Manual Therapy (2003) 8(1), 1 1356-689X/03/$ - see front matter # 2003 Published by Elsevier Science Ltd. doi:10.1054/math.2002.0492
Editorial
Editorials and Scholarly Debate analysis of the work published in this or past issues, we would like you to use the facility of published comment in the letters to editors section. It is likely that others may or may not agree with you and they too could write to the Journal. Few persons have used this section of the journal to date. We encourage you to do so in order that some healthy, challenging and scholarly debate can emerge. Such debate is a sign of a vibrant profession. On another issue, you will notice that another change of content has occurred in this issue of the Journal, following other changes such as the amended name change of the Journal and formalisation of Technical and Measurement Section. The latest change is that there is no longer a bibliography section. The Editorial Board considered that the information carried in this section is freely available to the majority of the readership using the current internet search facilities available worldwide. Your comments on this decision would be welcome as would any suggestion for other modifications of the Journal. We look forward to developing a very active ‘Letters to the Editor’ section of the journal to further foster international debate.
Welcome to volume 8 of the Manual Therapy Journal and the first editorial for the volume. In this editorial we seek to increase the interaction between the Journal and its readers. The editorial offers the editors or invited persons the opportunity to write opinions on current trends in clinical practice, research or other academic topics as well as professional issues pertaining to the practice of manual and musculoskeletal therapy. Editorials raise what we believe to be ‘‘hot topics’’ which relate to the current political climate and new innovations in musculoskeletal therapy research and clinical practice. It is hoped that the editorials are thought provoking, sometimes challenging and perhaps inspiring to some readers. On occasions, editorials can produce counter-irritation in some of the readership, personifying some of your thoughts and feelings about musculoskeletal therapy. What we wish to encourage is further interaction between the Journal and its readership. We very much welcome your comments on Journal content and indeed suggestions for editorials in areas of politics or aspects of clinical practice which you believe require comment. There is a questionnaire about the Journal on the Journal’s web site. However, if you have something to say about the issues raised in editorials or some constructive critical
Ann Moore and Gwen Jull Editors
1
Manual Therapy (2003) 8(1), 2–9 1356-689X/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved. doi:10.1054/math.2002.0487
Masterclass
Manipulation of the cervical spine W. A. Hing*, D. A. Reid*, M. Monaghanw *School of Physiotherapy, Faculty of Health Studies, Auckland University of Technology, Auckland, New Zealand, w Physical Medicine Centre, Nelson, New Zealand
SUMMARY. In New Zealand, a new approach to manual therapy of the cervical spine has integrated physiotherapy and osteopathy techniques. The combination of the philosophies of these two professions has added a new dimension to the management of cervical spine pain. Emphasis is placed on issues of safety, such as the degree of cervical rotation and comfort for both the patient and the therapist. This is combined with biomechanical considerations, which have made the teaching and learning of these manipulative techniques less complicated and easily progressed from palpation to mobilization and onto manipulation. Appropriate patient screening and selection identified through thorough subjective and objective assessments are important aspects of this approach and reflective interpretation of all clinical findings is essential. The refinement of cervical joint positioning and an increased anatomical awareness have led to the utilization of new upper cervical high-velocity thrust techniques. Consequently, it is envisaged that an increase in the safety and specificity of cervical manipulative techniques is achieved. r 2003 Elsevier Science Ltd. All rights reserved.
Existing techniques have been modified and are considered easy to learn, as a result of progressing from assessment to treatment and from mobilization to manipulation. The purpose of this paper is to discuss manipulation of the cervical spine, detail the teaching strategies developed for cervical spine manipulation in New Zealand, outline the clinical assessment and provide examples of the procedures in practice.
INTRODUCTION In New Zealand, manipulative physiotherapy of the spine has evolved considerably in recent years. A fresh approach, integrating physiotherapy and osteopathy techniques, has emerged adding a new dimension to the management of cervical spine pain. Michael Monaghan, a physiotherapist, who subsequently trained to be an osteopath, joined the teaching faculty of the New Zealand Manipulative Physiotherapists Association (NZMPA) and this has facilitated the inclusion of this osteopathic approach. In combining these professions’ philosophies, great emphasis has been placed on issues of safety and comfort for both the patient and the therapist (Monaghan, 2001). In addition, there is an increased consideration for the anatomical and biomechanical attributes specific to this region of the cervical spine.
Current New Zealand model Since the early 1970s, the teaching of manual and manipulative therapy in New Zealand has not adhered to any particular philosophy, being an eclectic approach and including aspects of Maitland, Kaltenborn, McKenzie, Mulligan, Cyriax and other philosophies and principles. Courses have been run by special interest groups of the New Zealand Society of Physiotherapists (NZSP) and by New Zealand universities and have met the International Federation of Orthopaedic Manual Therapists’ (IFOMT) educational standards. The physiotherapy-osteopathic approach to treatment and management of the cervical spine instigated in the mid-1980s was in contrast to the older torsional techniques of past medical manipulators performed
W. A. Hing, MSc (Hons), ADP (OMT), Dip MT, Dip Phys, D. A. Reid, PGD (Manip Phys), Dip MT, BSc, Dip Phys, School of Physiotherapy, Faculty of Health Studies, Auckland, New Zealand, M. Monaghan, D.O., Dip MT, Dip Phys, Physical Medicine Centre, Nelson, New Zealand. Correspondence to: WH, School of Physiotherapy, Faculty of Health Studies, Auckland University of Technology, Private Bag 92006, Auckland 1020, New Zealand. Tel.: +64 9 9179999 x7800; Fax: +64 9 9179620; E-mail:
[email protected] 2
Manipulation of the cervical spine 3
at end of range of movement often with traction (Cyriax 1984). Techniques applied in a more controlled, comfortable manner carried out in midphysiological range appeared to be far less traumatic to the spine. In addition, some types of physiotherapy assessment and treatment were traditionally carried out in the prone position. However, a number of patients are incapable of, or have great difficulty in, assuming the prone position, (i.e. pregnant women, patients with thoracic kyphosis, the elderly and obese patients). The integration of osteopathic principles utilizes mainly supine patient positioning. These refined techniques and alternative positions offer a number of advantages that include improved therapist and patient comfort and communication. Techniques may be modified with feedback from the patient who is able to see the therapist which may reduce feelings of anxiety. These simple modifications enables a greater variety of patients to receive effective treatment for cervical pain and restricted range of motion. The therapist comfort has also been enhanced by improvements in the therapist handling and body positioning. The supine position is also preferred for assessment and can lead directly to segmental mobilization techniques and on to manipulative procedures. PATIENT ASSESSMENT Integration of the osteopathic model into physiotherapy assessment of the cervical spine requires the
practitioner to recognize all components of somatic dysfunction (Greenman, 1966; Hartman 1997; Gibbons & Tehan 2000) in the presenting patient. Somatic dysfunction is defined as ‘impaired or altered function related to components of the somatic system such as muscles, ligaments, bone and joints’ (Greenman 1966). The first stage of recognizing a patient with somatic dysfunction is derived from the subjective history. The key findings of the subjective history may be summarized under the following headings: site, stage, severity, stability, nature, irritability, progression, regularity and diagnosis (provisional) of the patient’s symptoms. These findings create the acronym SSSSNIPRD presented in Table 1. A comprehensive subjective examination should also allow the therapist to determine any contraindications to mobilization and manipulation. The second stage is the ability to combine the palpatory and objective examination findings with the subjective information gained from the ‘SSSSNIPRD’ analyses. If what is ‘felt’ is consistent with a diagnosis of somatic dysfunction, then the treatment will follow a logical progression from the assessment. The key features of the objective examination originates from the acronym ‘ARTT’ (Greenman 1966). These features are asymmetry, range of motion, tissue texture changes and tissue tenderness. In the New Zealand model, ARTT has been modified with the addition of relevant pain pattern recognition, now forming the acronym PARTT:
Table 1. SSSSNIPRD Summary Site
3
The area and site of the symptoms are clearly marked on the body chart with symptom details.
Stage
3
Is the problem acute, subacute or chronic?
Severity
3
The level of pain as determined by the patient. Pain intensity is measured with a visual analogue scale.
Stability
3
Is the condition improving, staying the same or worsening?
Nature
3
The patient’s description of their symptoms – may also be used to determine mechanical or inflammatory pain.
Irritability
3
The ease with which the symptoms are provoked, the intensity to which they arise and importantly how quickly they resolve.
Progression and rate
3
How long will the condition take to resolve and how many treatments will be required to achieve this?
Regular or irregular
3
Do the symptoms fit a regular or irregular pattern of presentation? This may include psych-social factors.
Diagnosis – provisional
3
Provisional diagnosis provided by the therapist.
# 2003 Elsevier Science Ltd. All rights reserved.
Manual Therapy (2003) 8(1), 2–9
4 Manual Therapy
function, treatment repetition, grade, amplitude and velocity of the techniques will be determined from a compilation of the SSSSNIPRD analysis and the PARTT findings. Safety aspects
Fig. 1FSegmental blocking. Example of blocking for left rotation. The therapist’s right thumb blocks the spinous process moving to the right.
Pain: The pain pattern will have been established in the history taking. This will now be tested against active movement and later passive segmental assessmentFboth physiological and accessory. Asymmetry: This needs to be related to function as, on its own, it is not relevant. An example in the cervical spine is an acute locking at C2-3 held in flexion and rotation away from the site of pain (wry neck). Functional movements would confirm this with an asymmetrical presentation. Asymmetry is not as common in the cervical spine as it is in the lumbar region. Range of movement changes: This clinical sign is the most useful, as it relates directly to the function of the cervical spine. It most often defines the direction of movement loss and, by pattern, may give a clue to the joint level. Diagnosis may be further clarified by simple active movement and segmental blocking (Figure 1). Special note is made of any referred symptoms on the active tests, whether somatic or radicular. These responses are correlated to the history findings. Passive intersegmental assessment may add information to the active tests by way of: (a) level confirmation, (b) quality of motion and (c) reactivity of tissues to movement. Tissue tension and texture changes: Information on the state of the soft tissues may also be gauged in sitting or supine lying, before assessing the active movements. The osteopathic concept places particular emphasis on this aspect of examination. Once the subjective and objective assessments are complete, confirming the presence of somatic dysManual Therapy (2003) 8(1), 2–9
With respect to the cervical spine, the osteopathic approach allows the clinician to gain information from a series of assessment procedures that test the movements of the small joints in a logical, sequential and graded sequence. These methods allow interpretation of ‘end feel’ and PARTTs. The nature and progression of the sequence allow the therapist to gain information on both joint motion and ligamentous integrity. Grading scales designed by Maitland et al. (2001) and Kaltenborn (1989) are still used to guide the therapist and can be used as an objective measure of the patient’s progress. However, in the osteopathic model, there is considerable emphasis placed on the physical assessment of the joint ‘barrier’ (Greenman 1966; Hartman 1997) and end feel. In this sense, treatment will either be short of the barrier (for a more painful problem) or into the barrier (for a more joint stiffness problem). As the patient’s signs and symptoms improve, the amount of force used to engage the barrier can be progressed. Recent literature (Thiel et al. 1994; Kuether et al. 1997) has documented that full cervical rotation and traction are the most provocative positions for vertebral artery compromise. Given that the older style of high-velocity manipulative techniques utilize end physiological range, often with a traction component, the potential for vertebral artery damage from a technical perspective was evident (Reid & Hing 2001). These factors have led to a potential reduction in the amount of manual therapy used in the cervical spine as a consequence of the potential dangers to the vertebral artery (Gibbons & Tehan 2001; Clubb 2002). The newly implemented Musculoskeletal Physiotherapy Australia (MPA) Vertebrobasilar Insufficiency (VBI) guidelines have addressed these issues with a greater emphasis on the subjective examination and the clinical reasoning process rather than the objective testing (Grant 1996; Magarey et al. 2000). Although there has been a considerable amount of evidence related to the reliability and validity of objective vertebral artery testing (Karnik et al. 1987; Refshauge 1994; Cote et al. 1996), there has been little evaluation of the physiotherapy techniques used in the cervical spine area (Reid & Hing 2001). Once the findings of the assessments have been established and a high velocity thrust (HVT) technique in the cervical spine indicated, then the type of techniques used are often termed ‘combined leverage, spinal # 2003 Elsevier Science Ltd. All rights reserved.
Manipulation of the cervical spine 5
Fig. 2FShort lever PAIVM upslope. (A) Skeletal view showing hand and finger positioning; (B) patient view with additional cervical rotation to view finger positioning. The sensor finger (a) and the motive finger (b) are marked.
manipulative thrust techniques’ (McCarthy 2001). Using the leverage of the head and those joints not included in the HVT, forces can be directed to the target joints. Thus, there is little stress on the rest of the neck and the elimination of full physiological cervical spine locking positions. In this way, the amount of cervical rotation will be minimized which has been shown to reduce the amount of stress and kinking of the vertebral artery (Haynes et al. 2002). This approach also provides a logical progression with a continuum, from palpation to mobilization then manipulation, particularly with the patient positioned in supine lying, a balance that is not achievable if palpation and mobilization are carried out in the prone position. Indications for manipulation There are a number of clinical indications that are useful in guiding therapists in the use of an HVT technique (Gibbons & Tehan 2000, 2001; McCarthy 2001): K
K
K
K
K
As a first option in acute cases, for example, if a patient is seen soon after an incident and muscle guarding is not extensive. This option is suitable if there are only two biomechanically linked directions of movement loss. If the problem is mechanical in nature and fits with a biomechanical pattern that is regular and recognizable (see Table 1, SSSSNIPRD analysis). There are no contraindications to manipulation and ligament integrity and the absence of VBI signs has been confirmed. Where the joint end feel is firm (not springy or empty) and is consistent with the clinical barrier identified during the mobilization techniques. The patient has been responding favourably through a progression of mobilization procedures, but has not progressed any further than expected.
# 2003 Elsevier Science Ltd. All rights reserved.
The next section of this paper details some of the techniques used in the New Zealand approach to cervical spine mobilization and manipulation. Commonly used manual therapy terms, utilized in the New Zealand physiotherapy and osteopathic manipulative approach, are described in Table 2. TECHNIQUES Passive intervertebral joint testing Localized passive movement has been traditionally utilized by physiotherapists and manual therapy professionals for many years. One of the most wellknown paradigms of passive movement spinal treatment is the Maitland Concept (Maitland et al. 2001). Passive spinal joint assessment consists of both passive accessory intervertebral movement (PAIVMs) and passive physiological intervertebral movement (PPIVMs). Passive accessory intervertebral movement (PAIVMS) So-called short lever techniques (Table 2) are useful for the assessment of joint glide and treatment of acute presentations and elderly patients. With all assessment and treatment using the ‘new’ approach, the patient is positioned in supine with the head supported by a pillow, while the therapist is positioned standing at the top of the plinth. Figure 2 illustrates the hand contact points and finger placement on a skeletal view (Fig. 2A) and on a patient (Fig. 2B). The therapist’s left hand is the ‘sensor’ while his right is the motive hand. The ‘sensor’ index finger (a) is placed on the articular pillar of the vertebral level to be tested (Fig. 2A). This finger senses the movement of the segment up or down the facet joint plane. The motive hand is placed with the hypothenar region contacting the occiput. By overlapping the sensing finger with the Manual Therapy (2003) 8(1), 2–9
6 Manual Therapy Table 2. Commonly used terms Term
Description
Sensing hand
This is the hand that is in direct contact with the joint to be tested. It may cover adjacent joint margins or adjacent bony point. A thorough knowledge of the anatomical landmarks is required to isolate these points.
Motive hand
This is the hand that creates the motion. It may be on another part of the head or neck or may be over the sensing hand. It is important to maintain the separate functions of these hands to increase the sensitivity of the information you are trying to gather.
Contact hand
This is the hand during a mobilising technique that is in direct contact with the joint to be mobilised.
Supportive hand
This hand supports the head during the mobilising movement and adds a counter pressure to the mobilising hand.
Short lever movements
These are testing movements or mobilisations that are in direct contact with the segments to be moved. The sensing finger and motive hand will create the movement together. They will generate accessory movement in the joint. They are useful for testing, acute spines and elderly spines that need minimal leverage and have limited physiological motion. Also applicable for hypermobile necks.
Long lever movements
These are testing and treating movements that utilise the locking of two or more cervical segments to create a lever. These are often helpful when assessing physiological movements and make the movement more specific to a particular spinal level. Combinations of rotation and side bending of the spine are utilised to achieve locking of the cervical joints.
Cradle hold
Refers to techniques where both hands cradle the head, using the soft parts of the hypothenar eminance. This allows the fingertips to remain free to palpate specific levels or create other movements. These are commonly used for long lever movements.
Chin hold
This is an alternative grip of the head where the therapist’s non-contact arm is placed along the side of the face with either a small amount of contact with the chin or none at all. This grip is used for manipulation where the therapist may have small hands making the cradle hold difficult, or for heavier heads and necks.
Upslope movement
Movements of the facet joints in the mid to lower cervical spine that occur during contra-lateral rotation or contra-lateral side bending.
Downslope movement
Movements of the facet joints in the mid to lower cervical spine that occur during ipsilateral side-bending, rotation and extention.
Fig. 3FLong lever PPIVM F mid-cervical rotation upslope to the right.
index finger of the motive hand (b), the desired movement is created, either cranially (upslope) or caudally (downslope), along the facet joint plane. If the sensing finger is over the spinous process then a central postero-anterior motion is tested. With practice, this becomes a comfortable and efficient assessment procedure (Monaghan 2001). Other directions are achieved as a modification of the above. Passive physiological intervertebral movement (PPIVMs) These mobilizations employ the principles of using a long lever (Table 2). That is, the head and neck are utilized in such a way as to create locking of the joints Manual Therapy (2003) 8(1), 2–9
Fig. 4FDownslope mobilization of the mid-cervical spine (arrow indicates direction of mobilization).
above the one to be tested. The patient position is in supine with their head supported on a pillow, while the therapist stands at the top of the plinth. Figure 3 illustrates a long lever PPIVM upslope, where the middle finger of the left sensing hand is placed over the spinous process of the level to be tested, while the index finger is over the articular pillar. These fingers move the segment up the facet plane (often referred to as upslope or flexion of the facet joint) to test, in this case, right rotation. The direction of movement should be 451 in an upwards direction to the opposite eye. The motive hand (right) cradles the side of the head over the zygomatic arch. This hand also keeps the head in # 2003 Elsevier Science Ltd. All rights reserved.
