoarthritis of the cervical spine. Spine 1994;19(5):502–6. Gross AR, Kay T, Hondras M, Goldsmith C, Haines T, Peloso P, Kennedy C, Hoving J. Manual therapy for mechanical neck

disorders: a systematic review. Manual Therapy 2002;7(3): 131–49. Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of the cervical spine. A systematic review of the literature. Spine 1996;21(15):1746–59 discussion 1759–60. Jull G. Management of cervical headache. Manual Therapy 1997;2(4):182–90. Jull G, Zito G, Trott P, Potter H, Shirley D. Inter-examiner reliability to detect painful upper cervical joint dysfunction. Australian Journal of Physiotherapy 1997;43(2):125–9. Jull G, Barrett C, Magee R, Ho P. Further clinical clarification of the muscle dysfunction in cervical headache. Cephalalgia 1999;19(3): 179–85. Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002;27(17):1835–43 discussion 1843. Kendall H, Kendall F, Boynton D. Posture and Pain. Huntington, NY: Robert E. Krieger Publishing Company; 1952. Kendall F, McCreary E, Provance P. Muscles: Testing and Function. Baltimore, MD: Williams & Wilkins; 1993. Kumar S, Narayan Y, Amell T. An electromyographic study of lowvelocity rear-end impacts. Spine 2002;27(10):1044–55. Kumar S, Ferrari R, Narayan Y. Cervical muscle response to whiplash-type right anterolateral impacts. European Spine Journal 2004. Kumar S, Ferrari R, Narayan Y. Electromyographic and kinematic exploration of whiplash-type neck perturbations in left lateral collisions. Spine 2004;29(6):650–9. Macnab I. The whiplash syndrome. Orthopedic Clinics of North America 1971;2(2):389–403. Nicholas N. Atlas of osteopathic techniques. Philadelphia, PA: Philadelphia College of Osteopathic Medicine; 1974. Nilsson N, Christensen HW, Hartvigsen J. The effect of spinal manipulation in the treatment of cervicogenic headache. Journal of Manipulative and Physiological Therapeutics 1997;20(5):326–30. Norkin C, White D. Measurement of Joint Motion: A Guide to Goniometry. Philadelphia, PA: FA Davis Co; 1995. Pollmann W, Keidel M, Pfaffenrath V. Headache and the cervical spine: a critical review. Cephalalgia 1997;17:801–16. Popov E. Mechanics of Materials. Englewood Cliffs, NJ: Prentice-Hall Inc; 1976. Smedmark V, Wallin M, Arvidsson I. Inter-examiner reliability in assessing passive intervertebral motion of the cervical spine. Manual Therapy 2000;5(2):97–101. Stanton WR, Jull GA. Cervicogenic headache: locus of control and success of treatment. Headache 2003;43(9):956–61. Uitvlugt A, Gndenbaum S. Clinical assessment of atlantoaxial instability using the Sharp-Purser test. Arthritis Rheum 1988; 31(7):918–22. Vernon H, Mior S. The neck disability index: a study of reliability and validity. Journal of Manipulative and Physiological Therapeutics 1991;14(7):409–15. Wadsworth CT, Krishnan R, Sear M, Harrold J, Nielsen DH. Intrarater reliability of manual muscle testing and handheld dynametric muscle testing. Physical Therapy 1987;67(9): 1342–7. Youdas JW, Garrett TR, Suman CL, Bogard VJ, Hallman HO, Carey JR. Normal range of motion of the cervical spine: an initial goniometric study. Physical Therapy 1992;72(11):770–80.