Manipulation of the cervical spine 7
some side flexion (in this case to the left). Both hands move together, to create right rotation, with the left hand predominantly sensing and the right hand being supportive. Mobilization techniques Mobilization requires the sensing hand to firm up and act as a fulcrum, while the motive hand directs the cervical spine up to the end range or clinical barrier. At this point a graded, rhythmic mobilization may be carried out. Figure 4 illustrates a long lever downslope. This technique may also be referred to as side bending or an extension mobilization. It is used to restore a loss of rotation and extension to the side of movement. The sensing hand can assist in the mobilization, but its prime function is to sense change at the level being treated. This feedback is essential to give control and safety to the technique. Manipulation techniques The sequence of palpation, mobilization and finally to manipulation, is easily learned, logical, and readily accepted by students. Other systems of manipulation may not flow as above, and the endpoint at which the thrust is applied is often poorly located, being either too tight, leading to a painful jarring, or too loose, leading to a wide amplitude thrust which may compromise safety. The use of a segmental approach also removes the emphasis from manipulation and leaves it as a natural treatment progression from mobilization. The palpation determines the quality of movement and provides information toward the decision process of treatment selection. Progressing to an HVT follows the previously described principles of mobilization, with the sensing hand firmed up and engaging the articular pillar and spinous process,
Fig. 5FCradle hold upslope on the right, HVT mid-cervical spine (arrow indicates direction of thrust). # 2003 Elsevier Science Ltd. All rights reserved.
while the motive hand cradles the occiput, directing the cervical spine to the end range or clinical barrier. The graded, rhythmic mobilization is simply progressed to a manipulative thrust that follows the desired direction (Monaghan 2001). There are two general approaches that can be considered when mobilizing and manipulating the cervical spine, direct and indirect. Direct techniques Techniques consist of the applied glide or thrust parallel to the facet joint plane. This can be referred to as a direct technique applied to that joint and is referred to as ‘upslope’ or ‘downslope’ techniques depending on the direction of the thrust. For example, consider a C4–5 segment presenting with a loss of left rotation due to a restriction of the right C4 facet gliding upwards (or cranially) on C5. A thrust is given on right C4 in an upslope (cranial) direction parallel to the facet plane (Fig. 5). In the scenario of a clinical loss of side bend of the right C5, a thrust is given on the right C4 in a downward (caudal) direction, parallel to the facet plane which is called a downslope technique (Fig. 4). If a cavitation occurs, in both the described techniques, it would occur beneath the contact hand. Indirect gapping technique This technique involves the direction of glide at right angles to the facet joint plane. It is referred to as an indirect technique. In this instance, the HVT is given on one side of the cervical spine with the aim of gapping the same level on the opposite side, an example being a thrust against the left C4–5 to ‘affect’ the right C4–5 joint. The indirect technique appears to improve all movements and appears to be a popular choice in circumstances such as an acute case of sudden onset of neck pain, as an initial treatment, as a progression or where the contact point is too tender.
Fig. 6FIndirect HVT gapping of the left C0–1 (arrow indicates direction of thrust). Manual Therapy (2003) 8(1), 2–9
8 Manual Therapy
Fig. 7FDirect HVT of C1–2Fupslope or rotation technique to the right (arrow indicates direction of thrust).
Cradle hold – chin hold The cradle hold technique (Figs. 4 and 5) follows directly from the long lever palpation, mobilization sequence and is an excellent starting point in learning cervical manipulation. Clinically, the cradle hold may be more appropriate for patients who have had a previously bad experience with a vigorous chin hold manipulation. Its only negative feature is its application in the lower cervical spine, by those therapists with small hands. The thumb on the contact point side of the neck needs to be utilized to contact the mandible to maintain control. Thus, those therapists with small hands are at a disadvantage. The chin hold grip (Figs. 6 and 7) is a potentially stronger hold, which requires practice to avoid pulling on the chin, rather then generating speed through the contact point.
UPPER CERVICAL HVT TECHNIQUES This section outlines specific manipulative techniques in the cervical spine. Particular emphasis is on the upper cervical spine, as this is the area of greatest potential danger for VBI. Each of the following upper cervical HVT techniques can be applied either using the cradle hold or chin hold and direct or indirect principles. A description of an indirect HVT to the left C0–1 segment and a direct HVT to the left C1–2 joint follow. Indirect C0–1 chin hold gapping technique To apply an HVT to the left C0–1 joint the patient is positioned in supine lying. Contact is established with the therapist’s right index finger placed posterior to the transverse process of C1 enabling the web space to cover the lower earlobe and support the head. The occiput is cradled in the therapist’s left forearm with the head rotated a few degrees to the left. Side bending of the occiput to the right follows. This has the effect of both closing the right C0–1 joint and Manual Therapy (2003) 8(1), 2–9
opening the left C0–1. To gap the left C0–1 joint (Fig. 6), the right hand must produce a force in a direction towards the opposite side of the client’s mouth, which is in the line of the C1 joint. Slight translation toward the side to be gapped (in this case to the left) to ‘lock’ the segment may be applied if required. The thrust is given via the right hand directed to the left mastoid region with 80% of the force given with the right hand and 20% countered with the left supporting forearm on the side of the face. Minimal side flexion may also be induced with the support forearm when warranted. Of note in using this technique is minimal rotation in the set up and no rotation in the thrust. These two features make this procedure both safe and comfortable. Once the indirect technique is mastered then HVT at the C0–1 segment is a very useful addition to one’s selection of treatment options. Direct C1–2 chin hold upslope technique One of the more difficult segments to manipulate with safety and comfort is C1–2. At this spinal level, it is imperative to seek end range by use of the coupled movements of side bending and rotation. Take, for example, a loss of rotation to the right due to dysfunction at the left C1–2 facet. To perform an HVT to the left C1–2, contact must be on the left C1– 2 facet. The therapist’s left index finger is placed on the arch of the atlas and the right forearm supports the occiput (Fig. 7). The occiput is side bent to the left, which effects right rotation at C1–2. This is followed by further rotation of the C1–2 joint until the end range for that segment is determined. This should be approximately half of the normal available physiological cervical rotation. The thrust is given via the left hand in an upslope direction towards the lower aspect of the right orbit and there is no added occipital rotation (Fig. 7). This procedure ensures that rotation at the C1–2 joint is still achieved, but the amount of physiological rotation is reduced. Again, the amount of force used is 80% with the left contact hand and 20% with the support hand and forearm. Importantly, as with the previous C0–1 technique described, the support hand is more of a counter pressure rather than an assistor.
CONCLUSION With the combination of osteopathy and physiotherapy, the new approach adopted in New Zealand focuses on a number of features. Appropriate patient selection is achieved through a thorough patient assessment, consisting of both subjective (SSSNIPRD) and objective (PARTT) components and analyses, and having a sound knowledge of contraindications to cervical manipulation. By refining the manual assessment and manipulative techniques, taking into # 2003 Elsevier Science Ltd. All rights reserved.
Manipulation of the cervical spine 9
consideration both the patient and therapist position and a knowledge of anatomy and biomechanics in the cervical region, it is envisaged that an increase in the safety and specificity of cervical manipulative techniques is achieved. References Clubb D 2002 Cervical manipulation and vertebral artery injury: A literature review. The Journal of Manual and Manipulative Therapy 10(1), 11–16 Cote P, Kreitz BG, Cassidy JD, Thiel H 1996 The validity of the extension–rotation test as a clinical screening procedure before neck manipulation: A secondary analysis. Journal of Manipulative and Physiological Therapeutics 19(3), 159–163 Cyriax J 1984 Textbook of Orthopaedic Medicine 11th edn. Balliere Tindall, London Gibbons P, Tehan P 2000 Manipulation of the Spine, Thorax and Pelvis: An Osteopathic Perspective, 1st edn. Churchill Livingstone, Edinburgh Gibbons P, Tehan P 2001 Spinal manipulation: Indications, risks and benefits. Journal of Bodywork and Movement Therapies 5(2), 110–119 Grant R 1996 Vertebral artery testingFThe Australian Physiotherapy Association protocol after 6 years. Manual Therapy 1, 149–153 Greenman PE 1966 Principles of Manual Medicine, 2nd edn. Wilkins and Wilkins, Baltimore Hartman L 1997 Handbook of Osteopathic Technique, 3rd edn. Chapman & Hall, London Haynes MJ, Cala LA, Melsom A, Mastaglia FL, Milne N, McGeachie JK 2002 Vertebral arteries and cervical rotation:
# 2003 Elsevier Science Ltd. All rights reserved.
Modeling and magnetic resonance angiography studies. Journal of Manipulative and Physiological Therapeutics 25, 370–383 Kaltenborn FM 1989 Manual Mobilisation of the Extremity Joints. 4th edn. Olaf Norlis Bokhandel, Oslo Karnik R, Stollberger C, Ammerer H, Perneczky G, Slany J, Brenner H 1987 Validity of continous-wave Doppler sonography of the vertebrobasilar system. Angiology 38, 556–561 Kuether TA, Nesbit Clark W, Barnwell S 1997 Rotational vertebral artery occlusion: A mechanism of vertebrobasilar insufficiency. Neurosurgery 41(2), 427–432 Magarey M, Rebbeck T, Coughlan B, Rivett D 2000 APA premanipulative testing protocol for the cervical spineFresearched and renewed. Part 2FRevised clinical guidelines. Australian Physiotherapy Association, Australia Maitland GD, Hengeveld E, Banks K, English K 2001 Maitland Vertebral Manipulation, 6th edn. Churchill Livingston, Edinburgh McCarthy C J 2001 Spinal manipulative thrust technique using combined movement theory. Manual Therapy 6(4), 197–204 Monaghan M 2001 Spinal Manipulation: A Manual for Physiotherapists. The Copy Press Ltd., Nelson, New Zealand Refshauge KM 1994 Rotation: A valid premanipulative test: does it predict safe manipulation? Journal of Manipulative and Physiological Therapeutics 17(1), 15–19 Reid DA, Hing WA 2001 AJP Forum: Pre-manipulative testing of the cervical spine. Australian Journal of Physiotherapy 47, 163–167 Thiel H, Wallace K, Donat J, Yong-Hing K 1994 Effect of various head and neck positions on vertebral artery blood flow. Clinical Biomechanics 9, 105–110
Manual Therapy (2003) 8(1), 2–9
Manual Therapy (2003) 8(1), 10–20 1356-689X/03/$ - see front matter # 2003 Elsevier Science Ltd. All rights reserved. doi:10.1054/math.2002.0480
Review article
Evidence for exercise therapy in mechanical neck disorders H. Sarig-Bahat Department of Physical Therapy, University of Haifa, Haifa, Israel
SUMMARY. In spite of neck disorders being so common in the population, little evidence supporting effective interventions has been identified. The objective of this systematic review was to determine if various exercise methods are effective in treating the different mechanical neck disorders occurring in adults. Sixteen trials were included: nine randomized controlled trials (RCTs) and seven randomized comparative trials (CTs). The average PEDro score indicated moderate methodological quality. PEDro results showed the subject- and therapist-blinding criteria to be inappropriate. Findings revealed relatively strong evidence supporting the effectiveness of proprioceptive exercises and dynamic resisted strengthening exercises of the neck–shoulder musculature for chronic or frequent neck disorders. Moderate evidence was found to support early mobilizing exercises in acute whiplash patients. The evidence identified could not support the effectiveness of group exercise, neck schools or single sessions of extension–retraction exercises. Clinicians are encouraged to incorporate these findings into their practice when planning the management of mechanical neck disorders. There is great need for well-designed RCTs to further investigate the topic and perhaps evaluate exercise effectiveness in relation to more specific disorders, e.g., discogenic vs facet joint originated disorder. r 2003 Elsevier Science Ltd. All rights reserved. active participation of the patient in treatment, which may play an important psychological role, by transferring responsibility for wellbeing to the patient. Exercise therapy incorporates a large variety of methods such as mobilizing exercises, stretching, isometric/static or dynamic strengthening, endurance training and proprioceptive exercises. The various exercise types are commonly applied according to the clinician’s perception of their benefits, reasoned by various theories, but seldom based on evidence. In this age of increasing accountability, health fund and compensation demands, there are increasing expectations of evidence-based treatment. Thus the objectives of this review were to present existing evidence for the use of exercise therapy in the management of mechanical neck disorder, and to determine which exercise methods are effective in treating the various mechanical neck disorders.
BACKGROUND Modern lifestyle seems to be changing the prevalence of cervical compared to lumbar disorders. In North America (Saskatchewan, Canada) lifetime prevalence of neck pain is 66.7% (Coˆte´ et al. 1998). The reason for this may lie in the increasing time spent on office and computer work. Also, a significant proportion of mechanical neck disorders consist of whiplashassociated disorders (WAD). Substantial proportions of the population are affected for up to 2 years postinjury: 44% of those involved in a rear-end collision complained of neck stiffness at 6 months after injury (Brison et al. 2000). In spite of neck disorders being so common in the population, little evidence supporting effective interventions has been identified (Gross et al. 2001). Exercise therapy is one commonly used treatment modality for mechanical neck disorders. It demands
METHOD
Received: 8 November 2001 Revised: 12 June 2002 Accepted: 25 July 2002
Search strategy Five databases were searched: AMED, CINAHL, EMBASE, SportsDiscus and PEDro. Keywords used: neck or cervical and exercise, combined with trial or RCT.
Hilla Sarig-Bahat B.P.T, M Phys (Manip), MAPA, MMPA, Manipulative Physiotherapist, Department of Physical Therapy, University of Haifa, Mount Carmel, Haifa 31905, Israel. Correspondence to: HS-B. E-mail:
[email protected] 10
Exercise therapy for neck disorders 11 Table 1. An example search from CINAHL No. 1 2 3
Critical appraisal method
Search history
Results
[(neck or cervical) and exercise] and (limit to abstracts) (RCT or trial) and (limit to abstracts) 1&2
127 4768 12
The search was limited to studies published between January 1985 and October 2001, in the English or Hebrew language. An example of the search process and the results is presented in Table 1.
Inclusion and exclusion criteria Population Studies whose participants were human adults over 18 years of age, with mechanical neck disorder, were included in this review. Mechanical neck disorders correspond to diagnostic categories 1 and 2 (neck pain with or without referral to proximal extremity) of the classification system proposed by the Quebec Task Force on Spinal Disorders (Spitzer et al. 1987). These disorders include conditions with muscle, joint, ligament, disc, or degenerative involvement (e.g., myofascial pain syndrome, spondylosis, whiplash injuries, etc.). Studies that include subjects with neck disorders with definite neurological deficit, and those that include subjects with neck pain caused by other pathological entities such as diffuse connective tissue diseases, rheumatic syndromes, metabolic and endocrine diseases, neurological diseases, neoplasms, fractures or dislocation were excluded. Study design Randomized controlled trials (RCTs) and nonrandomized controlled trials (NRCTs) were accepted for inclusion in this review. RCTs and NRCTs had to compare at least two interventions (i.e. at least one exercise intervention compared with control or placebo, or a comparison of two or more interventions, exercise being one of them). Other study designs such as cohort studies or case series were excluded. Intervention Various types of active exercise were accepted: stretching, strengthening, endurance or aerobic training, postural correction, neuromuscular control and movement awareness. Exercise described as phasic, isometric, isotonic or isokinetic also fulfilled this inclusion criterion. Any passive intervention such as manual therapy, manipulative therapy and electrotherapy were excluded. Exercise used in combination with other passive interventions was also excluded. # 2003 Elsevier Science Ltd. All rights reserved.
The PEDro scale was used to evaluate the methodological quality of all trials identified. It has been developed by physiotherapists, for quality evaluation of physiotherapy trials and has been endorsed by the Cochrane Collaboration, the Australian Physiotherapy Association, and the School of Physiotherapy at the University of Sydney. Nine criteria are based on the Delphi list (Verhagen et al. 1998) established by expert consensus. Two criteria not on the Delphi list (adequacy of follow-up and between-group statistical comparison) have been added to the PEDro scale. The scale has been partially validated: randomization, concealed allocation, blinding and adequacy of follow-up were empirically validated (Moher et al. 1999). The other items have face validity but, however, are yet to be empirically validated (Moseley et al. 2002). Moseley et al. (1999) have shown acceptable inter-rater reliability of the PEDro scale. Quality evaluation blinding has been achieved using the rates published on the web site (http:// ptwww.cchs.usyd.edu.au/pedro) as an additional independent reviewer to the author. The author informed PEDro of any discrepancy found. A PEDro score was calculated by adding up all ‘yes’ answers from the 11 criteria. The first criterion (eligibility) was included in the total score (unlike the original scoring instructions), as it assesses external validity of the study, i.e. population selection could be biased if inclusion/exclusion criteria are not well defined.
Evidence weighting The evidence weighting system was based on that of Linton and van Tulder (2001) who defined four levels of evidence: Level AFStrong evidence: consistent findings from multiple RCTs. Level BFModerate evidence: one RCT or consistent findings from multiple NRCTs. Level CFLimited evidence: only one NRCT. Level DFNo evidence: no RCTs or NRCTs. As no NRCTs were identified in this review, level C became irrelevant and therefore only three levels remained: Strong, moderate and no evidence.
RESULTS Sixteen RCTs were included in this systematic review. The average PEDro score was 671.31 (54%). Scores ranged from 4 to 9, with only one trial achieving 9 (Bronfort et al. 2001), and no trial achieving 8. PEDro scores are presented in Table 2 in a descending fashion. Manual Therapy (2003) 8(1), 10–20
12 Manual Therapy Table 2. RCTs PEDro scores Criteria Author Bronfort et al. (2001) Kamwendo & Linton (1991) Vasseljen et al. (1995) Friedrich et al. (1996) Rosenfeld et al. (2000) Taimela et al. (2000) Jordan et al. (1998) Takala et al. (1994) Levoska and KeinanenKiukaanniemi (1993) McKinney (1989) So¨derlund et al. (2000) Wailing et al. (2000) Randlov et al. (1998) Revel et al. (1994) Hanten et al. (1997) Fitz-Ritson (1995)
A B C D E F G H I J K T Y Y Y Y N N Y Y Y Y Y 9 Y Y N Y N N N Y Y Y Y 7 Y Y Y Y Y N Y
Y Y Y Y Y Y Y
N N Y N N N N
Y Y Y Y Y Y Y
N N N N N N N
N N N N N N N
N Y N Y N Y N
Y Y Y Y Y Y Y
Y N N N N N N
Y Y Y Y Y Y Y
Y Y Y Y Y Y Y
7 7 7 7 6 6 6
Y Y Y Y Y N N
Y Y Y Y Y Y Y
Y N N N N N Y
Y Y Y Y Y Y N
N N N N N N N
N N N N N N N
N N N N N N N
N N N N N N Y
N N N N N N N
Y Y Y Y Y Y N
Y Y Y Y Y Y Y
6 5 5 5 5 4 4
Mean
6
Standard deviation
1.31
Key: A: Eligibility, B: Random allocation, C: Concealed allocation, D: Baseline comparability, E: Blind subjects, F: Method-blind therapists, G: Blind assessors, H: Adequate follow-up, I: Intention to treat analysis, J: Between-group comparisons, K: Point estimates and variability, T: Total (out of 11), Y: Yes, N: No.
Fig. 1FPercentage of rated RCTs that satisfied each criterion of the PEDro scale.