ARTICLE IN PRESS

Manual Therapy 11 (2006) 83–84 www.elsevier.com/locate/math

Letters to the Editor Book review: ‘Modern Neuromuscular Techniques’ by Marco Testa Manual Therapy 9(3):178–179 Dear Editors In his review Mr Testa states: The introduction to the viscerosomatic and somatovisceral reflexes could be interesting, but the reader could be thrown into confusion when the author follows this physiologic hypothesis and applies the diagnostic and therapeutic power of the so-called neurolymphatic and neurovascular reflexes (Chapman and Bennett). It is suggested that after reading this book, the reader could be able to diagnose and treat diffuse visceral symptoms and pathology. The book does not suggest that diagnosis and treatment of disease is possible via the assessment of these reflexes alone, merely that they can be of assistance in patient management. On p. 80, there is a clear statement of their potential value, as diagnostic aids, and of being potentially influential in enhancing lymphatic flow and as a means of reducing adverse sympathetic activity. This is a long way from suggesting: ‘the reader could be able to diagnose and treat diffuse visceral symptoms and pathology.’ The reviewer dismisses this long-established osteopathic approach to assessment, and in some instances to treatment (Owens, 1937; Patriquin, 1997), and while I agree that in the absence of research this remains a largely anecdeotal and ‘clinical experience’-driven approach, there is in fact supportive evidence. For example, recently Washingtom et al. (2003) undertook a case control study to determine whether hospitalized patients with pneumonia had reflex points on the anterior chest wall as described by Chapman (Owens, 1937). Sixty-nine hospitalized patients with an admitting diagnosis of pneumonia were examined. Patients with lung pathology other than pneumonia were excluded.

doi:10.1016/j.math.2005.02.006

Results demonstrated a statistically significant ‘high predictability’ relationship between the presence of these reflex points and pneumonia in hospitalized patients. These findings, it is suggested, indicate a potential usefulness in evaluating patients with a potential pneumonia diagnosis. There is no suggestion that the treatment of these reflexes would significantly influence the recovery of such patients, although there may be a potential for modification of symptoms (based on clinical experience). The dismissive nature of the review in relation to Neurolymphatic reflexes may negatively influence potential users of what is a simple and often effective assessment tool. The drive towards evidence-based medicine is praiseworthy, but Mr Testa (and your readers) might reflect that the vast majority of current medical, surgical (and manual therapy) methods remain a matter of traditional usage, authority opinion and anecdote, without which current practitioners and therapists of all schools might well be bereft of the majority of their clinical tools. References Owens C. An endocrine interpretation of Chapman’s reflexes. 2nd ed. Chattanooga Tenn: Chattanooga Printing Co.; 1937. Patriquin D. Chapman’s reflexes. In: Ward R, editor. Foundations for osteopathic medicine. Baltimore: Williams & Wilkins; 1997. Washingtom K, Mosiello R, Venditto M, et al. Presence of Chapman’s reflex points in hospitalized patients with pneumonia. Journal American Osteopathic Association 2003;103(10):479–83.

Leon Chaitow School of Integrated Health, University of Westminster, 115 New Cavendish Street, London W1M 8JS, UK E-mail address: [email protected]

ARTICLE IN PRESS 84

Letters to the Editor / Manual Therapy 11 (2006) 83–84

Response to Letter to the Editor: Re: Book review ‘Modern Neuromuscular Techniques’

Dear Editors I am grateful to the Manual Therapy Journal editors for giving me the opportunity to reply to Mr. Chaitows letter. The main criticisms in my review were not directed towards the single techniques or theories presented in the book, but to the use of ‘‘master’s words’’ as preferred support for their physiological mechanisms and clinical effectiveness. Mr. Chaitow underlines in his letter that Chapman Reflexes could influence lymphatic flow and reduce adverse sympathetic activity quoting as support simply a textbook and not published experimental studies (that do not exist at the moment) and forgetting that the paper by Washington et al. he suggests to read, clearly states: ‘‘tissue biopsy studies have been unable to demonstrate the reflex change’’. On the one hand ‘‘Modern Neuromuscular Techniques’’ offers good descriptions and a clear historical overview of many reflex therapies, but on the other hand the author does not inform the reader about the availability of scientific evidence for most of the therapeutic or assessment tools described in the book. Mr. Chaitow claims that, in absence of supportive evidence, he considers ‘‘anecdotal’’, as I do, approaches like the Chapman Reflexes. I was therefore happy to be informed about the paper by Washington et al., but unfortunately the reading was disappointing. The paper presents some methodological weaknesses that cast doubt on the results, but the main