Criteria E (blind subjects) and F (method-blind therapists) were never fulfilled. Figure 1 presents the frequency distribution for each criterion. Collected trials were subdivided according to population type: whiplash-associated disorders (WAD), chronic neck pain and others. The main parameters of each trial i.e. participants, intervention type, outcome measures and results are summarised in Tables 3–7. These tables are organized into two main categories, i.e. whiplash and chronic, and subdivided according to the type of exercise (group, proprioceptive, strengthening etc.). Four RCTs studied WAD: McKinney (1989) conducted a well-designed RCT (6 PEDro score) which showed early mobilization exercises to be effective in reducing pain and encouraging recovery in acute whiplash patients. Rosenfeld et al. (2000) also provided supportive evidence for the use of Manual Therapy (2003) 8(1), 10–20
active exercises in treatment of acute whiplash patients. In this relatively good quality (7 PEDro score) RCT, best results were gained when exercise therapy, comprising frequent active movements, was administered early (within 96 h) rather than after 2 weeks. So¨derlund et al. (2000) compared two exercise programmes given to acute whiplash patients. His basic program included active neck–shoulder training, relaxation and general advice. An additional isometric extension exercise given to the second group was found to have no benefit over the basic programme. All subjects showed significant improvement in physical measures; however, effectiveness of this exercise programme could have been strengthened by a comparison to a placebo/control group. Unlike the three studies above, Fitz-Ritson (1995) studied Phasic exercises for eye–neck–arm coordination. These proprioceptive exercises had a greater effect on pain reduction, than chiropractic treatment with strengthening exercises. In the Whiplash category, this trial scored lowest for quality (4). Fitz-Ritson considered the chiropractic and exercise group as a control group, based on findings of a pilot study, which treated whiplash patients with similar method, and resulted in no improvement. Various treatment approaches were evaluated in relation to chronic or recurrent neck pain. Three RCTs studied the effectiveness of group exercise (Jordan et al. 1998, Vasseljen et al. 1995, Takala et al. 1994). Exercise regimes included resisted neck/ shoulder exercises and aerobic training. Jordan et al. (1998) and Vasseljen et al. (1995) both showed that group exercise reduced pain, thus with no significant advantage over individual physiotherapy. When compared to a control group (Takala et al. 1994), only slight, if any, short-term effect was shown. These three studies scored 6–7 on the PEDro scale, reflecting relatively high methodological quality. Proprioceptive exercise and its effect on chronic neck pain were challenged by Taimela et al. (2000) and Revel et al. (1994). Findings were partially consistent: Revel et al. (1994) reported significant beneficial effect of the proprioceptive exercise, demonstrated by both subjective and objective measures. Taimela et al. (2000) found significant differences in favour of the exercising group only in the subjective measures, but not in the objective ones. They scored higher than Revel et al. on the PEDro scale (7 compared with 5, respectively). Four RCTs (Bronfort et al. 2001, Wailing et al. 2000, Randlov et al. 1998 and Levoska and Keinanen-Kiukaanniemi 1993) have shown supportive findings for strengthening exercises in chronic neck disorders. All four studies included dynamic resisted exercises for the neck and shoulder region in their training protocols. Equipment used for that purpose # 2003 Elsevier Science Ltd. All rights reserved.
Exercise therapy for neck disorders 13 Table 3. Whiplash-associated disorders (WAD) Participants Rosenfeld et al. (2000) 97 Patients with acute whiplash associated disorder (WAD). 88 followed up after 6 months (29M, 59F) G1, n=21 G2, n=23 G3, n=22 G4, n =22
So¨derlund et al. (2000) 59 (35F, 24M) Symptomatic patients with acute whiplash injury. Mean age 34 years. RT, n=29 AT n=30
McKinney (1989) 170 (88M, 82F) Age: G1F28.778.9 G2F31.6711.3 G3F30.2711.3 Whiplash injury, Acute (o7 days).
Fitz-Ritson (1995) 30 patients: age 3777yr. 19M, 11F G1, n=15 G2, n=15 12 wk after a vehicle accident, with cervical pain/ stiffness.
Intervention
Outcome measures
Reported results
G1FActive treatment within 96 h: repeated active, small range rotational neck movements consistent with McKenzie’s principles. These movements were repeated 10 times in each direction every waking hour. G2FStandard treatment within 96 h: initial rest, recommended use of soft collar, gradual active movements 2–3 times daily a few weeks after injury. G3FActive treatment after 2 weeks. G4FStandard treatment after 2 weeks.
(1) Cervical ROM: Inclinometer was used to measure flexion– extension. A compass was used to measure rotation. (2) Pain was measured by VAS. Measures were registered initially and at 6 months.
Active treatment reduce pain more than standard treatment (Po0.01). Active management gained best results when administered early. Standard treatment had better effect on pain reduction when administered late.
G1F Regular treatment group (RT) was given an exercise programme including instructions for self-neck-care, fair distance walking, and three exercises to pain limit: cervical rotations; arms elevation; deep breaths with shoulder shrugging and relaxing. G2F Additional exercise treatment group (AT) was given the same programme, with an additional exercise, pressing the corners of an imaginative quadrangle against the floor, 3 reps, 3/ day.
(1) (2) (3) (4)
Pain disability index. Self-Efficacy Scale. Coping strategies questionnaire. Patients’ cervicothoracic posture was assessed by a manual goniometer. (5) Cervical rotation range of motion.
No significant interaction effects or group differences were shown (ANOVA analysis). All showed significant improvement in physical measures over time. No additional benefit was demonstrated in the AT group.
G1Frest of 10–14 days + analgesic (considered control). G2FPhysiotherapy: heat/cold, short wave, diathermy, hydrotherapy, traction and active and passive mobilization. G3FAdvice on self-mobilization: posture, home self-mobilization exercises, restricted use of collar to short periods. All patients were fitted with a soft collar and were given analgesic.
(1) Pain (VAS). (2) Recovery time. Monthly follow up, for 12 months.
Recovery was significantly better in patients given advice on early mobilization to do at home, than in other patients (w2=5.43, df=1, P=0.02). Early mobilization was found more effective in relieving neck pain in acute neck sprains, than physiotherapy or rest.
G1FChiropractic treatment + exercises including ROM exercises, stretching, isometric-toning, isokinetic-strengthening.* G2FChiropractic treatment + Phasic exercises for eye–neck–arm coordination. *G1 was considered by the author as a control group, based on a pilot study described. This study was defined an RCT.
Neck Pain Disability Index (adapted).
Significant improvement was reported in both groups, greater in G2 (G1 7.4%, P40.05, G2 48.3%, P40.001). No in-between group statistical analysis was presented, giving no base to any conclusion.
Key: F: Female, M: Male, Yr: Years, G1: Group one, G2: Group two, G3: Group three, VAS: Visual Analogue Scale, Min: Minute, Wk: Week.
varied: Wailing et al. (2000) used air machines, which resisted the concentric part of movement. Levoska and Keinanen-Kiukaanniemi (1993) preferred the higher technology omnikinetic machine, similar in concept to the MedX machine used by Bronfort et al. (2001). Randlov et al. (1998) favoured simple free weights to provide resistance. # 2003 Elsevier Science Ltd. All rights reserved.
Both Wailing et al. (2000) and Levoska and Keinanen-Kiukaanniemi (1993) showed strengthening exercise significantly effective compared to the control group, however, not more beneficial than endurance training, body awareness training (Wailing et al. 2000), and passive physiotherapy (Levoska and Keinanen-Kiukaanniemi 1993). In addition, Bronfort Manual Therapy (2003) 8(1), 10–20
14 Manual Therapy Table 4. Chronic/frequent neck disordersFgroup exercise Participants Jordan et al. (1998) 119 Subjects, 20–60 years of age. Chronic neck pain, non-radicular extremity pain.
Vasseljen et al. (1995) 24F office workers, neck and shoulder pain 4for 3 days continuously during last 2 wk. G1, n=12 G2, n=12 G3, n=9: additional group of patients with more severe symptoms.
Takala et al. (1994) 44F, age 20–55yrs. Printing company. Frequent neck symptoms.
Intervention
Outcome measures
Reported results
G1FGroup exercise: bicycling 5 min, stretching 10 min, intensive training of neck muscles on isometric strength unit. 30% of maximal power, set=12 repetitions, 1 set for F, 3 sets for E, LF. Cool-down cycling 5 min. 1 h a session 2/wk for 6 wks. + home exercise programme. G2FIndividual physiotherapy: included a combination of passive (hot pack, US, traction, massage) and active elements = same home exercise given to G1. G3FChiropractic manipulation of cervical spine, traction, same home program. 45 min sessions 2/wk for 6 wks. All patients participated in a single ‘neck school’ session.
(1) Self-reporting disability scale (source reference given). (2) Doctor’s global assessment. (3) Patient perceived effect. (4) Self-reported pain (11-point scale). (5) Maximal isometric strength of flexor and extensor muscles. Follow-up at 4, 12 months.
Patients in all groups showed approximately 50% reduction in pain and disability. There was no significant difference between groups (P=0.44) at treatment conclusion.
G1FIndividual physiotherapy: 1 h treatment 10, included massage, strength and flexibility exercises, stretching, passive mobilization, ergonomic advice, home exercise. G2FGroup exercise: 30 min sessions, during working hours, 3/week, for 6 wk. Exercise regime adopted (Dyrssen et al. 1990) included resisted exercises for neck and shoulder. G3FIndividual physiotherapy: details were not provided.
(1) Trapezius muscle activity measured by surface EMG. (2) Pain (VAS). (3) Perceived general tension (VAS). (4) Trigger points, measured by an algometer for pressure pain sensitivity, and palpated. (5) Strength: for G3 only. Maximal shoulder elevation.
Perceived general tension and pain were significantly reduced in all groups (Po0.05), while muscle activity remained unchanged. Individual physiotherapy and group exercise at the workplace were approximately equally effective in alleviating pain and perceived general tension. The improvement was maintained better by G1 at 6 months follow-up than by G2.
Two groups were matched according to age, frequency of pain, work task. Cross-over design: treatment group and the control group were reversed in the second intervention. G1FGroup gymnastics during work hours, 45 min 1/wk, for 10 wk. Whole body training: aerobic dynamic exercise, stretching, relaxation. G2Fcontrol.
(1) Pain and disability (VAS). (2) Pressure pain threshold (PPT).
Only slight if any short-term effect of group gymnastics on neck pain, disability and PPT. The effect did not remain after cessation of the training.
Key: F: Female, M: Male, Yr: Years, G1: Group one, G2: Group two, G3: Group three, VAS: Visual Analogue Scale, Min: Minute, Wk: Week.
et al. (2001) could not demonstrate the superiority of the MedX program, and Randlov et al. (1998) showed no significant difference when altering training intensity. Sporadic trials studied additional aspects of exercise therapy in mechanical neck disorders. Hanten et al. (1997) studied patients with trigger points, and found one session of extension/retraction exercises to be of no benefit. Neck schools’ ineffectiveness was demonstrated in the work of Kamwendo and Linton (1991). Manual Therapy (2003) 8(1), 10–20
DISCUSSION Methodological quality The majority of trials were rated 7 or less on the PEDro scale, leading to two possible explanations. One explanation could be that the trials have presented limited quality. Another could be that the PEDro scale does not fully express the true methodological quality of physiotherapy trials. The ‘blind subjects’ and ‘Method# 2003 Elsevier Science Ltd. All rights reserved.
Exercise therapy for neck disorders 15 Table 5. Chronic/frequent neck disordersFproprioceptive exercises Participants Taimela et al. (2000) 76 Patients (22M, 54F) with nonspecific recurrent or chronic neck pain, longer than 3 months. G1, n=25 G2, n=25 G3, n=26 62 participated in 1-year follow-up.
Revel et al. (1994) 60 Subjects with chronic neck pain for more than 3 months. G1, n=30 G2, n=30
Intervention
Outcome measures
Reported results
G1FActive treatment included cervicothoracic stabilization, relaxation, eye fixation exercises, seated wobble board training to improve postural control and behavioral support to reduce anxiety. Two 45-min sessions per week, during 12 wk. G2FHome regimen included a neck lecture and two practical training sessions for home exercises. G3FControl group received one lecture regarding neck care and written information about home exercises.
(1) Subjective pain and disability: A questionnaire inquired about above and included a VAS. (2) Cervical ROM was assessed with a helmet equipped with a goniometer. (3) Pressure pain threshold in the upper trapezius and levator scapula muscles was assessed using a mechanical force gauge. All the above were measured at baseline, at 3 months, and at 12 months.
Subjective measurements differed significantly in favuor of the active group (Po0.01– 0.03) that emphasized exercises. No significant differences were shown in objective measurements of cervical function among the three groups.
G1Fproprioceptive rehabilitation: 15 individual exercise sessions 2/wk, for 8 wk. Exercise were mainly concerned with eye–neck coordination, detailed protocol presented in article. G2FControl: only symptomatic treatment (anti-inflammatory drugs, etc.).
(1) Pain (VAS). (2) Medication intake. (3) Measurements of cervicocephalic kinesthesia = head relocation ability. (4) Patient’s overall assessment of functional improvement. (5) Cervical ROM. Follow-up at 10 wk.
Difference between mean head relocation ability (HRA) before and after Rx was highly significant in G1 (P=0.0004), and none in G2. Neck pain decreased in both groups, but improvement in G1 was significantly greater. Small but significantly greater improvement in rotation ROM in G1 compared to G2.
Key: F: Female, M: Male, Yr: Years, G1: Group one, G2: Group two, G3: Group three, VAS: Visual Analogue Scale, Min: Minute, Wk: Week.
blind therapists’ criteria were never fulfilled. They seem to be irrelevant and unrealistic for physiotherapy trials, and therefore this strengthens the second theory. ‘Concealed allocation’ and ‘intention to treat’ were rarely fulfilled; however, the author believes these do demonstrate true quality faults. Methodological limitations of this systematic review included searching in English alone, lack of trials selection blinding and absence of metaanalyses.
persistent neck pain. Takala et al. (1994) could not demostrate evidence of benefit while Jordan et al. (1998) and Vesseljen et al. (1995) showed favourable results for exercising although not greater than that of individual physiotherapy. If one uses the weighing system alone, ignoring the negating evidence (Takala et al. 1994), it may seem that strong supportive evidence (2 RCTs) has been collected. Nevertheless, it is important to note that exercise protocols were not identical, e.g. frequency of sessions varied, which may limit comparability between trials.
Exercise therapy in whiplash associated disorders
Proprioceptive exercises for chronic neck pain
Strong evidence (level A) exists to support the effectiveness of early active mobilizing exercises in acute whiplash patients based on the findings of McKinney (1989), Rosenfeld et al. (2000), and So¨derlund et al. (2000). The effectiveness of phasic exercises in treatment of whiplash patients is questioned due to the low quality of the one RCT identified (Fitz-Ritson 1995) that studied the subject.
There is strong evidence (level A) to support the effectiveness of proprioceptive exercise in reducing subjective pain and disability. Conflicting evidence exists in regard to the effect of this intervention on objective neck function. Further research is needed of new and intriguing exercise method to reliably evaluate effectiveness.
Strengthening exercises for chronic neck pain Group exercise for chronic/frequent neck pain Takala et al. (1994), Vasseljen et al. (1995) and Jordan et al. (1998) provide inconsistent evidence regarding the use of group exercise when treating # 2003 Elsevier Science Ltd. All rights reserved.
Strong evidence (level A) supporting the use of strengthening exercises was identified, which consisted of dynamic resisted exercises for the neck and shoulder region. Although shown effective, these Manual Therapy (2003) 8(1), 10–20
16 Manual Therapy Table 6. Chronic/frequent neck disorders Participants Bronfort et al. (2001) 191 patients with chronic mechanical neck pain for 12 wk or more. Age: 20–65 years G1, n=63 G2, n=60 G3, n=64
Wailing et al. (2000) 103 Women with work-related neck–shoulder pain. Mean age 38.275.8. All had history of at least 1 year, decreased cervical ROM, and one or more trigger points tender in the Trapezius muscle.
Randlov et al. (1998) 77F: G1, n=36 G2, n=41 Chronic neck/shoulder (>6 months)
pain
Manual Therapy (2003) 8(1), 10–20
strengthening exercises Intervention
Outcome measures
Reported results
G1FSpinal manipulation with neck exercises: 20 sessions of 15-min manipulations by a chiropractor, followed by a 45 min exercise session including strengthening exercises for neck and upper body (push ups and dumbbell weights shoulder exercises), aerobic warm up and light stretching. G2FNeck exercise: Individual sessions supervised by a physiotherapist. Sessions included stretching, upper body, strengthening using MedX machine (resisted cervical extension and rotation), and 15– 20 min aerobic exercise. G3FSpinal Manipulation alone: 15 min chiropractic treatment as described in G1. This group also received 45 min sham micro-current therapy.
Subjective measures: (1) Neck painF11 box scale*. (2) Neck Disability Index (adapted). (3) Functional health statusmeasured by Short Form 36. (4) Global improvementF9 point ordinal scale*. (5) Satisfaction with careF7 point scale*. (6) Medication useF5 point scale*. *Reliability not reported. Objective measures (assessed by blinded examiners): (1) ROM for flexion, extension, rotation and side bending was measured with a CA6000 Spine Motion Analyzer. (2) Isometric muscle strength F measured using computerized dynamometer for cervical flexion, extension and rotation. (3) Muscle enduranceFstatic endurance was measured by elevating head just free of support with 60% MVC. Dynamic endurance was recorded as number of repartitions until failure.
There were no significant differences between groups in subjective measures. All groups presented substantial subjective improvement. Manipulation with exercise group showed greater gains in all objective measures than the manipulation group. Also gained more improvement in flexion endurance and flexion/rotation strength. Exercise group had better improvement in extension strength and flexion-extension ROM than manipulation group.
G1FStrength training: concentric resisted exercises including latissimus pulldown, triceps press, shoulder flexion and scapular retraction. 3 10 repetitions. G2FEndurance training: arm cycling 3 min + arm exercises using rubber expanders 3 min. G3FCo-ordination training: Body awareness training classes. G4FControl group: no exercise were performed. Control group studied and discussed stress management.
(1) PainFusing VAS for ‘pain in general’, ‘pain at worst’, ‘pain at present’. (2) Pressure pain threshold was evaluated using a pressure algometer, over 3 trigger points in the Trapezius muscle. (3) A five graded categorical scale evaluated satisfaction regarding effect of training.
The exercise groups decreased pain at present and at worst significantly compared to the control group (Po05). Pain thresholds were significantly reduced in the three trigger points in the exercisers compared to the controls (Po0.05). No significant differences were found in comparisons between exercise groups.
G1FIntensive training: bicycling and stretching 10 min, seven neck and shoulder exercises (different from the other group’s) 20 repetitions, five rounds, resistance increased. G2FLight training: Hot pack 14 min, bicycling and stretching 15 min, six neck and shoulder exercises, each 20 repetitions. Group sessions of 1.5 h 3/wk, for 3 months, total 36 sessions both groups.
(1) Pain (11-point scale). (2) Pain relieving medication intake. (3) Disability scale (demonstrated good reliability & validity). (4) Maximal voluntary isometric contraction of flexors and extensors of the cervical spine.
Both groups improved significantly with regards to objective measurements (Po0.05), but no significant difference between groups could be demonstrated.
# 2003 Elsevier Science Ltd. All rights reserved.
Exercise therapy for neck disorders 17 Levoska & Keinanen-Kiukaanniemi (1993) 47 Females who worked using personal computers. Neck & shoulder symptoms once a week or more. Muscle spasm and tenderness in neck & shoulder regions on palpation. G1, n=22 G2, n=20 G3, n=14
G1FPassive Physiotherapy: Surface heat, massage, stretching and physical exercising of neck & shoulder muscles. No home exercise. G2FActive physiotherapy: Stretching & dynamic muscle training of neck & shoulder regions. Resistance provided via an omnikinetic training machine, endurance was trained according to measurements before treatment. Daily home exercises programme. 60 min sessions 3/wk, total 15 sessions. G3FControl: no treatment group.
(1) Maximal isormetric neck muscle strengthFmeasured using a dynamometer for cervical E, LF, grip, elbow F & shoulder elevation. (2) Endurance forces of shoulder muscles. (3) Muscle tone in neck, shoulder and scapular areas, assessed by manual palpation. (4) Tender points in trapezius & levator scapulae ms. Assessed using a pressure threshold meter. (5) Neck and shoulder symptoms were assessed by a questionnaire standardized for this purpose.
Both active & passive physiotherapy relieved neck & shoulder symptoms effectively. Occurrence of those symptoms was significantly lower after active than after passive physiotherapy (Po0.05). Both interventions resulted in a decrease of muscle tone and of tender palpated points in neck region. Muscle tone decreased significantly only in G1. Maximal isometric & endurance forces were improved by active training. In conclusion, active physiotherapy was at least as effective as passive physiotherapy.
Key: F: Female, M: Male, Yr: Years, G1: Group one, G2: Group two, G3: Group three, VAS: Visual Analogue Scale, Min: Minute, Wk: Week.
Table 7. Others Participants Hanten et al. (1997) 60 Subjects (42F, 18M). Age: 2979.2 yr Subjects presented with one or more active or latent cervical and/ or scapular trigger points. Friedrich et al. (1996) 87 patients (33F, 54M). G1: n=47, age 49713.6 G2: n =40, age 47711.6. Neck or low-back pain for more than 6 wks.
Kamwendo & Linton (1991) 79 Females Age: 39.47 10.7 yr Disorder: Neck pain without radiation, or shoulder region. ‘During previous year’
Intervention
Outcome measures
Reported results
G1FOccipital release = manual traction for up to 15 min. G2FActive head retraction and retraction/ extension exercises. 10 repetitions 5 sets. G3FControlFNo treatment.
Pressure pain threshold was measured using a pressure algometer.
No significant difference was shown between the treatment groups and the control group (P40.05) after one session of treatment.
G1FSupervised group: individual instructions by a physiotherapist in 8 sessions+ daily home exercise 20 min G2FBrochure group: patients were given a brochure describing the exercises to carry out. Patients continued home exercising without guidance. Were told to exercise 20 min once daily. All patients received one of three different brochures.
(1) Pain (VAS) (2) Muscle force: The force of the deep cervical flexors, rhomboids, abdominal muscles, gluteus maximus & medius was assessed by a manual muscle testing (0–5 scale). (3) Muscle length: Muscles assessed: upper trapezius, pectorlais major, iliopasoas, quadratus lumbroum. 4level scale. (4) Performance of exercises (4-grade quality scale).
A significant difference between the groups was shown with in all outcome measures in favour of the supervised group. The quality of exercise performance was correlated both with muscle status (r= 0.47, Po0.01) and with pain relief (r=30, Po0.01).
(1) Traditional neck school: exercise, self-care, and relaxation. Exercise = active, stretching for neck and shoulder. ‘The importance of regularly performing exercise was stressed’. (2) Reinforced neck school: psychological counseling ergonomics, exercise, self- care, and relaxation. (3) Control = no treatment. 4 wk of treatment. Follow-up: 6 months.
(1) VAS for pain and for fatigue. (2) ROM. (3) Sick leave. (4) Ergonomic knowledge (13 question test). (5) Expectancy. (6) Workload rating. (7) Implemented change and acquired equipment. (8) Compliance. (9) Additional health care contacts.
No significant reduction in pain was reported by the authors (P40.05). No treatment effect was noted for either traditional neck school nor for traditional neck school.
Key: F: Female, M: Male, Yr: Years, G1: Group one, G2: Group two, G3: Group three, VAS: Visual Analogue Scale, Min: Minute, Wk: Week. # 2003 Elsevier Science Ltd. All rights reserved.
Manual Therapy (2003) 8(1), 10–20
18 Manual Therapy
exercises were not shown to be more beneficial than endurance training, body awareness and passive physiotherapy, i.e. manipulation alone. Other exercise programs, i.e. ‘neck schools’ and extension retraction exercises, were not shown effective in single trials.
CONCLUSION Findings revealed significant evidence to support the effectiveness of exercise in two main fields of mechanical neck disorders, whiplash-associated disorders and chronic neck pain. When evaluating different exercise methods for chronic or frequent neck pain, one may consider the use of proprioceptive or dynamic strengthening exercises, based on relatively strong evidence. Strong evidence exists to encourage clinicians to use early mobilizing exercises for acute whiplash-associated disorders. Evidence identified cannot support the use of group exercise, neck schools or single sessions of extension– retraction exercises. In relation to methodological quality, concealed allocation and analysis by ‘intention to treat’ should be addressed in future studies, as the reviewed papers rarely fulfilled this criteria. The results suggest that the subject- and therapistblinding criteria may be irrelevant for trials in the exercise-therapy field. A great need exists for well-designed randomized controlled trials to further enhance the conclusions regarding effectiveness of active exercises in mechanical neck disorders perhaps involving the study of exercise therapy in more specific disorders, such as discogenic disorders, myofascial pain, cervical facet joint disorders.
Acknowledgements The author would like to acknowledge the PEDro project for establishing a high standard collection of evidence, accessible and relevant to physiotherapists. The centre for Allied Health Research and especially Dr Karen Grimmer is acknowledged for conducting the evidence-based physiotherapy workshop, and coordinating the research project of the Master of Manipulative Physiotherapy program, University of South Australia. Thanks to Dr Ruth Dickstein (University of Haifa) and Mrs Karen Giddings (University of South Australia) for reviewing this text. Special thanks to my dearest husband, Lior Bahat, for his technical and spiritual support during the extended compilation of this paper.
References Bonfort G, Evans R, Nelson B, Aker PD, Goldshmith CH, Vernon H 2001 A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain. Spine 26(7): 788–797 Brison RJ, Hartling L, Pickett W 2000 A prospective study of acceleration–extension injuries following rear-end motor vehicle collisionsyWorld Congress on Whiplash-Associated Manual Therapy (2003) 8(1), 10–20
Disorders in Vancouver, British Colombia, Canada, February 1999. Journal of Musculoskeletal Pain 8(1/2): 7–113 Coˆte´ P, Cassidy JD, Carroll L 1998 The Saskatchewan Health and Back Pain Survey: The prevalence of neck pain and related disability in the Saskatchewan adults. Spine 23(15): 1689–1698 Dyrssen T, Paasikivi J, Svedenkrans M 1990 Beneficial exercise programme for office workers with shoulder and neck complaints. In: Berlinguet L, Berthelette D (eds) Work and Display Units 89. Elsevier Science, North Holland, Amsterdam, pp. 129–138 Fitz-Ritson D 1995 Phasic exercises for cervical rehabilitation after ‘whiplash’ trauma. Journal of Manipulative and Physiological Therapeutics 18(1): 21–24 Friedrich M, Cermak T, Maderbacher P 1996 The effect of brochure use versus therapist teaching on patients performing therapeutic exercise and on changes in impairment status. Physical Therapy 76(10): 1082–1088 Gross AR, Aker PD, Goldsmith CH, Peloso P 2001 Physical medicine modalities for mechanical neck disorders (Cochrane Review). In: The Cochrane Library, Issue 3. Update Software: Oxford Hanten WP, Barrett M, Gillespie-Plesko M, Jump KA, Olson SL 1997 Effects of active head retraction with retraction/extension and occipital release on the pressure pain threshold of cervical and scapular trigger points. Physiotherapy Theory and Practice 13(4): 285–291 Jordan A, Bendix T, Nielsen H, Hansen FR, Host D, Winkel A 1998 Intensive training, physiotherapy, or manipulation for patients with chronic neck pain. A prospective, single-blinded, randomized clinical trial. Spine 23(3): 311–317 Kamwendo K, Linton SJ 1991 A controlled study of the effect of neck school in medical secretaries. Scandinavian Journal of Rehabilitation Medicine 23: 143–152 Levoska S, Keinanen-Kiukaanniemi S 1993 Active or passive physiotherapy for occupational cervicobrachial disorders? A comparison of two treatment methods with a 1-year follow-up. Archives of Physical Medicine and Rehabilitation 74: 425–430 Linton SJ, Van Tudler MW 2001 Preventive interventions for back and neck pain problems: What is the evidence? Spine 26(7): 778–787 McKinney LA 1989 Early mobilisation and outcome in acute sprains of the neck. British Medical Journal 299: 1006–1008 Moher D, Cook DJ, Jadad AR, Tugwell P, Moher M, Jones A, Pham B, Klassen TP 1999 Assessing the quality of reports of randomised trials: Implications for the conduct of metaanalyses. Health Technology Assessment 3: 1–98 Moseley AM, Maher C, Herbert RD, Sherrington C 1999 Reliability of a scale for measuring the methodological quality of clinical trials. Proceedings of the VIIth Cochrane Colloquium, Rome, p 39 Moseley AM, Herbert RD, Sherrington C, Maher C 2002 Evidence for physiotherapy practice: A survey of the Physiotherapy Evidence Database (PEDro). Australian Journal of Physiotherapy 48(1): 43–49 Randlov A, Ostergaard M, Manniche C, Kryger P, Jordan A, Heegaard S, Holm B 1998 Intensive dynamic training for females with chronic neck/shoulder pain. A randomized controlled trial. Clinical Rehabilitation 12(3): 200–210 Revel M, Minguet M, Gregoy P, Vaillant J, Manuel JL 1994 Changes in cervicocephalic kinesthesia after a proprioceptive rehabilitation program in patients with neck pain: A randomized controlled study. Archives of Physical Medicine and Rehabilitation 75(8): 895–899 Rosenfeld ME, Gunnarsson R, Borenstein P, Cassidy JD 2000 Early intervention in whiplash-associated disorders: A comparison of two treatment protocols. Spine 25(14): 1782–1787 So¨derlund A, Olerud C, Lindberg P 2000 Acute whiplash associated disorders (WAD): The effect of early mobilisation and prognostic factors in long term symptomatology. Clinical Rehabilitation 14(5): 457–467 Spitzer WO, Leblanc FE, Dupuis M 1987 Scientific approach to the assessment and management of activity related spinal disorders. Spine 7(suppl): S1–S59 Taimela S, Takala E-P, Asklof T, Seppala K, Parviainen S 2000 Active treatment of chronic neck pain: A prospective randomized intervention. Spine 25(8): 1021–1027 # 2003 Elsevier Science Ltd. All rights reserved.
Exercise therapy for neck disorders 19 Takala EP, Viikari Juntura E, Tynkkynen EM 1994 Does group gymnastics at the workplace help in neck pain? A controlled study. Scandinavian Journal of Rehabilitation Medicine 26(1): 17–20 Vasseljen O Jr, Johansen BM, Westgaard RH 1995 The effect of pain reduction on perceived tension and EMG-recorded trapezius muscle activity in workers with shoulder and neck pain. Scandinavian Journal of Rehabilitation Medicine 27(4): 243–252 Verhagen AP, de Vet HC, de Bie RA, Kessels AG, Boers M, Bouter LM, Knipschild PG 1998 The Delphi list: A criteria list
for quality assessment of randomised clinical trials for conducting systematic reviews developed by Delphi consensus. Journal of Clinical Epidemiology 51: 1235–1241 Wailing K, Sundelin G, Ahlgren C, Jarvholm B 2000 Perceived pain before and after three exercise programsFa controlled clinical trial of women with work-related trapezius myalgia. Pain 85(1–2): 201–207
FURTHER READING Excluded references Reference
Reason for exclusion
Pollock ML, Graves JE, Bamman MM, Leggett SH, Carpenter DM, Carr C, Cirulli J, Matkozich J, Fulton M 1993 Frequency and volume of resistance training: effect on cervical extension strength. Archives of Physical Medicine and Rehabilitation 74: 1080–1086. Stump J, Rash G, Semon J, Christian W, Miller K 1993 A comparison of two modes of cervical exercise in adolescent male athletes. Journal of Manipulative and Physiological Therapeutics 16(3): 155–160. McCarthy PW, Olsen JP, Smeby IH 1997 Effects of contract-relax stretching procedures on active range of motion of the cervical spine in the transverse plane. Clinical Biomechanics 12(2): 136–138. Nelson BW, Carpenter DM, Dreisinger TE, Mitchell M, Kelly CE, Wegner JA 1999 Can spinal surgery be prevented by aggressive strengthening exercises? A prospective study of cervical and lumbar patients. Archives of Physical Medicine & Rehabilitation 80(1): 20–25. Koes BW, Bouter LM, van Mameren H, Esser AH, Verstegen GM, Hofhuizen DM, Houben JP, Knipschild PG 1993 A randomized clinical trial of manual therapy and Physiotherapy for persistent back and neck complaints: Subgroup analysis and relationship between outcome measures. Journal of Manipulative and Physiological Therapeutics 16(4): 211–219. Gam AN, Warming S, Hordum L, Jensen B, Hoydalsmo O, Allon I, Anderson B, Gotzsche NE, Petrsen M, Mathiesen B 1998 Treatment of myofacial trigger-points with ultrasound combined with massage and exercise, a randomised controlled trial. Pain 77: 17–19. Leggett SH, Graves JE, Pollock ML, Shank M, Carpenter DM, Holmes B, Fulton M 1991 Quantitative assessment and training of isometric cervical extension strength. The American Journal of Sports Medicine 18(6): 653–655. Axen K, Haas F, Schicchi J, Merrick J 1992 Progressive Resistance Neck Exercises Using a Compressible Ball Coupled with an Air Pressure Gauge. Journal of Orthopaedic and Sports Physical Therapy 16(6): 275–280. Pennie B, Agambar L 1990 Whiplash injuries. A trial of early management. Journal of Bone and Joint Surgery 72(2): 277–279. Highland TR, Dreisinger TE, Vie LL, Russel GS 1992 Changes in isometric strength and range of motion of the isolated cervical spine after eight weeks of clinical rehabilitation. Spine 17(6): 77–82. Yilnen J, Ruuska J (1994): Clinical use of neck isometric strength measurement in rehabilitation. Archives of Physical Medicine and Rehabilitation 75: 465–469. Berg HE, Berggren G, Tesch PA 1994 Dynamic neck strength training effect on pain and function. Archives of Physical Medicine and Rehabilitation 75(6): 661–665.
Population: volunteers with no neck disorder specified.
# 2003 Elsevier Science Ltd. All rights reserved.
Population: asymptomatic athletes, no prior injury or abnormality. Population: Asymptomatic volunteers.
Study design: prospective study. Not a comparative trial.
Intervention: exercise combined with other treatment modalities.
Intervention: exercise combined with other treatment modalities.
Population: healthy subjects, with no cervical problems.
Population: healthy subjects, with no cervical problems.
Intervention: exercise combined with other treatment modalities. Study design: non-comparative trial.
Study design: non-comparative trial. Study design: non-comparative trial.
Manual Therapy (2003) 8(1), 10–20
20 Manual Therapy Provinciali L, Baroni M, Illuminati L, Ceravolo MG 1996 Multimodal treatment to prevent the late whiplash syndrome. Scandinavian Journal of Rehabilitation Medicine 28: 105–111. Davidson D 1998 Effectiveness of cervical stabilisation training and correction of muscle imbalance, following reduction of Atlanto-Axial Rotary Subluxation: A single case study. Physiotherapy 54(3): 4–7. Beeton K, Jull G 1994 Effectiveness of manipulative physiotherapy in the management of cervicogenic headache: A single case study. Physiotherapy 80(7): 417–423. Jordan A, Ostergaard K 1995 Implementation of neck/shoulder rehabilitation in primary health care clinics. Journal of Manipulative and Physiological Therapeutics 19(1): 36–40. Helliwell PS, Abbott CA, Chamberlain MA 1996 A randomised trial of three different physiotherapy regimes in Ankylosing Spondylitis. Physiotherapy 82(2): 85–90. Olson VL 1997 Whiplash-associated chronic headache treated with home cervical traction. Physical Therapy 77: 417–424.
Manual Therapy (2003) 8(1), 10–20
Intervention: exercise combined with other treatment modalities. Study design: case study.
Study design: case study. Study design: review paper. Population = patients with Ankylosing Spondylitis. Intervention = home cervical traction. Although self-treatment, passive and not considered exercise.
# 2003 Elsevier Science Ltd. All rights reserved.
Manual Therapy (2003) 8(1), 21–28 1356-689X/03/$ - see front matter # 2003 Elsevier Science Ltd. All rights reserved. doi:10.1054/math.2002.0476
Original article
Neuromuscular control of walking with chronic low-back pain L. Vogt*, K. Pfeiferw, W. Banzer* *Department of Sports Medicine, Institute for Sport Sciences, Johann Wolfgang Goethe-University, Frankfurt/ Main, Germany, wOtto-von-Guericke University Magdeburg, Training and Health, Germany
SUMMARY. The reported association of low-back pain and musculoskeletal disorders contributed to the examination of the lumbar spine and hip extensor activation patterns in back pain sufferers during walking. Seventeen idiopathic low-back pain male subjects and 16 healthy volunteers participated in the study. Hip joint ROMs in the sagittal plane and neuromuscular activities of erector spinae [L3, T12], gluteus maximus and biceps femoris were recorded on one randomly selected body side in each group. Analysis using the Student’s t-test revealed significant differences for hip joint range of motion, stride time and significantly earlier onsets of the lumbar spine and hip extensors of the back pain sufferers compared with the healthy controls. It is assumed, that low-back disorders are related to changes of the lumbar spine and hip extensor recruitment pattern. r 2003 Elsevier Science Ltd. All rights reserved.
suggested that deficiencies in movement patterns and motor regulation play a major role in the development of musculoskeletal dysfunction (Singer 1986; Jull & Janda 1987, Janda 1992; Bittmann & Badtke 1994). Neural dysregulation due to musculoskeletal pain syndromes might contribute to alterations in the recruitment pattern of various synergistic muscles. Alterations in motor control may cause muscles to be activated in an inappropriate manner (i.e. timing, rate of force development), interfering with a subject’s ability to automatically perform adequate movement patterns. Janda postulated in 1978 that at least some cases of low-back pain may occur due to deficiencies in the central nervous control of locomotion. It is assumed that especially disturbances of the activation pattern of the hip extensor and pelvic stabilization muscles are a factor in the genesis of low-back disorders. Even impairments in the peripheral parts of the body seem to be complemented by changes in the central nervous system regulation of the muscles in the lumbo-pelvic region (Bullock-Saxton et al. 1994, Bullock-Saxton 1994; Beckmann & Buchanan 1995). Prone hip extension is an assessment procedure which has been used by various authors (Pierce & Lee 1990; Liefring et al. 1991; Janda 1992; Lewit 1992; Badtke et al. 1994; Bullock-Saxton et al. 1994; Vogt & Banzer 1997) to evaluate the neuromuscular
INTRODUCTION Low-back pain is one of the most common musculoskeletal problems in modern society. Demonstrated by the high direct and indirect costs, it also causes major economic problems in industrialized nations (Berger-Schmitt et al. 1996; Maniadakis & Gray 2000). Thus, chronic low-back pain problems have been the reason for many clinical investigations. Although there is disagreement in the literature with regard to the etiology (White & Gordon 1982; Bernard & Kirkaldy-Willis 1987; Nachemson 1992), it seems evident that idiopathic low-back pain is often associated with musculoskeletal disorders and imbalances in lumbar spine and pelvic stabilization muscles (Schneider 1981; Janda 1984; Liebenson 1990; Bourdillon et al. 1994; Norris 1995). It is Received: 30 January 2002 Revised: 20 June 2002 Accepted: 18 July 2002 Lutz Vogt PhD, Winfried Banzer MD, PhD, Department of Sports Medicine, Institute for Sport Sciences, Johann Wolfgang GoetheUniversity, Frankfurt/Main, Klaus Pfeifer PhD, Otto-vonGuericke University, Magdeburg, Training and Health, Germany. Correspondence to: LV, Department of Sports Medicine, Institute for Sport Sciences, Johann Wolfgang Goethe-University, Ginnheimer Landstrasse 39, 60487 Frankfurt/Main, Germany. Tel.: +49-69-798-24586; Fax: +49-69-798-24592; E-mail:
[email protected] 21
22 Manual Therapy
activation pattern (order of muscle contraction) of surrounding hip muscles. Isolated extension of the hip from the neutral position is normally selected because of its functional importance in stance and locomotion. However, prone hip extension is a open kinetic chain non-weight-bearing position performed by concentric muscle contraction, so joint afferent activity and muscle recruitment strategies will be considerably different from those in gait. Thus, it seems questionable if isolated laboratory test conditions will be able to monitor the authentic muscle recruitment pattern around the trunk and pelvis and identify functional adaptations to back pain. Although a few back pain studies have already analysed muscle activity during gait (Ahern et al. 1986, Arendt-Nielsen et al. 1995, Arendt-Nielsen 1996) no study has clearly described the muscle firing order of the lumbar and hip muscles in walking. Therefore, it still remains unclear how human musculoskeletal pain modulates motor performance in every day tasks. The aim of the current study was to examine changes in the lumbar spine and hip extensor activation patterns in chronic low-back pain patients in a more functional and complex test situation like walking.