doi:10.1016/j.math.2005.03.005

problem is that results reported in that paper appear to be wrong. I have recalculated the data (thanks to the honesty of the authors that clearly presented them): the actual value of sensitivity is 0.37 instead of 0.67 and specificity is 0.87 instead of 0.64. The conclusion drawn by the author: ‘‘hospitalised patients with pneumonia have a high predictability of presenting with Chapman reflex point for lung’’ is therefore not valid because only 37% of patients affected by pneumonia presented the Chapman point detectable. Because pneumonia is quite an important pathology, with a negative predictive value of 0.64 and a positive predictive value 0.69 and more valid tests being available (conventional X-rays), the authors should discourage the practitioner from using the Chapman reflex of the lung as a diagnostic test for pneumonia. As physiotherapist and osteopath I have a great respect of the contributions of the ‘‘masters’’ and I think that without their work our discipline would have progressed much less, but nowadays we should be ready to ‘‘deprive’’ ourselves of clinical tools or theories that have demonstrated their inconsistency if we want to balance the ‘‘artistic’’ component of our work with the scientific one and defend and improve the place our professions have gained in the health system. Best Regards,

Marco Testa Coordinator of the Master in Rehabilitation of the Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Genova, Italy

ARTICLE IN PRESS 84

Letters to the Editor / Manual Therapy 11 (2006) 83–84

Response to Letter to the Editor: Re: Book review ‘Modern Neuromuscular Techniques’

Dear Editors I am grateful to the Manual Therapy Journal editors for giving me the opportunity to reply to Mr. Chaitows letter. The main criticisms in my review were not directed towards the single techniques or theories presented in the book, but to the use of ‘‘master’s words’’ as preferred support for their physiological mechanisms and clinical effectiveness. Mr. Chaitow underlines in his letter that Chapman Reflexes could influence lymphatic flow and reduce adverse sympathetic activity quoting as support simply a textbook and not published experimental studies (that do not exist at the moment) and forgetting that the paper by Washington et al. he suggests to read, clearly states: ‘‘tissue biopsy studies have been unable to demonstrate the reflex change’’. On the one hand ‘‘Modern Neuromuscular Techniques’’ offers good descriptions and a clear historical overview of many reflex therapies, but on the other hand the author does not inform the reader about the availability of scientific evidence for most of the therapeutic or assessment tools described in the book. Mr. Chaitow claims that, in absence of supportive evidence, he considers ‘‘anecdotal’’, as I do, approaches like the Chapman Reflexes. I was therefore happy to be informed about the paper by Washington et al., but unfortunately the reading was disappointing. The paper presents some methodological weaknesses that cast doubt on the results, but the main

doi:10.1016/j.math.2005.03.005

problem is that results reported in that paper appear to be wrong. I have recalculated the data (thanks to the honesty of the authors that clearly presented them): the actual value of sensitivity is 0.37 instead of 0.67 and specificity is 0.87 instead of 0.64. The conclusion drawn by the author: ‘‘hospitalised patients with pneumonia have a high predictability of presenting with Chapman reflex point for lung’’ is therefore not valid because only 37% of patients affected by pneumonia presented the Chapman point detectable. Because pneumonia is quite an important pathology, with a negative predictive value of 0.64 and a positive predictive value 0.69 and more valid tests being available (conventional X-rays), the authors should discourage the practitioner from using the Chapman reflex of the lung as a diagnostic test for pneumonia. As physiotherapist and osteopath I have a great respect of the contributions of the ‘‘masters’’ and I think that without their work our discipline would have progressed much less, but nowadays we should be ready to ‘‘deprive’’ ourselves of clinical tools or theories that have demonstrated their inconsistency if we want to balance the ‘‘artistic’’ component of our work with the scientific one and defend and improve the place our professions have gained in the health system. Best Regards,

Marco Testa Coordinator of the Master in Rehabilitation of the Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Genova, Italy

ARTICLE IN PRESS

Manual Therapy 11 (2006) 85–86 www.elsevier.com/locate/math

MACP Report

Priorities for research into the neurovascular complications of cervical spine manual therapy Report from the MACP Chair on a discussion session at the 2004 CSP AGM—A session jointly chaired by Chris McCarthy MMACP, Roger Kerry MMACP, Gordon Smith MSOP and John Brew MMACP Chris McCarthy The Centre for Rehabilitation Science, The University of Manchester, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK

1. Introduction

structured around the following areas:

The use of cervical manipulation and mobilization techniques by physiotherapists holds inherent risks in terms of neurovascular dysfunction as a result of apparent insult to the vertebrobasilar arterial system (Kerry, 2002). As such, over the years, physiotherapists around the world have made great efforts to provide clinical guidance for the safest implementation of such techniques. This clinical guidance has traditionally been driven by work from the Australian Physiotherapy Association (APA, 2001; Magarey et al., 2004) and has formed the basis of other national published guidance (e.g. Barker et al., 2001). Discussion with physiotherapists, including members of the Manipulation Association of Chartered Physiotherapists (MACP), suggests there is still a need for more consideration of this important clinical area, and that there is still a high level of uncertainty and unease regarding the ‘‘best’’ way in identifying patients at risk from potential neurovascular complications. As such, the MACP has commissioned an extensive literature review, which will form a basis for identifying key areas of research. This work is to be undertaken by a team of reviewers from a number of countries and various clinical and academic backgrounds. The review will be

 

E-mail address: [email protected]. 1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.06.001

  

Blood flow studies. Case studies and reports of neurovascular complications following treatment. Reviews of retrospective and prospective studies. Haemodynamic principles, vascular pathology and thrombogenesis. Risks and benefits of cervical manipulation and mobilization.

These broad areas will provide a rich picture of the current knowledge base in this area. From this, an assessment of the meaningful gaps in the knowledge base can be made, and areas of potential research priorities identified. In addition to this review, a discussion forum was conducted at the CSP Congress in 2004 during which delegates had the chance to identify what they felt were research priorities in this area. The outcomes of this discussion forum are to be used as a basis for a Delphi questionnaire to develop consensus on which topics developed at the forum should be rated as the highest priority for research. The Delphi technique is a methodology used for canvassing opinion and structured decisionmaking and consists of consecutive rounds of questionnaires designed to achieve increasing consensus of opinion (Goodman, 1987). The technique has been widely used in the medical and nursing fields and has been suggested for use when seeking national opinion and developing priority issues (Walker and Selfe, 1996; Beech, 2001).

ARTICLE IN PRESS C. McCarthy / Manual Therapy 11 (2006) 85–86

86

2. Methods

Suggested action

——

Review of the literature

——

Development of a legal resource discussions with users about the information provided to patients

2.1. Subjects Subjects were attendees at an MACP discussion session held at the Chartered Society of Physiotherapy’s Annual General Conference in Birmingham, Sunday, 10 October 2004. The 120 attendees were split into four groups and were asked to discuss priority issues for future research in the field of cervical spine mobilization and manipulative techniques and neurovascular complications. Groups were facilitated by one of the four authors who also took notes on the topics raised. The notes from the four facilitators were then synthesized and grouped into themes by the lead author and circulated for further comments. The topics raised are presented in no priority of importance.

Consent/legal issues  Involvement of user groups in what is considered to be appropriate information by patients  Development of a body of opinion on what should be offered to patients  Development of a ‘‘legal update’’ database on this issue Suggested actions

3. Results Topics suggested and suggested actions: Risk/benefit of manipulation  How much do we do it?  How do we do it?  On whom do we do it?  What are the risks?  What are the benefits? Suggested action

4. Discussion

——

A survey of current practice

Testing for the degree of risk  Reliability of subjective and objective tests  Criterion related validity of the above  What is the profession’s opinion of the value of developing Guidelines? Suggested actions

Haemodynamic issues  Effects on vascular structures of cervical positioning  Effects of manipulation on vascular structures  Effects of testing on vascular structures

The topics raised above will now form the basis of a Delphi questionnaire that will be circulated to interested clinicians, nationally and internationally. The aim of the Delphi technique will be to establish the priority areas for future research in this area of clinical practice. If you would like to be involved in the Delphi process please contact the Chair of the MACP at the address above.