METHODS Seventeen male subjects (Age: 36.372.1 year, Height: 174.777.3 cm, Weight: 78.8714.6 kg) with chronic idiopathic low-back pain (CLBP) diagnosed by a physician (Table 1) and 16 age matched healthy males (Age: 33.773.1 year, Height: 178.875.2 cm, Weight: 77.276.4 kg) (Table 2) participated in the study. Due to the small sample size, and to control for confounding variables, such as gender differences, the study concentrated on one gender only. Individuals were recruited from co-operating rehabilitation clinics and university staff. In both groups, measurements were carried out unilaterally on one randomly selected side of the body. The visual analogue scale (VAS; 0=no pain and 10=most severe pain) (Triano et al. 1993) and Oswestry Disability Questionnaire (Fairbanks et al. 1980) were used for actual pain intensity and disability ratings. Both of these instruments have
previously been tested for reliability and validity (Deyo et al. 1986, Graver et al. 1998). To ensure that the back pain sufferers experienced at least moderate pain intensities at the time of testing, patients with self-reported pain ratings below 3 (VAS) were not included in the study (Arendt-Nielsen et al. 1996). Hip joint range of motion in the sagittal plane and neuromuscular activities of lumbar and thoracolumbar erector spinae [L3, T12], gluteus maximus and biceps femoris were recorded unilaterally during treadmill walking (HP-Cosmoss-Quasarmed, Germany) at 1.25 m/s. Relative hip flexion and extension was recorded by an electronic goniometer (Biovisions, Germany) with the axis of rotation aligned to the greater trochanter. The goniometer was calibrated in neutral upright standing. Pregelled (Ag/ AgCl) surface electrodes (BlueSensors) with an interelectrode distance of 20 mm were applied longitudinally over the selected muscles referring to international recommendations (Hermens & Freriks 1997). The reference electrode was attached to the subjects’ posterior superior iliac spine. The skin of the recording site was prepared according to the International Society of Electrophysiology and Kinesiology (ISEK) standards (Winter et al. 1980) by shaving as required, sanding, and rubbing with gauze, saturated with alcohol. All electrode cables were lightly secured with tape to reduce any possibility of artefacts produced by cable movement. In order to relate the EMG activity to the instant of heel-strike, pressure-sensitive footswitches were secured at both heels. The subjects had time to practice treadmill walking until they reported that they had become accustomed to the walking conditions. After a rest period of at least 15 min the subjects started to walk again until they reported to feel comfortable. Then data over a minimum of 20 strides were collected for each subject using a multi-channel EMG datalogger system (Biovisions, Germany; input impedance: 10 GO, CMRR: 130 db, RTI noise 8 nV/Hz, gain: 2500, filter: 10 Hz low cut-off, 700 Hz high cut-off, amplifier close to the detection site) operating at 1000 Hz per channel. Muscle on/offset was considered to have occurred when 25 consecutive data points of a sliding window exceeded the current mean baseline by three-standard deviations. The threestandard deviation threshold was selected referring to
Table 1. Inclusion and exclusion criteria for 17 male subjects of CLBP group Inclusion criteria
Exclusion criteria
Age between 25 and 55, full-time employment LBP limited to the lumbar area and buttocks (between T12 and gluteal folds) Low-back pain on at least half the days in a single or in multiple episodes within the past 12 months
LBP lower than buttocks Bowel or urinary tract problems Neurological deficit or nerve root tension signs Leg length discrepancy 41 cm Vascular insufficiency Any major surgery of the spine or lower limbs Systemic problems (cancer, cardiovascular, endocrine, etc.)
Manual Therapy (2003) 8(1), 21–28
# 2003 Elsevier Science Ltd. All rights reserved.
Neuromuscular control of walking with chronic low-back pain 23 Table 2. Inclusion and exclusion criteria for male control (normal) group (n=16) Inclusion criteria
Exclusion criteria
Full-time employment Age between 25 and 55 Normal spinal curvature and range of motion (total flexion o871, total extension o181, lateral flexion o241, Waddell 1998) No thoracic or lumbar pathology, including history
Previous surgery of the spine or lower extremities Any low-back pain in the previous 12 months Any loss of time from work for low-back pain Leg length discrepancy 41 cm Any history of arthritis in the lower extremities joints
DiFabio (1987). To account for different cycle durations between subjects selected EMG onset and cessation times were normalized in time for each muscle group and each stride per subject. This was achieved by computing on/offset times relative to the cycle duration of the recording site (heel contact to heel contact corresponding to 0–100%) (Fig. 1). The heel-strike, determined by the footswitch signal ipsilateral to the recording site, was used to define the start/stop of each cycle and to calculate cycle durations. Herewith, the analysis focused on the temporal characteristics (onset and cessation times) of the raw EMG signals during the gait cycle. To gain additional information from the ‘phasic’ EMG activity and to concentrate on the shape of the EMG profiles, linear envelopes (full-wave-rectifier followed by a second-order low-pass filter with cutoff at 8 Hz) were calculated (Winter 1984). This reliable method (Kadaba et al. 1989; Kleissen et al. 1997), applied in most gait laboratories (Harris & Wertsch 1994; Whittle 1996), is thought to mathematically model the muscle tension by the use of a single pass second-order low-pass system (Winter
1984, 1990). Due to the time delays introduced by the applied digital filter and the thereby affected occurrence of peaks the current analysis focused on the pattern of the averaged EMG profiles instead of peak characteristics. The signals were normalized with regard to the stride time (one cycle corresponds to 100%) to maintain timing relative to the walking cycle for the comparison of different subjects. In this way, more than 20 time-normalized EMG profiles formed the data base for the within-subject ensemble average. EMG amplitudes were normalized to the average EMG activity per gait cycle (Yang & Winter 1984). The second averaging procedure resulted in a profile for each group (grand average; CLBP, Controls). Kinematic signals were filtered using a low-pass, zero-lag, critical damped, fourth-order filter (8 Hz cut-off) (Wells & Winter 1980) to allow smoothing without introducing any time delay and time normalized to the ipsilateral heel strike. Student’s independent samples t-tests were selected to determine significant differences in muscle on/offset, hip movement, and cycle durations between groups.
Heel strike
Heel strike
Heel strike
Offset %
Onset %
100% gait cycle
1200
Offset %
100% gait cycle
Onset %
Foot switch signals
800
EMG offset
EMG onset
EMG offset
EMG onset
400
µV 0
0
500
1000
1500
2000
2500
Real time
-400
-800
-1200
Fig. 1FNormalized EMG on/offset time detection. # 2003 Elsevier Science Ltd. All rights reserved.
Manual Therapy (2003) 8(1), 21–28
24 Manual Therapy
Cross-correlation values were computed for pairwise comparisons of the time history of the interindividual EMG profiles between groups. Po0.05 was regarded as significant.
in EMG profiles between groups (Fig. 3). Phase shifts identified by the cross-correlation calculations confirmed the pre-matured EMG activity of the biceps femoris and gluteus maximus in CLBP patients (Fig. 3).
RESULTS DISCUSSION In chronic low-back pain subjects the self-reported back pain intensity (VAS) ranged from 3 to 5.3 (mean: 3.9) indicating intermediate pain intensities during testing. The subjective disability index (Oswestry-Questionnaire) demonstrated moderate limitations in every day life activities (mean: 26.3%; range: 24–48) within the patient sample. The history of low-back pain ranged from 24 months to 4 years. Student’s t-tests demonstrated significant differences (Po0.01) for hip joint range of motion (38.379.11 vs 25.277.91) and stride time (1.0670.05s vs 1.0370.09 s) between healthy controls and back pain patients. Significant EMG onset differences (Po0.01) were found in comparing hip extensors (biceps femoris muscle, gluteus maximus muscle) of the pathological group and the healthy controls. Significant group differences (Po0.01) were also calculated for the onset of both EMG bursts of the bi-phasic activation pattern of the lumbar erector spinae [L3] muscles. Additionally, the analysis revealed a significantly prolonged electrical activity of the gluteus maximus and lumbar erector spinae muscles in the back pain group (Po0.01). No significant group differences in EMG peak characteristics were detected for the thoracolumbar erector spinae [T12]. EMG onset and cessation times of all selected muscles for the independent groups are given in Fig. 2. Cross-correlation values demonstrated almost identical patterns of falling and rising trends
The neuromuscular activation of the muscles in the pelvic region plays a primary role for the physiologic coordination and interaction of pelvis, spine and lower limb movements in human gait. Referring to the stabilization concept postulated by Panjabi (1992a,b; Norris 1995), disturbances of the musculoskeletal and fascial system can be prerequisites for or also consequences of pathological syndromes of the spine. Thus, in pain syndromes of the lumbar/ sacral/hip region the gluteal and hamstring muscles may play a role which is often overlooked. The recent study, therefore, intends to provide a more detailed look on low-back pain subjects’ muscle contractile patterns of lumbar spine and hip extensors in cyclic movements like walking. Concentrating on patients with a history of back pain, the recent investigation demonstrated reductions in hip flexion/extension movements as well as reduced gait cycle durations. The kinematic changes seen in the current investigation are consistent with those of other authors (Keefe & Hill 1985; Khodadadeh et al. 1988), who also found that back pain patients walked more slowly and took shorter strides. Therefore, the results provide support for the short strided gait and the observations of a more cautious walking pattern in chronic low-back patients (Zebouni et al. 1992; Dananberg 1998). The detection procedure of relative EMG on/offset times used in the present study tried to account for
38.6
M.erector spinae [T12]
M.gluteus maximus
M.biceps femoris
60.3
38.9
CLBP
M.erector spinae [L3]
58.1
Controls
8.7
Controls
44.4
60.4
92.9
p<0.01 CLBP
12.9
Controls
13.1
p<0.01
42.0
61.2
88.2
94.2 p<0.01
CLBP
18.1
Controls
17.7
p<0.01
89.9
85.8 p<0.01
p<0.01
82.2
11.9
CLBP 0
20
40
60
80
100
% gait cycle
Fig. 2FAverage EMG on/offset times of lumbar and thoracolumbar erector spinae [L3, T12], biceps femoris and gluteus maximus for CLBP and healthy controls. Manual Therapy (2003) 8(1), 21–28
# 2003 Elsevier Science Ltd. All rights reserved.
Neuromuscular control of walking with chronic low-back pain 25 erector spinae [T12] 300.00
CLBP
% mean EMG activity
Ctrl
200.00
100.00
0.00 0
20
40
100
80
60
r=.95; lag 0% gait cycle
% gait cycle
erector spinae [L3] 300.00
CLBP
% mean EMG activity
Ctrl
200.00
100.00
0.00 0
20
40
60
80
100
r=.89; lag -2% gait cycle
% gait cycle
gluteus maximus % mean EMG activity
400.00 CLBP Ctrl 300.00 200.00
100.00
0.00 0
20
40
60
100
80
r=.92; lag -2% gait cycle
% gait cycle
biceps femoris % mean EMG activity
300.00
CLBP Ctrl
200.00
100.00
0.00 0
20
40 % gait cycle
60
80
100
r=.91; lag 0% gait cycle
Fig. 3FAverage EMG group profiles and cross-correlation values [r] of pairwise comparisons for CLBP patients and healthy controls (Po0.001).
the different stride times between groups and the speed-dependence of the EMG variables. Calculating EMG peak characteristics relative to the individual cycle durations the study revealed significantly prematured innervation of the lumbar erector spinae [L3], gluteus maximus, and hamstring muscles in back pain patients compared to the healthy controls. The averaged EMG profiles, produced by linear envelope processing, from the four target muscles are in accordance with findings from other authors (Winter 1984; Kadaba et al. 1989). The crosscorrelation values, indicating almost similar patterns # 2003 Elsevier Science Ltd. All rights reserved.
of rises and falls between patients and healthy controls, confirmed the pre-matured activity in lumbar spine and hip extensor muscles in back pain sufferers. Therefore, the results of this study support the idea that some facet of muscle contraction is altered in the presence of low-back dysfunction and do not preclude the idea that back injury is associated with a delayed activation of the gluteus maximus muscle (Janda 1978). Therefore, based on the findings of this study, future work should examine if prone hip extension can be used for the valid assessment of pathological muscle coordination or the evaluation of intervention strategies in the pelvic hip region (Badtke et al. 1994). In addition to the self-reported pain intensity at the time of testing and the mentioned alterations in the muscle firing pattern, the current findings point towards a protective activation mechanism. Importantly, the pre-matured recruitment strategy of the lumbar spine and hip extensors and the prolonged activity of the gluteus maximus and lumbar spine extensors could be interpreted as a functional adaptation of the neuromuscular system to provide extra stability and to prevent additional pain. Although, there is no causal evidence that the recent muscle activation patterns are exclusively adaptive factors of idiopathic CLBP, the interpretation of the EMG changes as a functional adaptation to muscle pain are in agreement with results presented by Arendt-Nielsen et al. (1995) and Graven-Nielsen et al. (1997). Their findings of increased lower limb and back muscle activity due to clinical and experimentally provoked muscle pain confirms the hypothesis of pain as a motor output modulator. Herewith, the present results of prematured muscle activities would support the ‘pain adaptation model’ or ‘muscle spasm theory’ concerning the interaction between motor output and musculoskeletal pain (Collins et al. 1982, Lund et al. 1991). Additionally, the recent concepts of pain and neuronal plasticity point toward long-term adaptations in sense of facilitating changes in pain-related systems (Zieglgansberger & Tolle 1993). Therefore, prolonged musculoskeletal pain syndromes might contribute to alterations of dynamic motor stereotypes and motor regulation. Likewise, changes of the neuromuscular coordination in association with functional disturbances and pain itself could be considered as a possible underlying source of recurrent or chronic back pain symptoms. Janda (1978) and also Lewit (1992) consider neuromuscular changes as frequent causes for functional disorders of the spine. In this concept, it has been proposed that musculoskeletal dysfunctions associated with CLBP typically present specific movement patterns of the trunk, pelvis or hips in conjunction with markedly altered activation patterns of the stabilizing muscles of the pelvis, hips, and trunk such as the gluteus Manual Therapy (2003) 8(1), 21–28
26 Manual Therapy
maximus and multifidus (Janda 1984). Changes of the dynamic stereotype of locomotion are attributed to the plasticity of the neuromuscular control system. However, it is unclear whether and how the alterations shown in the present study are associated with ‘plastic’ changes of the human nervous system. Human locomotion is first controlled segmentally and then becomes progressively more dependent on supraspinal systems (Leonhard 1998). Therefore, it has been postulated that collections of neurons termed central pattern generators (CPG) are responsible for the generation of rhythmic activities, such as bipedal locomotion. It has been suggested that spinal cord CPGs generate the basic locomotor rhythm and supramaximal systems serve to initiate and drive the CPGs (Forssberg 1986). Although no direct evidence exists that the neural substrate for human locomotion changes with pathology, learning and modulation plays a critical role in the attainment and maturation of human bipedal gait. This is reflected in the differences between the gait patterns of human infants and adults as well as in the inter-subject variability of movements. However, this does not provide direct evidence that pathology triggers alterations in the shape of neural connectivity, while changes in the human nervous system can be the result of genetically predetermined neural structures, their connectivity and their physiological functioning as well (Grillner 1985). Regardless of whether the mentioned changes are consequences or causes of the present pathological situation, out-of-phase activity can cause uneconomic movement coordination and changes of the physiological tissue loading. In such cases, the direction and magnitude of joint forces could be affected and other structures of the locomotor system may become painful. Changed functional conditions due to disturbances or dysfunctions caused by adaptations of the neuromuscular system have been reported frequently in studies of different joint systems (McNair et al. 1992; Davis & Dickhoff-Hoffman 1993; Lo¨fvenberg et al. 1995; Pfeifer & Banzer 1999). The functional importance of a well-coordinated muscular control of the spine and the possibility to influence the intensity and timing of muscle activation has, for example, been shown by Bullock-Saxton et al. (1993). It can be speculated that subjects with non-specific low-back pain like those investigated in the present study may profit from specific intervention programmes to activate muscles more functionally in different types of motor activities and to achieve adequate muscle balance and coordination. Overlooking the underlying pathology can perhaps contribute to rehabilitation failure and prolong therapeutic interventions. Therefore, future studies have to show, whether it is possible to change the firing patterns of the participating muscles Manual Therapy (2003) 8(1), 21–28
and which kind of therapy intervention may be adequate.
CONCLUSION This work was indicated that the analysis of the hip extensor activation pattern in gait may be an essential factor in detecting abnormalities in chronic low-back patients. Following the presented results, it can be assumed that low-back disorders are related to changes of the hip extensor recruitment pattern. The altered muscle activation pattern could have impact on the physiological loading and alter the direction and magnitude of joint reaction forces. Thus, the pre-matured electrical activity itself could be considered as a possible underlying source of recurrent or chronic back pain symptoms. However, it still remains unclear how human musculoskeletal pain modulates motor performance and it is not known whether abnormalities in muscle function precede the onset of idiopathic low-back pain. Whether or not muscle disturbances are significant causative factors or late complicating factors of idiopathic LBP, it is concluded that the importance of pelvis stabilization muscles in the etiology of CLBP cannot be denied. More study is needed to obtain information on the behaviour of CLBP patients in different therapy intervention programmes.
References Ahern DK, Follick MJ, Council JR, Laser-Wolston N 1986 Reliability of lumbar paravertebral EMG assessment in chronic low-back pain. Archives of Physical Medicine and Rehabilitation 67: 762–765 Arendt-Nielsen L 1996 Quantification of human gait with the presence of low-back pain. In: Hermens HJ, Merletti R, Freriks B (eds) European Activities on Surface ElectroMyoGraphy. Proceedings of the First General SENIAM Workshop. Roessingh Research and Development b.v, The Netherlands. Arendt-Nielsen L, Graven-Nielsen T, Svorrer H, Svensson P 1995 The influence of low-back pain on muscle activity and coordination during gait: A clinical and experimental study. Pain 64: 231–240 Badtke G, Bittmann F, Sotzko A 1994 Muskelfunktion bei der Hu¨ftextension in der Bauchlage untersucht an Kindern der 2. Klasse. Man and Medicine 32: 98–101 Beckmann SM, Buchanan TS 1995 Ankle inversion injury and hypermobility: Effect on hip and ankle muscle electromyography onset latency. Archives of Physical Medicine and Rehabilitation 76: 1138–1143 Berger-Schmitt R, Kohlmann T, Raspe H 1996 Ru¨ckenschmerzen in Ost- und Westdeutschland. Gesundheitswesen 58: 519–524 Bernard TN, Kirkaldy-Willis WH 1987 Recognizing specific characteristics of nonspecific low-back pain. Clinical Orthopaedics and Related Research 217: 266–280 Bittmann F, Badtke G 1994 BewegungsmusterFprima¨rer Faktor von Fehlentwicklungen des Muskel-Skelett-Systems. Man and Medicine 32: 61–65 Bourdillon JF, Day EA, Bookhout MR 1994 Spinal Manipulation, 5th edn. Butterworth-Heinemann, Stoheham, MA, pp. 313–333 # 2003 Elsevier Science Ltd. All rights reserved.
Neuromuscular control of walking with chronic low-back pain 27 Bullock-Saxton JE, Janda V, Bullock MI 1993 Reflex activation of gluteal muscles in walking. Spine 6: 704–708 Bullock-Saxton JE, Janda V, Bullock MI 1994 The influence of ankle sprain injury on muscle activation during hip extension. International Journal of Sports Medicine 15: 330–334 Bullock-Saxton JE 1994 Local sensation changes and altered hip muscle function following severe ankle sprain. Physical Therapy 74(1): 17–31 Collins GA, Cohen MJ, Naliboff BD, Schandler SL 1982 Comparative analysis of paraspinal and frontalis EMG, heart rate and skin conductance in chronic low-back pain patients and normals to various postures and stress. Scandinavian Journal of Rehabilitation Medicine 14: 39–46 Dananberg HJ 1998. Gait mechanics and their relationship to lower back pain: An outcome study. Third Interdisciplinary World Congress on Low-back and Pelvic Pain. Vienna, November, pp 239–241 Davies GJ, Dickhoff-Hoffman S. 1993 Neuromuscular testing and rehabilitation of the shoulder complex. J Sports Phys Ther 2: 449–458 Deyo RA, Battie M, Beurokes A 1986 Outcome measures for lowback pain research: A proposal for standardized use. Spine 23: 2003–2013 DiFabio R 1987 Reliability of computerized surface electromyography for determining the onset of muscle activity. Physical Therapy 67: 43–48 Fairbanks JCT, Couper J, Davies JB, O’Brien JP 1980 The Oswestry low-back pain disability questionnaire. Physiotherapy 66: 271–273 Forssberg H 1986 Development and integration of human locomotor functions. In: Goldberger ME, Gorio A, Murray M (eds) Development and Plasticity of the Mammalian Spinal Cord. Liviuna Press, Padova, pp 53–63 Graven-Nielsen T, Svensson P, Arendt-Nielsen L 1997 Effects of experimental muscle pain on muscle activity and coordination during static and dynamic motor function. Electroencephalography and Clinical Neurophysiology 105: 156–164 Graver V, Loeb M, Rasmussen F, Lie H, Ljunggren AE 1998 Clinical overall score: Outcome evaluation after lumbar disc surgery, assessments of reliability and validity. Scandinavian Journal of Rehabilitation Medicine 30: 227–234 Grillner S 1985 Neurobiological bases of rhythmic motor acts in vertebrates. Science 228: 143–149 Harris GF, Wertsch JJ 1994 Procedures for gait analysis. Archives of Physical Medicine and Rehabilitation 75: 216–225 Hermens HJ, Freriks B 1997 The state of the art on sensors and sensor placement procedures for surface electromyography: A proposal for sensor placement procedures. SENIAMDeliverable 5, Roessingh Research and Development b.v, The Netherlands. Janda V 1978 Muscles, central nervous motor regulation and back problems. Neurobiologic mechanisms. In: Korr M (ed.) Manipulative Therapy. Plenum Press, New York, pp 27–41 Janda V 1984 Gesto¨rte Bewegungsabla¨ufe und Ru¨ckenschmerzen. Man and Medicine 22: 74–78 Janda V 1992 Treatment of chronic pain. Journal of Man and Medicine 6: 166–168 Jull GA, Janda V 1987 Muscles and motor control in low back pain: Assessment and management. In: Twomey LT, Taylor JR (eds) Physical Therapy of the Low Back. Churchill Livingstone, New York, pp 253–278 Kadaba MP, Ramakrishnan HK, Wootten ME, Gainey J, Gorton G, Cochran GVB 1989 Repeatability of kinematic, kinetic, and electromyographic data in normal adult gait. Journal of Orthopaedic Research 7(6): 849–860 Keefe FJ, Hill RW 1985 An objective approach to quantifying pain behaviour and gait patterns in low back pain patients. Pain 21: 153–161 Khodadadeh S, Eisenstein S, Summers B, Patrick J 1988 Gait asymmetry in patients with low back pain. Neuro-Orthopedics 6: 24–27 Kleissen RFM, Litjens MCA, Baten CTM, Harlaar J, Hof AL, Zilvold G 1997 Consistency of surface EMG patterns obtained during gait from three laboratories using standardised measurement technique. Gait Posture 6: 200–209 # 2003 Elsevier Science Ltd. All rights reserved.
Leonhard CT 1998 Neural control of human locomotion. In: Leonhard CT (ed.) The Neuroscience of Human Movement. Mosby, St Louis, pp 146–175 Lewit K 1992 Manuelle Medizin, 6th edn. Ambrosius, Heidelberg Liebenson C 1990 Active muscular relaxation techniques. Part II: Clinical application. Journal of Manipulative and Physiological Therapy 13(1): 2–6 Liefring V, Hinz K, Seidel W, Conradi E 1991 Objektivierung der Muskelaktivita¨t bei krankengymnastischen Bewegungsabla¨ufen mit Mehrkanalelektromyographie. Z Phys Rehab Kur Med 1: 33–37 Lo¨fvenberg R, Ka¨rrholm J, Sundelin G, Ahlgren O 1995 Prolonged Reaction Time in Patients with Chronic Lateral Instability of the Ankle. American Journal of Sports Medicine 4: 414–417 Lund JP, Donga R, Widmer CG, Stohler CS 1991 The painadaptation model: A discussion of the relationship between chronic musculoskeletal pain and motor activity. Canadian Journal of Physiology and Pharmacol 69: 683–694 Maniadakis N, Gray A 2000 The economic burden of back pain in the UK. Pain 84: 95–103 McNair PJ, Wood GA, Marshall RN 1992 Stiffness of the hamstrings muscles and its relationship to function in anterior cruciate ligament deficient individuals. Clinical Biomechanics 131–137 Nachemson AL 1992 Newest knowledge of low-back pain. A critical look. Clinical Orthopaedics and Related Research 279: 8–20 Norris CM 1995 Spinal stabilisation 1. Active lumbar stabilisationFconcepts. Physiotherapy 81(2): 61–64 Norris CM 1995 Spinal stabilisation 4. Muscle imbalance and the low back. Physiotherapy 81(3): 127–138 Panjabi MM 1992a The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement. Journal of Spinal Disorders 4: 383–389 Panjabi MM 1992b The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. Journal of Spinal Disorders 4: 390–397 Pfeifer K, Banzer W 1999 Motor performance in different dynamic tests in knee rehabilitation. Scandinavian Journal of Medicine and Science of Sports 1: 11–17 Pierce MN, Lee WA. 1990 Muscle firing order during active prone hip extension. Journal of Orthopaedics, Sports and Physical Therapy 12: 2–9 Schneider W 1981 Manuelle Therapie degenerativer Erkrankungen der Wirbelsa¨ule. Therapeutische Umschau 38(7): 656–659 Singer K 1986 Suggestions from the clinic: A new musculoskeletal assessment in a student population. Journal of Sports and Physical Therapy 8: 34–41 Triano JJ, McGregor M, Craimer GD, Deborah LE 1993 A comparison of outcome measures for use with back pain patients; results of a feasibility study. Journal of Manipulative and Physiological Therapy 16: 67–73 Vogt L, Banzer W 1997 Dynamic testing of the motorial stereotype in prone hip extension from neutral position. Clinical Biomechanics 12(2): 122–127 Waddell G 1998 The Back Pain Revolution. Churchill Livingstone, London Wells RP, Winter DA 1980 Assessment of signal and noise in the kinematics of normal, pathological and sporting gaits. Proceedings of the Special Conference of the CSB, Human Locomotion I, London, Ontario, Canada White AA, Gordon SL 1982 Synopsis: Workshop on idiopathic low-back pain. Spine 7(2): 141–149 Whittle MW 1996 Clinical gait analysis: A review. Human Movement Science 15: 369–387 Winter DA, Rau G, Kadefors R 1980 Units, terms and standards in the reporting of EMG Research. Report by the Ad Hoc Committee of the International Society of Electrophysiological Kinesiology. Department of Medical Research, Rehabilitation Institute of Montreal, Montreal Winter DA 1984 Pathologic gait diagnosis with computer-averaged electromyographic profiles. Archives of Physical Medicine and Rehabilitation 65: 393–398 Winter DA 1990 Biomechanics and Motor Control of Human Movement, 2nd edn. Wiley, Ontario, Canada Manual Therapy (2003) 8(1), 21–28
28 Manual Therapy Yang JF, Winter DA 1984 Electromyographic amplitude normalization methods: Improving their sensitivity as diagnostic tools in gait analysis. Archives of Physical Medicine and Rehabilitation 65: 517–521
Manual Therapy (2003) 8(1), 21–28
Zebouni L, Helliwell PS, Howe A, Wright V 1992 Gait analysis in ankylosing spondylitis. Annals of Rheumatic Disease 51: 898–899 Zieglgansberger W, Tolle TR 1993 The pharmacology of pain signalling. Current Opinion in Neurobiology 3: 611–618
# 2003 Elsevier Science Ltd. All rights reserved.
Manual Therapy (2003) 8(1), 29–36 1356-689X/03/$ - see front matter # 2003 Elsevier Science Ltd. All rights reserved. doi:10.1054/math.2002.0484
Original article
Psychometric properties of the Tampa Scale for kinesiophobia and the fear-avoidance beliefs questionnaire in acute low back pain E. J. C. M. Swinkels-Meewisse*wz, R. A. H. M. Swinkels*w, A. L. M. Verbeek}, J. W. S. Vlaeyenz, R. A. B. Oostendorp*z8 *Centre for Quality of Care Research, University Medical Centre St Radboud, Nijmegen, The Netherlands, w Practice of Physical Therapy and Manual Therapy, Eindhoven, The Netherlands, zFaculty of Medicine and Pharmacology, Free University Brussels, Postgraduate Education Manual Therapy, Brussels, Belgium, }University Medical Centre St Radboud, Nijmegen, The Netherlands, zDepartment of Medical, Clinical and Experimental Psychology, University of Maastricht, Maastricht, The Netherlands, 8Dutch Institute of Allied Health Professions, Amersfoort, The Netherlands
SUMMARY. The transition from acute to chronic low back pain (LBP) is influenced by many interacting factors. Pain-related fear, as measured by the Tampa Scale for Kinesiophobia (TSK) and the Fear-Avoidance Beliefs Questionnaire (FABQ), is one of these factors. The objectives of this study were to investigate, in a population with acute LBP, the reliability of TSK and FABQ through evaluation of the internal consistency, the test–retest reliability, and the concurrent validity between TSK and FABQ. One hundred and Seventy-Six patients suffering LBP for no longer than 4 weeks completed a Visual Analogue Scale for pain (VAS), the TSK, the FABQ, and a socio-demographic questionnaire. Each patient completed the VAS, TSK, and FABQ twice within 24 h. Internal consistency of TSK and FABQ scores range from a=0.70 to 0.83. Test–retest reliability ranges from rs=0.64 to 0.80 (Po0.01). Concurrent validity is moderate, ranging from rs=0.33 to 0.59 (Po0.01). It may be concluded that in a population with acute LBP, both the TSK and the FABQ are reliable measures of pain-related fear. In the clinical setting they may provide the practitioner a means of identifying pain-related fear in a patient with acute LBP. r 2003 Elsevier Science Ltd. All rights reserved.
INTRODUCTION
Received: 10 May 2002 Revised: 28 August 2002 Accepted: 25 September 2002
Low Back Pain (LBP) is one of the major reasons patients with musculoskeletal disorders visit their general practitioners (Fordyce 1995). The total annual cost of LBP in The Netherlands amounts to $4.9 billion (Van Tulder et al., 1995). Seventy-five to ninety per cent of these costs are accounted for by the relatively small group of patients with chronic LBP (Frymoyer et al. 1983; Volinn et al. 1991; Nachemson 1992; Van Tulder 1996). The prevalence and costs of LBP are still increasing (Waddell 1998; Maniadakis & Gray 2000). Early identification of LBP patients at risk of becoming chronic is needed in order to focus early optimal intervention and possibly prevent chronicity, thus reducing the personal, social, and economic consequences. The transition of acute to chronic LBP is influenced by many factors, and these prognostic factors probably interact (Flor & Turk 1984; Turk
E.J.C.M. Swinkels-Meewisse, MScMT, PT, R.A.H.M. Swinkels MScMS, PT, MT, R.A.B. Oostendorp, PhD, PT, MT, Research Fellow, Professor in Allied Health Care, Centre for Quality of Care Research, University Medical Centre St Radboud, Nijmegen, The Netherlands. E.J.C.M. Swinkels-Meewisse, MScMT, PT, R.A.H.M. Swinkels MScMs, PT, MT, Physiotherapist/Manual Therapist, Practice of Physical Therapy and Manual Therapy, Eindhoven, The Netherlands. E.J.C.M. Swinkels-Meewisse, MScMT, PT, R.A.B. Oostendorp, PhD, PT, MT Assistant Professor in Manual Therapy, Faculty of Medicine and Pharmacology, Free University Brussels, Postgraduate Education Manual Therapy, Brussels, Belgium. A.L.M. Verbeek MD, PhD, Professor in Clinical Epidemiology, University Medical Centre St Radboud, Nijmegen, The Netherlands. J.W.S. Vlaeyen, PhD, Associate Professor, Department of Medical, Clinical and Experimental Psychology, University of Maastricht, Maastricht, The Netherlands. R.A.B. Oostendorp PHD, PT, MT, Research Director, Dutch Institute of Allied Health Professions, Amersfoort, The Netherlands. Correspondence to: ISM, Ulenpas 80, 5655 JD Eindhoven, The Netherlands. Tel/fax: +31 40 252 8687; E-mail:
[email protected] 29
30 Manual Therapy
1997). There is growing evidence that the persistence of pain is not explained by objective clinical findings (Sternbach 1977; Nachemson 1992; Waddell et al. 1993; Waddell 1998) but that it depends as much on cognitive, affective, behavioural and social factors as on the underlying physical disorder (Burton et al. 1995; Croft et al. 1995; Klenerman et al. 1995; Pincus et al. 2002). There is increasing evidence that LBP and disability are better understood and managed according to the biopsychosocial model (Waddell, 1998: Burton et al. 1999). The same development is reflected in the implementation of the biopsychosocial model in clinical settings in manual therapy (Jones et al. 2002). In the last decade, there has been a shift from the biomedical model to the biopsychosocial approach in manual therapy, and within the framework of this model the utilization of questionnaires is essential to objectify patient characteristics, in particular personal factors. There are some theoretical avoidance-based models, which attempt to explain the perpetuation of pain and pain behaviour, although evidence of the role of fear-avoidance is scarce (Asmundson et al. 1999; Vlaeyen & Linton 2000; Pincus et al. 2002). Two models are outlined below. Lethem et al. (1983) tried to explain the persistence of LBP by introducing the ‘fear-avoidance model of exaggerated pain perception’. Central to this model is the idea that fear is the most important affective dimension of pain with two possible coping responses; ‘confrontation’ and ‘avoidance’. Chronic LBP patients may be classified as confronters or as avoiders (Philips & Jahansjahi 1986; Crombez et al. 1995). Avoidance is enhanced by fear. Kori et al. (1990) use the term ‘kinesiophobia’. They defined ‘kinesiophobia’ as: ‘an excessive, irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to
painful injury or reinjury’. In LBP patients, the resulting inactivity may lead to a deterioration of physical and mental health, i.e. decreased muscle strength, and mobility, an increased fear of pain, somatic preoccupation, and depressive symptoms (Bortz 1984; Kori et al. 1990; Vlaeyen et al. 1995b). Vlaeyen et al. developed a cognitive-behavioural model of fear of movement and (re)injury as a possible explanation of chronic pain (Vlaeyen et al. 1995a,b; Vlaeyen & Crombez 1999; Vlaeyen & Linton 2000) (Fig. 1). In this theoretical model, pain catastrophising influences fear of (re)injury, which in its turn enhances avoidance behaviour, in the long run resulting in disuse, depression and disability. In their model, Vlaeyen et al. emphasize the influence of attributional factors, especially catastrophising, on pain-related fear. Founded on the avoidance-based models two questionnaires were developed to measure painrelated fear or fear-avoidance beliefs. The first is the Tampa Scale for Kinesiophobia (TSK; Miller et al. 1991) and the second is the Fear-Avoidance Beliefs Questionnaire (FABQ; Waddell et al. 1993). The FABQ consists of two subscales, one regarding physical activities (FABQ/pa) and one concerning work-related items (FABQ/w). At the time of writing no published studies are known to the authors that investigate the psychometric properties of the TSK and FABQ in populations of acute LBP patients. In a population of chronic LBP patients, the TSK is a reliable instrument with internal consistency ranging from a=0.68 to 0.80 (Vlaeyen et al. 1995a,b; Crombez et al. 1999). At the time of writing test– retest reliability has not investigated before. The two FABQ subscales, the FABQ/w and FABQ/pa, have good internal consistency ranging from a=0.84 to 0.92 on the work subscale and a=0.52 to 0.77 on the physical activity subscale
Fig. 1FCognitive-behavioural model of fear of movement/(re)injury. (Vlaeyen et al. (1995a), Reproduced by kind permission of Elsevier Science, from Pain Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eek H 1995 Fear of movement/(re)injury in chronic low back pain and its relation to behavioural performance. Pain 62: 363–372.) Manual Therapy (2003) 8(1), 29–36
# 2003 Elsevier Science Ltd. All rights reserved.
Psychometric properties of the Tampa Scale
(Waddell et al. 1993; Symonds et al. 1996; Vendrig et al. 1998; Crombez et al. 1999). The two subscales interact significantly with correlations varying from r=0.39 to 0.60 (Waddell et al. 1993; Crombez et al. 1999). The relationship between TSK and subscales of the FABQ shows moderate correlations with Pearson’s r=0.57 and 0.76 (Po0.001) for the physical activity subscale and r=0.53 and 0.56 (Po0.001) for the FABQ/w (Crombez et al. 1999). The questionnaire has good test–retest stability (Waddell et al. 1993; Pfingsten et al. 2000). With the exception of the study by Fritz et al. (2001), the above-mentioned studies used prevalent cases of LBP or chronic LBP patients. In the study by Fritz et al. patients with work-related, acute LBP were used. The patterns of correlation between FABQ and concurrently measured variables were similar to those reported in patients with chronic LBP (Fritz et al. 2001). STUDY OBJECTIVES Some of the psychometric properties of the TSK and FABQ have been investigated in chronic pain populations (Vlaeyen et al. 1995a,b; Crombez et al. 1999). However, before being eligible to use the questionnaires in cases with acute LBP and draw valid conclusions, the psychometric qualities of the TSK and FABQ in a population with acute LBP must be examined. The objectives of this study are threefold: (1) to investigate the internal consistency of the Dutch version of the TSK (Vlaeyen et al. 1995a) and FABQ (Crombez et al. 1999); (2) to investigate the test–retest reliability of the abovementioned questionnaires; and (3) to examine the concurrent validity between the TSK and FABQ.