References

——

Review of the literature and a survey of the profession on the need for guidelines

Australian Physiotherapy Association. Protocol for pre-manipulative testing of the cervical spine. Australian Journal of Physiotherapy 2001;34:97–100. Barker S, Kesson M, Asmore J, Turner G, Conway J, Stevens D. Guidance for pre-manipulative testing of the cervical spine. Physiotherapy 2001;87(6):318–22. Beech B. The Delphi approach: recent applications in health care. Nurse Researcher 2001;8(4):38–47. Goodman CM. The Delphi technique: a critique. Journal of Advanced Nursing 1987;12(6):729–34. Kerry R. Pre-manipulative procedures for the cervical spine—new guidelines and a time for dialectics: knowledge, risks, evidence and consent. Physiotherapy 2002;88(7):417–20. Magarey ME, Rebbeck T, Coughlan B, Grimmer K, Rivett DA, Refshauge K. Pre-manipulative testing of the cervical spine review. Revision and New Clinical Guidelines 2004;9(2):95–108. Walker AM, Selfe J. The Delphi method: a useful tool for the allied health researcher. British Journal of Therapy and Rehabilitation 1996;3(12):677–81.

ARTICLE IN PRESS

Manual Therapy 11 (2006) 87 www.elsevier.com/locate/math

Book reviews Beeton Karen (Ed.), Manual Therapy Masterclasses— The Vertebral Column, 1st Ed, Churchill Livingstone, New York, ISBN 0443074038, 2003 Price £ 24,99, No of pages: 256. Manual Therapy Masterclass The Vertebral Column edited by Karen Beeton is a collection of articles published in Manual Therapy. These carefully selected masterclass articles can be seen as a textbook for physical and manual therapists. Some articles have the potential to be evidence based, Jull and Richardson, but the majority of articles are ‘‘model based’’ or ‘‘authority’’ based. All the authors had the opportunity to write a postscript, after all new developments can occur and most authors used that opportunity. Sometimes the evidence is evaluated and sometimes a model or technique changed in time. They give a nice overview of the current status of manual therapy with all possible

musculoskeletal issues. This book is divided into five sections; cervical spine, thoracic spine, lumbar spine, sacro-iliac joint and a general chapter. The lumbar spine section represents seven articles, but the sacroiliac joint only one and for a specific patient population. The reason is probably a lack of masterclass articles for that subject. For a physical therapist or a manual therapist this book is recommended, for students a highly recommended textbook and for the readers of Manual Therapy this book is also recommended after all, this book gives an easy access to the articles and offers a nice overview. Jan Pool Institute for Research in Extramural Medicine, VU University medical center, Amsterdam, The Netherlands E-mail address: [email protected]

doi: 10.1016/j.math.2005.06.008

Karen Beeton (Ed.), Manual Therapy Masterclasses— The Peripheral Joints, first ed., Churchill Livingstone, New York, ISBN 044307402X, 2003 (£17,99, 168pp.). This book consists of 10 sections. Each section contains an article previously be published in Manual Therapy and selected by Karen Beeton. In the preface, it is stated that each section will describe clinical aspects of patient management within a theoretical evidence-based framework. Indeed this book gives an impression of the state of art in manual therapy in concern with clinical practice. The evidence is mostly based on literature review on which practical models are built. The evidence for practice, ‘‘does it work’’ is lacking although some authors have attempted to include some evidence that is available in the postscripts and describe new developments, which have occurred. The lower doi: 10.1016/j.math.2005.06.009

extremity is represented by the hip, knee and foot. The upper extremity only by the shoulder. In the general section two articles are presented which involves mobilisation techniques. The evidence in these articles is fully lacking but it provides the reader a nice overview of the therapy models. In summary for the clinician a nice overview of the existing methods and ideas within manual therapy. The postscripts are very interesting to read. For a physical therapist manual therapist and for students this book is recommended, after all, this book gives an easy access to the articles. Jan Pool Institute for Research in Extramural Medicine, VU University medical center, Amsterdam, The Netherlands E-mail address: [email protected]

ARTICLE IN PRESS

Manual Therapy 11 (2006) 88–89 www.elsevier.com/locate/math

List of Reviewers 2005 I. Beith UK K. Bennell Australia K. Bo Norway R. Boland Australia J. D. Boyling UK A. Breen UK K. Burton UK M. Callaghan UK G. Canby UK D. Critchley UK L. Danneels Belgium K. Dziedzic UK

A. Green UK J. Greening UK A. Gross Canada B. Haas UK J. Hides Australia A. Hough UK Z. Hudson UK D. Hurley-Osing Republic of Ireland M. Jones Australia A. Julius UK E. Kristjansson Iceland

I. Edwards Australia

J. Langendoen Germany

L. Exelby UK

R. Lee UK

D.L. Falla Denmark

G. Louw UK

1356-689X/$ - see front matter doi:10.1016/j.math.2005.11.001

ARTICLE IN PRESS List of Reviewers / Manual Therapy 11 (2006) 88–89

C. Maher Australia

C. Richardson Australia

S. May UK

D. Rivett Australia

C. McCarthy UK

A. Rushton UK

T. McClune UK

D. Schuit USA

J. McConnell Australia

M. Sterling Australia

A. McGregor UK

R. Swinkels The Netherlands

S. Mottram UK

J. Treleaven Australia

D. Newham UK

H. Tsao Australia

J. Ng Hong Kong

P. van der Wurff

K. Niere Australia R. Ostelo The Netherlands A. Pool-Goudzwaard The Netherlands G. Rankin UK K. Refshauge Australia

B. Vicenzino Australia S. Vogel UK T. Watson UK D. Watt UK T. Wright Australia

89

Manual Therapy (2006) 11(1), 91

Diary of events

Delegate places are limited, so book early to secure your place as well as benefiting from the early bird discount (must be booked before February 28th 2006).

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

Website www.heseminars.com/conference_2006.htm Contact Health Education Seminars 42 Richmond Road Poole Dorset BH14 0BU Tel/fax: 01202 568898 Email: [email protected]

2nd International Evidence Based Physical Therapy Conference & Exhibition Date: Saturday May 20th 2006 Venue: Business Design Centre, Islington, London This multi-disciplinary conference is relevant for all physiotherapists, osteopaths, chiropractors, as well as sport scientists, sports therapists, sports massage therapists and all medical and healthcare professionals working or having an interest in physical therapy.

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]

The conference will bring together expert clinicians and researchers to present evidence based lectures that are pertinent and relevant to all clinicians working in the area of musculoskeletal health. The presentations will either support or challenge current practice but will remain true to the aim of the conference, that being to provide a review of the current evidence in the area relevant to the lecture.

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

Ken Joy (Managing Director & Chartered Physiotherapist) says ‘‘This International Evidence Based Conference will enable all musculoskeletal professionals to hear first hand, from highly respected experts, the very latest evidence & research. It is an event not to be missed’’.

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.

A percentage of the conference proceeds will be donated to Physical therapy research.

91

ARTICLE IN PRESS

Manual Therapy 11 (2006) e1 www.elsevier.com/locate/math

Book Review Manu Peter, The Psychopathology of Functional Somatic Syndromes—Neurobiology and Illness Behavior in Chronic Fatigue Syndrome, Fibromyalgia, Gulf War Illness, Irritable Bowel, and Premenstrual Dysphoria, The Haworth Medical Press, ISBN 0-7890-1259-6, 2004 299pp., £ 34.95. This book is a comprehensive overview of the available literature data on psychopathology in patients with Chronic Fatigue Syndrome (CFS), Fibromyalgia, Gulf War Illness (GWI), Irritable Bowel, and Premenstrual Dysphoria. The first part of the book provides the reader with an overview of (the history towards) the current diagnostic criteria of these ‘functional somatic syndromes’, and confronts the reader with the substantial overlap between these ‘tight-knit family of syndromes’. The second part summarizes the available evidence on the presence and clinical importance of psychiatric morbidity in each of the functional somatic syndromes. In part III, Dr. Manu examines the best research addressing the psychobiology of functional somatic syndromes, including the best evidence on abnormalities in neuroanatomy/brain perfusion, neuropsychological deficits, hypothalamic-pituitary-adrenal axis impairments, and serotonin metabolism. Special emphasis is given to the clinical significance of the observed impairments. The final part provides knowledge and insight into abnormal personality, sexual