METHODS Subjects Patients with LBP were recruited by general practitioners (GP) and physiotherapists in the southeast region of The Netherlands between April 1998 and January 1999. Patients were included who were aged between 18 and 65 years and who had non-specific LBP independent of radiation for no longer than a maximum of 4 weeks with a pain-free period of at least 3 months preceding this episode of LBP. Criteria for exclusion were: LBP with a specific underlying pathology (e.g. tumours, trauma, infection, inflammatory disorders); presence of malignancies; operations in the lumbar area; or pregnancy. Procedure At the first consultation with their GP or physiotherapist patients were asked if they would be # 2003 Elsevier Science Ltd. All rights reserved.
31
willing to cooperate with the study and they were given written information about it. After written informed consent was obtained, a battery of questionnaires was completed twice by each patient: the first time at the first consultation with the health-care provider (t1); and the second time (t2) at home the same evening or with a maximum of 24 h after the questionnaires were first completed. This time interval was chosen to minimize clinical or cognitive change. It was also unlikely that patients would remember their previous answers given the number and length of the questionnaires. Measures Socio-demographic variables A questionnaire was completed covering different socio-demographical elements and biographical data (age, gender, education level, pain onset, sick-leave, time since onset, and preceding episodes). Current pain intensity A Visual Analogue Scale (VAS) for pain was used (Jensen & Karoly 1992). A VAS is a standardized instrument to measure pain intensity with high test– retest reliability (r40.95; Wewers and Lowe 1990), and criterion-related validity with established instruments (e.g. Numerical rating scale, and McGill Pain Questionnaire) ranging from r=0.42 to 0.91 (Downie et al. 1978; Wewers and Lowe 1990). Pain-related fear measures The Dutch versions of the TSK (Miller et al. unpublished report, 1991; Vlaeyen et al. 1995a) and the FABQ (Waddell et al. 1993; Crombez et al. 1999) were used. The TSK is a 17-item questionnaire developed to identify fear of (re)injury due to movement or activities. Items are scored on a 4-point Likert scale with scoring possibilities ranging from ‘strongly disagree’ (score=1) to ‘strongly agree’ (score=4). The scores on items 4, 8, 12, and 16 are reversed. Total scores range from 17 to 68. The FABQ is a 16-item measure comprising two subscales: a seven-item subscale of fear-avoidance beliefs about work-related activities (FABQ/w), and a four-item subscale regarding fear-avoidance beliefs about physical activities (FABQ/pa). Items are scored on a 7-point Likert scale ranging from 0 (strongly disagree) to 6 (strongly agree). Total score for the FABQ/pa ranges from 0 to 24, the total score for the FABQ/w subscale ranges between 0 and 42. Statistical procedure The statistical analysis only includes results for those patients who fully completed the battery of questionnaires twice within the 24-h period. The statistical analyses use the subscales FABQ/w and FABQ/pa. Manual Therapy (2003) 8(1), 29–36
32 Manual Therapy
Pearson’s correlation coefficients were calculated in order to investigate the test–retest stability, and the relationship between the questionnaires. It was decided before the analysis was undertaken that the correlational criteria according to Landis and Koch should be used (Landis and Koch 1977). Cronbach’s alpha was used to calculate the internal consistency of the two questionnaires and Feinstein’s criteria for internal consistency were applied (Feinstein 1987). The criterion for significance was set at ar0.05. For all statistical analyses the Statistical Package for Social Science (SPSS/PC+, version 8.0) was used.
RESULTS Two hundred and twelve patients entered the study, of which 36 (17%) were omitted from the analysis, leaving 176 patients for whom there are complete data. Patients were excluded because of incomplete questionnaires (n=28), missing socio-demographic data (n=5), and by being above the age of 65 (n=3). There were no statistical differences between the excluded cases and the analysed cases regarding age (t=1.22, P=0.22), gender (w2=0.21, df=1, P=0.65), sick-leave (w2=1.1, df=2, P=0.58), pain onset (w2=0.92, df=1, P=0.34), or educational level (w2=0.33, df=2, P=0.85). The patient’s mean age was 42.7 years (SD=11.5). Of the sample 60% were male (n=105), 40% were female (n=71). 55.7% of the patients were employed, in 37.5% the employment status was not applicable (e.g. students, early retirement, house wives, unemployment), and 6.8% regarding employment status were missing data (Table 1).
Tampa Scale for Kinesiophobia The total scores of the TSK on the first measurement (TSK-t1) and the second measurement (TSK-t2) ranged from 18 to 55 and 17 to 55, respectively. The mean of TSK-t1 and TSK-t2 was 36.3 (SD=6.8) and 36.0 (SD=7.4). The median for both measurements was 36 (Table 2). Total scores were normally distributed for TSK-t1 as well as for TSK-t2 (Kolmogorov-Smirnov goodness-of-fit test, P40.05) The internal consistency of TSK was at1=0.70 for t1 and at2=0.76 for t2. The items 4, 8, 12, and 16 (the ‘reverse’ items) reduce the internal consistency. If these items are deleted the alpha increased to at1=0.76 and at2=0.80, respectively. The test–retest reliability was ‘substantial’ with Pearson’s r=0.78 (P0.01) (Table 3). If the reverse items are deleted test–retest reliability slightly increases to r=0.79. Manual Therapy (2003) 8(1), 29–36
Table 1. Patient characteristics on t1 (n=176) Variable
Percentage
Age (mean years7SD) Gender (% male) Education level Less than secondary education Secondary education Higher education/university Missing Pain onset (% sudden) Sick-leave On sick-leave No sick-leave Not applicable Missing Time since onset o7 days 7–14 days 14–21 days 21–28 days Preceding episodes First episode 1–5 episodes 6–10 episodes 411 episodes Missing
42.7 (711.5) 59.7 38.1 26.7 33.5 1.7 61.9 38.1 17.6 37.5 6.8 36.9 29.5 16.5 17 15.3 59.7 13.6 6.3 5.1
Fear-Avoidance Beliefs Questionnaire The total scores of the FABQ/pa for t1 and t2 both ranged from 0 to 24. The means on t1 and t2 were 14.1 (SD=5.5) and 13.3 (SD=5.8), respectively; with medians of 15 and 14, respectively. Total scores of FABQ/pa were negatively skewed (Skt1=0.539, Skt2=0.367, Kolmogorov-Smirnov goodness-of-fit test, Po0.05). The scores of the FABQ/w for t1 and t2 ranged from 0 to 38 with a median of 14 and means of 14.4 (SD=10.1) and 14.7 (SD=10.32), respectively (Table 2). Total scores of FABQ/w were positively skewed (Skt1=0.256, Skt2=0.209, Kolmogorov–Smirnov goodness-of-fit test, Po0.05). The internal consistency of the FABQ/pa for t1 and t2 were at1=0.70 and at2=0.72, and of the FABQ/w were at1=0.82, and at2=0.83. Test-retest reliability of FABQ/pa and FABQ/w was ‘substantial’ (r=0.64 and r=0.80; P0.01) (Table 3). The two subscales were significantly intercorrelated (rt1=0.33, and rt2=0.47; P0.01). Visual Analogue Scale for pain The mean scores for the VAS were t1 and t2 for 49 mm (SD=25.7) and 45 mm (SD=25.3), respectively, with medians of 49 and 45 mm. Concurrent validity between TSK and FABQ Pearson’s rho between TSK and FABQ/w for t1 and t2 was ‘weak’ to ‘moderately strong’ (rt1=0.33 and rt2=0.38 respectively; P0.01) (Table 3). With the reverse-items of the TSK deleted the correlation # 2003 Elsevier Science Ltd. All rights reserved.
Psychometric properties of the Tampa Scale
coefficients increased to rt1=0.37 and rt2=0.41, respectively (P0.01). The correlation between TSK and FABQ/pa for t1 and t2 for ‘moderately strong’ to ‘strong’ with rt1=0.39 and rt2=0.59 (P0.01) (Table 3). After deletion of the items 4, 8, 12, and 16 of the TSK Pearson’s rho was rt1=0.38 and rt2=0.59 (P0.01).
DISCUSSION This study was carried out to investigate the psychometric properties (internal consistency, (i.c.) test–retest stability and concurrent validity) of the pain-related fear measures TSK and FABQ in a population of acute LBP patients. With the exception of the study by Fritz et al. (2001) there have been no published studies that have investigated these qualities in acute LBP, only with chronic LBP, and therefore comparisons will be made with studies that used populations with chronic LBP patients. Tampa Scale for Kinesiophobia The internal consistency of the TSK equals the values found by Vlaeyen et al. (1995a, b) and Crombez et al. (1999). If the reverse items (4, 8, 12, and 16) are deleted, the i.c. increases slightly. To date there are no studies published investigating the test–retest reliability in either the acute or chronic stages of LBP. The test–retest reliability is ‘substantial’, and increases slightly if the reverse items are deleted. The items that are responsible for this decrease (items 4, 8, 12, and 16) are those where the score should be
Table 2. Mean (standard deviation), range and median of the TSK and FABQ on time t1 and t2 (n=176)
TSK-t1 TSK-t2 FABQ/pa-t1 FABQ/pa-t2 FABQ/w-t1 FABQ/w-t2
Mean (SD)
Range
Median
36.3 (6.8) 36.0 (7.4) 14.1 (5.5) 13.4 (5.8) 14.4 (10.1) 14.7 (10.3)
18–55 17–55 0 0 0–38 0–38
36 36 15 14 14 14
Fear-avoidance beliefs questionnaire physical activity subscale: FABQ/pa; fear-avoidance beliefs questionnaire work subscale: FABQ/w; Tampa Scale for kinesiophobia: TSK.
33
reversed. Goubert et al. (2000) found the reverseitems 4, 8, 12, and 16 most frequently to be missing. In our experience, the difficulties encountered by patients in interpreting the structure and content of these items is caused by their formulation.
Fear-Avoidance Beliefs Questionnaire The reported positive skewness of the FABQ/w is mainly caused by a high frequency of zero total scores, which may have been responsible for an eventual floor-effect. The test–retest reliability of both the FABQ/w and FABQ/pa subscales is ‘substantial’. The higher retest stability of the FABQ/w vs the FABQ/pa (r=0.80 vs r=0.64) may be caused by the relatively high frequency of zero total scores thus making it easier for the patient to remember which answers were given on the first occasion. Waddell et al. (1993) found higher correlation coefficients for the two scales (0.95 and 0.88) in testing the reproducibility, but the majority (75%) of the population they studied consisted of chronic LBP patients and the reproducibility was tested in a small population of 26 patients. Pfingsten et al. (2000) calculated the test–retest stability of the total FABQ, that is of all 16 items, and found a Pearson’s rho of 0.87. In this study a small group of chronic LBP patient was used (n=30). The i.c. of both the FABQ/w and FABQ/pa resemble previous studies (Waddell et al. 1993; Symonds et al. 1996; Crombez et al. 1999), although the i.c. of the FABQ/pa subscale in the studies by Crombez et al. was lower. In the statistical analyses it was not taken into account whether patients were employed, although modified instructions were given (e.g. housewives were given instructions to regard their household duties as their work), or whether they were absent from work due to back pain. Repeating the analyses, excluding patients absent due to their LBP (38.1%), i.c. and test–retest reliability of both the FABQ/pa and FABQ/w were comparable with the results of the total group (FABQ/pa: Cronbach’s alpha was 0.75; test–retest r=0.64, Po0.01, and FABQ/w: Cronbach’s alpha was 0.82; test–retest r=0.80, Po0.01). This means that, despite being a point of concern to Waddell and colleagues (1993), the FABQ can be
Table 3. Pearson’s correlation coefficients between TSK and FABQ on time t1 and t2 (n=176)
TSK-t1 TSK-t2 FABQ/pa-t1 FABQ/pa-t2 FABQ/w-t1
TSK-t2
FABQ/pa-t1
FABQ/pa-t2
FABQ/w-t1
FABQ/w-t2
0.78**
0.39**
F 0.59** 0.64**
0.33** F 0.33**
F 0.39** F 0.47** 0.80**
Fear-avoidance beliefs questionnaire physical activity subscale: FABQ/pa; fear-avoidance beliefs questionnaire work subscale: FABQ/w; Tampa Scale for kinesiophobia: TSK **po0.01. # 2003 Elsevier Science Ltd. All rights reserved.
Manual Therapy (2003) 8(1), 29–36
34 Manual Therapy
used in cases of unemployment or absence due to LBP, with the proviso that modified instructions are given. As expected, in this study a significant correlation was found between the two subscales of the FABQ, which corroborates previous findings (Waddell et al. 1993; Crombez et al. 1999; Fritz et al. 2001). This raises questions about the orthogonality of the two subscales. Relationship between the measures The intercorrelations between the FABQ/pa and TSK or FABQ/w for t2 were higher than for t1. Looking at the test–retest correlations of the measures, this difference may be caused by the only ‘moderate’ test–retest reliability of the FABQ/pa. One study investigated the concurrent validity of the TSK and FABQ. Crombez et al. (1999) reported higher correlations between TSK and FABQ. The fact that the calculated correlation between the two questionnaires does not exceed ‘moderate’ might mean that the theoretical constructs are not completely the same (although they show an empirical ‘moderate’ overlap), or it might mean that the validity of each questionnaire is only moderate. The TSK may be aimed more at measuring a fear of (re)injury, whereas the FABQ measures more a fear of pain directly caused by physical activities or work. This might explain the difference as well as it explains the correlation of the two measures. On the other hand, the high percentage of zero total scores of the FABQ/w may influence the correlational analyses with TSK and FABQ/pa. The high percentage of zero scores may be explained by the fact that, in the statistical analysis, it was not taken into account whether patients were working or were on sick leave. This may also explain the contrast with the findings of Crombez et al. (1999), who found higher significant correlational values between TSK, FABQ/pa, and FABQ/w, ranging from 0.53 to 0.76, but who gave no information about the work status of their patients. It is unclear to what extent the study of acute LBP patients is responsible for the different findings in our study and those of Crombez et al. (1999). We are not aware of studies reporting normative scores for the TSK and FABQ. It would be interesting to know whether scores for TSK and FABQ differ if measured in a general population without LBP as compared to a population with LBP: this might give an insight into the interpretation of the scores of TSK and FABQ. Limitations of the study There are some methodological aspects of this study that need considering. First, 212 patients were Manual Therapy (2003) 8(1), 29–36
included during a 9-month period. The incidence of patients reporting LBP to GPs in The Netherlands (Van der Velden et al. 1991) indicates that more patients could have been included. The researchers learned by asking GPs and physiotherapists that they often forgot to ask for patients’ cooperation in the study. The number of non-responders and their characteristics are therefore unknown and no insight can be provided into a possible selection bias. Second, the population included in the study was in fact heterogeneous: it comprised both patients who make a quick recovery from their back pain episode and those who do not. Much discussion exists regarding the definition of chronicity (Verhaak et al. 1998; McGorry et al. 2000). Although one of the inclusion criteria for this study was having had a period of at least 3 month free of back pain before the current LBP episode, there is a chance the population is biased with patients already having a chronic condition if the definition of chronic LBP is characterized by an episodic, recurrent course (Von Korff 1994; Von Korff & Saunders 1996; McGorry et al. 2000). Third, in investigating the test–retest reliability a maximum interval of 24 h was chosen, because patients with LBP of short duration are likely to show true change from 1 day to another (Coste et al. 1994). It is possible that recall played a role, although patients had to complete four questionnaires and they were not told that in the second battery three out of four questionnaires were the same as in the first battery. If memory had played an important role one might expect the correlation to be higher than the results have shown. The second reason for choosing this short interval was to minimize the influence of interventions, such as medication and activity-related instructions or advice (Burton et al. 1999). These factors may have affected the scores for t2. Practical implications of the current findings in the examination or treatment of patients with acute LBP During the last five decades it has increasingly become clear that pain is multi-dimensional, and this is confirmed by the IASP definition of pain (IASP 1986). The biopsychosocial model as a new paradigm in the diagnostics and treatment of patients with benign pain (e.g. LBP) is gradually winning acceptance by manual therapists (Jones et al. 2002). In applying this new model, it is important to obtain an overview of all relevant patient characteristics, so treatment or advice can be tailored (Keen et al. 1999). Pain-related fear, as part of the cognitive dimension of pain (Philips 1987; Vlaeyen et al. 1995a,b), may be a precursor of chronic LBP (Klenerman et al. 1995; Fritz et al. 2001). Early identification of patients who have an abnormal pain-related fear is of the utmost importance in order to focus intervention on those # 2003 Elsevier Science Ltd. All rights reserved.
Psychometric properties of the Tampa Scale
beliefs instead of focusing treatment on impairments of anatomical structures in the lumbar and sacral regions, and possibly prevent acute patients becoming chronic. A more cognitive-behaviourally oriented treatment combined with manual therapeutic treatment on the level of impairments in physiological functions, in the early stage, may be very effective in reducing pain-related fear and hence the development of chronic disability (Linton & Ryberg 2001; Marhold et al. 2001; VanTulder et al. 1997). A cognitivebehavioural intervention based on exposure in vivo treatment has shown to be quite effective in patients with chronic LBP reporting elevated scores on the TSK (Vlaeyen et al. 2001). Focusing on patients’ beliefs can have a positive affect on those beliefs and on disability (Burton et al. 1999; Walsh and Radcliffe 2002). Similar studies with a slightly modified intervention adapted to the primary care setting with acute LBP patients are badly needed, and are likely to be promising. Both the TSK and the FABQ have the potential to distinguish patients with abnormal painrelated fear (Miller et al. unpublished report, 1991; Waddell et al. 1993; Vlaeyen et al. 1995a,b; Crombez et al. 1999).