doi:10.1016/j.math.2005.06.011

victimization, somatic attributions, and maladaptive coping in each of the functional somatic syndromes. The author has done a superb job in summarizing, discussing, and organizing a body of literature in four parts, subdivided in 15 chapters. Still, the reader must be cautious: the available evidence addressing the biological abnormalities in CFS, Fibromyalgia, and GWI is growing. Consequently, it is somewhat surprising that the author stated that ‘CFS, Fibromyalgia and GWI lack demonstrable structural or biochemical abnormalities’ (page 1). In addition, the practical implications (i.e. treatment options) of our current understanding of psychopathology in patients with functional somatic syndromes are not discussed, and a final chapter summarizing and discussing the main conclusions from this literature overview is lacking. Nevertheless, this book is relevant and highly recommended to all researchers and health care workers involved with patients with ‘functional somatic syndromes’. Jo Nijs Department of Human Physiology, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Belgium Division of Musculoskeletal Physiotherapy, Higher Institute of Physiotherapy, Hogeschool Antwerpen, Belgium E-mail address: [email protected]

ARTICLE IN PRESS

Manual Therapy 11 (2006) e2 www.elsevier.com/locate/math

Book Review L. Chaitow, Fibromyalgia Syndrome: A Practitioner’s Guide to Treatment, second ed., Churchill Livingstone, New York, NY, ISBN 0443072191, 2003 (368pp., £38.99). This is a comprehensive reference guide to treatment for Fibromyalgia syndrome (FMS). FMS is a generalized chronic pain problem that is typically presented with a heterogeneous group of co-morbid functional disorders and neuropsychoendocrine abnormalities. Because of the diffuse nature of the problem and the multi-system involvement, the integrated knowledge of research findings, clinical characteristics and treatment issues is critical, yet difficult to assemble. Knowing this difficulty, I am genuinely impressed with this guide book. The title may be somewhat misleading, as it suggests that this is a treatment guide; rather, the book covers a wide range of issues related to FMS. The author did a superb job in assembling information in such a varying range of topics related to FMS. For example, let us take Chapter 2. The chapter presents a comprehensive list of clinical features associated with FMS. Readers learn the epidemiology of the associated features, the summaries of the laboratory findings and the risk factors, and the sample treatment protocols by the well-known FMS clinicians. The author then introduces the conceptual model of FMS based upon the descriptive and narrative information. The content is extensive and provides an excellent overview of the disorder. The book has several chapters dedicated to the discussions of specific treatment modalities for FMS, including complimentary techniques, interdisciplinary treatment, and bodywork approaches. It probably is worth mentioning, however, that the book is less comprehensive in discussing what seem to be the most common approaches to FMS: medication management, exercise programs, and psychological (cognitive-behavioral) treatments. There are short descriptions on the

doi:10.1016/j.math.2005.06.013

results of the published clinical trials testing the medications commonly used for FMS, including antidepressant and muscle relaxants. As for the physical therapy and psychological treatments, they are described in the content of the interdisciplinary pain management and in less detailed manner, compared to other modalities. It is important for practitioners to understand that the comprehensive, interdisciplinary pain management is not just about providing physical therapy and psychological modalities and that any of the modalities listed in this book can be incorporated into the comprehensive treatment plan. One of the major strengths of the book is the detailed presentations of the bodywork approaches. There are many pictorial exhibitions and summary boxes that facilitate the visual learning for readers. There is a CD ROM that comes with the book; the CD includes the video presentations of specific techniques. The book also includes the topics that answer the common questions about FMS, such as the difference between FMS and chronic fatigue syndrome, how to handle co-morbid disorders, and how to do the differential diagnosis from myofascial pain syndrome. Overall, I find that this book can serve as an excellent reference book as well as guidebook on a wide range of the topics relevant to FMS. The usefulness of the book should not be restricted to clinicians. The book can be extremely helpful for anyone who would like to have a comprehensive reference book, particularly researchers who would like to learn the basic aspects of what we know about FMS, and trainees who are interested in pain medicine in general.

Akiko Okifuji Pain Research & Management Center, Department of Anesthesiology, University of Utah, Salt Lake City, USA E-mail address: [email protected]