CONCLUSIONS Before using the TSK and FABQ in the assessment of acute LBP patients the reliability in the acute phase needed to be examined. From this study it may be concluded that both the TSK and the FABQ are reliable questionnaires with good internal consistency and substantial test–retest reliability. Internal consistency of both questionnaires is independent of the phase of the LBP. Concurrent validity between TSK and FABQ/pa is ‘moderately strong’ to ’strong’, and higher than between TSK and FABQ/w.
Acknowledgements This work was partly supported by a grant from the Royal Dutch Association of Physiotherapists. Much gratitude is extended to William Duquet PhD for his statistical advice, and to the GPs and physiotherapists for the inclusion of their patients. Without their cooperation this research would not have been possible.
References Asmundson GJG, Norton PJ, Norton GR 1999 Beyond pain: The role of fear and avoidance in chronicity. Clinical Psychology Review 19: 97–119 Bortz WM 1984 The disuse syndrome. Western Journal of Medicine 141: 691–694 Burton AK, Tillotson KM, Main CJ,Hollis S 1995 Psychosocial predictors of outcome in acute and subchronic low back trouble. Spine 20: 722–728 Burton AK, Waddell G, Tillotson KM, Summerton N 1999 Information and advice to patients with back pain can have a positive effect. A randomized controlles trial of a novel educational booklet in primary care. Spine 24: 2484–2491 # 2003 Elsevier Science Ltd. All rights reserved.
35
Coste J, Delecoeuillerie G, Cohen de Lara A, Le Parc JM, Paolaggi JB 1994 Clinical course and prognostic factors in acute low back pain: An inception cohort study in primary care practice. British Medical Journal 308; 577–580 Croft PR, Papageorgiou AC, Ferry S, Thomas E, Jayson MIV, Silman AJ 1995 Psychologic Distress and low back pain: Evidence from a prospective study in the general population. Spine 20: 2731–2737 Crombez G, Govaerts K, Vervaet L, Lysens R, Eelen P, Baeyens F 1995 Vermijden en volharden van bewegingen bij patienten met chronische lage-rugpijn. Gedragstherapie 28: 69–84 Crombez G, Vlaeyen JWS, Heuts PHTG, Lysens R 1999 Painrelated fear is more disabling than pain itself. Evidence on the role of pain-related fear in chronic back pain disability. Pain 80: 329–339 Downie WW, Leatham PA, Rhind VM, Wright V, Branco JA, Anderson JA 1978 Studies with pain rating scales. Annals of the Rheumatic Diseases 37: 378–381 Feinstein AR 1987 Clinimetrics. Yale University Press, New Haven, 1987 Flor H, Turk DC 1984 Etiological theories and treatments for chronic back pain. I. Somatic models and interventions. Pain 19: 105–121 Fordyce WE 1995 Back pain in the workplace. Management of disability in nonspecific conditions. In: Fordyce WE (ed.) Task Force on Pain in the Workplace. IASP-Press, Seattle, pp 1–72 Fritz JM, George SZ, Delitto A 2001 The role of fear-avoidance beliefs in acute low back pain: Relationships with current and future disability and work status. Pain 94: 7–15 Frymoyer JW, Pope MH, Clements JH, Wilder DG, MacPherson B, Ashikaga T 1983 Risk factors in low-back pain. An epidemiological survey. Journal of Bone and Joint Surgery 65-A: 213–218 Goubert L, Crombez G, Vlaeyen JWS, Van Damme S, Van den Broeck A, Van Houdenhove B 2000 De Tampa Schaal voor Kinesiofobie. Psychometrische karakteristieken en normering. Gedrag en Gezondheid 28: 54–62 International Association for the Study of Pain (IASP), Subcommittee on Taxonomy 1986 Classification of chronic pain. Descriptions of pain syndromes and definitions of pain terms. Pain (Suppl): 3: S1–S225 Jensen MP, Karoly P 1992 Self-report scales and procedures for assessing pain in adults. In: Turk DC, Melzack R (eds) Handbook of Pain Assessment. The Guilford Press, New York, pp. 135–151 Jones M, Edwards I, Gifford L 2002 Conceptual models for implementing biopsychosocial theory in clinical practice. Manual Therapy 7: 2–9 Keen S, Dowell AC, Hurst K, Klaber Moffett JA, Tovey P, Williams R 1999 Individuals with low back pain: How do they view physical activities? Family Practice 16; 39–45 Klenerman L, Slade PD, Stanley IM, Pennie B, Reilly JP, Atchison LE, Troup JDG, Rose MJ 1995 The prediction of chronicity in patients with an acute attack of low back pain in a general practice setting. Spine 20: 478–484 Kori SH, Miller RP,Todd DD 1990 Kinesophobia: A new view of chronic pain behaviour. Pain Management 35–43 Landis JR, Koch GG 1977 The measurement of observer agreement for categorical data. Biometrics 33 159–33 174 Lethem J, Slade PD, Troup JDG, Bentley G 1983 Outline of a fearavoidance model of exaggerated pain perceptionFI. Behavavioral Research and Therapy 21: 401–408 Linton SJ, Ryberg M 2001 A cognitive-behavioral group intervention as prevention for persistent neck and back pain in a non-patient population: A randomized controlled trial. Pain 90: 83–90 Maniadakis N, Gray A 2000 The economic burden of back pain in the UK. Pain 84: 95–103 Marhold C, Linton SJ, Melin L 2001 A cognitive-behavioural return-to-work program: Effects on pain patients with a history of long-term versus short-term sick leave. Pain 91: 155–163 McGorry RW, Webster BS, Snook SH, Hsiang SM 2000 The relation between pain intensity, disability, and the episodic nature of chronic and recurrent low back pain. Spine 25: 834–841 Manual Therapy (2003) 8(1), 29–36
36 Manual Therapy Miller RP, Kori SH, Todd DD 1991 The Tampa Scale. Unpublished Report, Tampa Nachemson A 1992 Newest knowledge of low back pain. Clinical Orthopaedic Related Research (279); 8–20 Pfingsten M, Kroner-Herwig B, Leibing E, Kronshage U, Hildebrandt J 2000 Validation of the German version of the Fear-Avoidance Beliefs Questionnaire. European Journal of Pain 4: 259–266 Philips HC 1987 Avoidance behaviour and its role in sustaining chronic pain. Behavioral Research and Therary 25: 273–279 Philips HC, Jahanshahi M 1986 The components of pain behaviour report. Behavioral Research and Therary 24: 117–125 Pincus T, Burton AK, Vogel S, Field AP 2002 A systematic review of psychological factors as predictors of chronicity/ disability in prospective cohorts of low back pain. Spine 27: E109–E120 Sternbach RA 1977 Psychological aspects of chronic pain. Clinical Orthopaedic Related Research 129: 150–155 Symonds TL, Burton AK, Tillotson KM, Main CJ 1996 Do attitudes and beliefs influence work loss due to low back trouble? Ocupational Medicine 46: 25–32 Turk DC 1997 The role of demographic and psychosocial factors in transition from acute to chronic pain. In: Jensen TS, Turner JA, Wiesenfeld Z (eds) Progress in Pain Research and Management, Vol 8. IASP, Seattle, pp 185–214 Van Tulder MW 1996 Diagnostics and treatment of chronic low back pain in primary care. Dissertation, Free University of Amsterdam, pp 1–164 Van der Velden J, De Bakker DH, Claessens AAMC, Schellevis FG 1991 Een nationale studie naar ziekten en verrichtingen in de huisartsenpraktijk. Basisrapport morbiditeit in de huisartsenpraktijk. Netherlands Institute of Primary Care (Nivel), Utrecht Van Tulder MW, Koes BW, Bouter LM 1995 A cost-ofillness study of back pain in The Netherlands. Pain 62: 233–240 Van Tulder MW, Koes BW, Bouter LM 1997 Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions. Spine 22: 2128–2156
Manual Therapy (2003) 8(1), 29–36
Vendrig A, Deutz P, Vink I 1998 Nederlandse vertaling en bewerking van de fearFavoidance beliefs questionnaire. Nederlands Tijdschrift voor Psychology 18: 11–14 Verhaak PFM, Kerssens JJ, Dekker J, Sorbi MJ, Bensing JM 1998 Prevalence of chronic benign pain disorder between adults: a review of the literature. Pain 77: 231–239 Vlaeyen JWS, Crombez G 1999 Fear of movement/(re)injury, avoidance and pain disability in chronic low back pain patients. Manual Therapy 4: 187–195 Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eek H 1995a Fear of movement/(re)injury in chronic low back pain and its relation to behavioural performance. Pain 62: 363–372 Vlaeyen JWS, Kole-Snijders AMJ, Rotteveel AM, Ruesink R, Heuts PHTG 1995b The role of fear of movement/(re)injury in pain disability. Journal of Occupational Rehabilitation 5: 235–252 Vlaeyen JWS, Linton SJ 2000 Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art. Pain 85: 317–332 Vlaeyen JW, de Jong J, Geilen M, Heuts PH, van Breukelen G 2001 Graded exposure in vivo in the treatment of pain-related fear: a replicated single-case experimental design in four patients with chronic low back pain. Behavioural Research and Therapy 39: 151–166 Volinn E, van Koevering D, Loeser JD 1991 Back sprain in industry. The role of socioeconomic factors in chronicity. Spine 16: 542–548 Von Korff M 1994 Studying the natural history of back pain. Spine 19 (Suppl): S2041–S2046 Von Korff M, Saunders K 1996 The course of back pain in primary care. Spine 21: 2833–2837 Waddell G 1998 The Back Pain Revolution. Churchill Livingstone, London Waddell G, Newton M, Henderson I, Somerville D, Main CJ 1993 A fear avoidance beliefs questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain 52: 157–168 Walsh DA, Radcliffe JC 2002 Pain beliefs and perceived physical disability of patients with chronic low back pain. Pain 97: 23–31 Wewers ME, Lowe NK 1990 A critical review of Visual Analogue Scales in the measurement of clinical phenomena. Research in Nursing & Health 13: 227–236
# 2003 Elsevier Science Ltd. All rights reserved.
Manual Therapy (2003) 8(1), 37–41 1356-689X/03/$ - see front matter # 2003 Elsevier Science Ltd. All rights reserved. doi:10.1054/math.2002.0485
Original article
Does tape facilitate or inhibit the lower fibres of trapezius? C. M. Alexandern, S. Stynesn, A. Thomasn, J. Lewisw, P. J. Harrisonn Department of Physiology, University College London, London, UK, wPhysiotherapy Department, Chelsea and Westminster NHS Healthcare Trust, London, UK
n
SUMMARY. The application of tape to the skin overlying the lower fibres of trapezius is generally thought to facilitate this muscle. However, this facilitation has not been thoroughly investigated. In this study, the effect of tape upon trapezius motoneurone pool excitability was assessed using the trapezius H reflex. The amplitude of the H reflex was measured across four conditions: before tape application, with Endura Fix tape, with the addition of Endura Sports tape and finally with the tape removed. Instead of the expected facilitation of lower trapezius, this tape inhibited lower trapezius activity. On average, the application of Endura Fix tape inhibited trapezius by 4%. The application of Endura Sports tape overlaying the Endura Fix tape inhibited trapezius on average by 22%. This inhibition did not last once the tape was removed. This suggests that any change in shoulder girdle symptoms or movement, which occurs with the application of this particular tape is not explicable on the basis of the facilitation of the lower fibres of trapezius. r 2003 Elsevier Science Ltd. All rights reserved.
is able to draw the origin of the muscle towards its insertion. It is proposed that this muscle shortening optimizes the length–tension relationship of a lengthened muscle, enhancing its ability to generate force (Morrissey 2000). On the other hand, other proposed mechanisms include the biomechanical realignment of a joint, which may optimize its ability to move normally (Host 1995; Turner 1996), as well as cutaneous afferent input from the application of tape, altering motoneurone output (Simoneau 1997; McNair & Heine 1999). Tape is often applied around the shoulder girdle. One of the most popular techniques is the placement of tape from the medial end of the spine of the scapula extending down to the lower thoracic spine. This application approximately mirrors the direction of pull of the lower fibres of trapezius and is commonly believed to facilitate this part of the muscle. One way of exploring whether or not taping the muscle does facilitate trapezius is to investigate whether the application of tape affects trapezius reflexes. A change in the amplitude of a reflex reflects a change in the level of facilitation or inhibition acting upon the motoneurone pool. Indeed, if reflex amplitude increases, the motoneurone pool has been facilitated and if reflex amplitude decreases, it has been inhibited. A reflex that lends itself to such a
INTRODUCTION Tape is in widespread use amongst physiotherapists. One reason for its use is the belief, based, in the main, upon anecdotal evidence, that tape facilitates and inhibits muscles depending upon the way it is applied. For example, tape applied under tension in the direction of the muscle fibres is thought to facilitate the underlying muscle (Morrissey 2000). However, tape applied across the belly of the muscle is thought to inhibit the muscle (Tobin & Robinson 2000). An understanding of the mechanisms by which taping achieves its effects is limited. It has been hypothesized that tape applied in the direction of the muscle fibres
Recieved: 25 April 2002 Accepted: 25 Sepember 2002 Caroline M. Alexander, MSc, PhD, MCSP, MMACP, Senior Research Assistant, Siobhan Stynes, MSc, MCSP, MMACP, Postgraduate student, Ashima Thomas, BSc, Under-graduate student, Philip J. Harrison, BSc, PhD, LLB, Senior Lecturer, Department of Physiology, University College London, Gower Street, London WC1E 6BT, UK, Jeremy Lewis, MSc, PhD, MCSP, MAPA, MMACP, MMPAA, Research Co-ordinator, Physiotherapy Department, Chelsea and Westminster NHS Healthcare Trust, 369, Fulham Road, London SW10 9WH, UK. Correspondence to: CMA, Department of Physiology, University College London, Gower Street, London WC1E 6BT, UK. Tel: +44 20 7679 3238; Fax: +44 20 7679 1342; E-mail: c.alexander @ucl.ac.uk 37
38 Manual Therapy
study is the H reflex. An H reflex is the electrically evoked equivalent of the tendon jerk and has been characterized in the trapezius muscles by Alexander and Harrison (2002). Thus, whether or not trapezius is actually facilitated by application of this tape can be investigated by electrical stimulation of the sensory nerve of trapezius, which then evokes a monosynaptic reflex (see Fig. 1). This, then allows an assessment of the effect of tape applied to the skin overlying and aligned with the lower fibres of trapezius upon the H reflex as an index of trapezius motoneurone pool excitability. This was the aim of the study.
METHOD The H reflex of trapezius was evoked by electrically stimulating the cervical nerve of C3/4 (Alexander & Harrison 2002). The C3/4 cervical nerve is the sensory supply to the trapezius muscle and carries not only the afferent supply to trapezius but also a varying compliment of motor axons (Williams et al. 1989; Krause et al. 1991). Thus, stimulation of the cervical nerve of C3/4 evokes an H reflex and in some subjects, where motor axons are present, an M response is also evoked (see Fig. 1B). Electrical stimulation of a mixed peripheral nerve activates
Fig. 1FA diagrammatic representation of the H reflex pathway (top) and the trapezius H reflex (bottom). (A) Electrical stimulation of a mixed peripheral nerve evokes two responses from the muscle it supplies. The first response is the motor response (M response). This is from the direct stimulation of the motor axons. The second response (or H reflex) is evoked by stimulation of the afferent supply, which monosynaptically activates the efferent axons. (B) The trapezius responses to electrical stimulation of the cervical nerve of C3/4. The downward arrows mark the responses. The upward arrow marks the onset of the stimulus. This average is the result of 10 stimuli. Manual Therapy (2003) 8(1), 37–41
# 2003 Elsevier Science Ltd. All rights reserved.
Tape and lower fibres of trapezius 39
both sensory axons and motor axons. Activation of the sensory axons produces monosynaptic activation of the motor neurones and as a consequence the H reflex. Activation of the motor axons causes direct activation of the muscle. This is the M response and is not a reflex. The presence of the M response is useful since it gives an index of consistency in the application of the stimulus to the nerve. As long as the M response is consistent, then consistent changes to the H reflex can be inferred as being changes in motoneurone excitability (see Fig. 1A). This is particularly pertinent as the application of the tape upon the skin can pull upon the stimulation site and possibly alter the effectiveness of the stimulus to the cervical nerve. However, by monitoring the amplitude of the M response, the effectiveness of the stimulus can be monitored and any inconsistent responses can be scrutinized. Recordings were made, with local ethical approval and informed consent, from 18 healthy subjects aged between 21 and 36 years. Responses of trapezius were evoked by a 1 ms square-wave electrical stimulus (Digitimer DS7) applied to the cervical nerve of C3/4, with an inter-stimulus interval of 3 s. The anode, a gauze-covered metal plate, was positioned just below the clavicle. The cathode, a roving and gauze-covered probe, was used to locate the cervical nerve of C3/4. This is superficially located on the anterior surface of the upper fibres of trapezius above the clavicle. Accurate positioning of the cathode was confirmed by the resulting contraction of the trapezius muscle. The cathode was then replaced with a self-adhesive Ag/AgCl electrode. Surface EMG was recorded from the lower fibres of trapezius using adhesive electrodes (Blue Sensor) placed edge to edge with the recording area 3 cm apart. The electrodes were positioned in line with these fibres at the level of T6/7. The EMG was amplified (Digitimer NL824) and filtered (Neurolog NL125) with a bandwidth of 30 Hz–3 kHz. The data were converted from an analogue to a digital signal at a sampling frequency of 4 kHz (CED 1401) and stored for later analysis by CED Signal software. The experiments were carried out with the subject sitting. Subjects performed a maximum voluntary contraction (MVC) of the lower trapezius, which was determined by a combined retraction and depression of the shoulder girdle. Particular levels of contraction were controlled with the aid of a visual feedback device. Throughout the experimental procedure the subject contracted the lower fibres of trapezius at 10–20% of MVC. The procedure began by evoking a control sequence of approximately 50 trapezius reflexes. An under tape (Endura Fix tape), was then gently applied so as not to create tension upon the skin. It was aligned with the lower trapezius fibres as per Figure 2A and a further 50 reflexes were evoked. Rigid tape (Endura Sports tape) was then applied # 2003 Elsevier Science Ltd. All rights reserved.
Fig. 2FThe location and position of the Endura Fix tape (left) and Endura Sports tape (right). The Endura Fix tape was positioned without tension across the skin, whilst the Endura Sports tape was positioned with tension along the line of the tape.
over the under tape ‘under tension’ as applied in common clinical practise (see Fig. 2B). A further 50 reflexes were evoked. Finally, the tapes were removed and 50 more reflexes were evoked. The amplitude (measured from peak to peak) of the M response and the H reflex were then measured. The stability of the M response was then scrutinized before assessing any change in the amplitude of the H reflex. Thus, for each subject it was ensured that the amplitude of the M response was not significantly different throughout the four experimental conditions by removing any spurious M responses. The H reflexes accompanying spurious M responses were also discarded. In two subjects the amplitude of the M response could not be accurately assessed and so the results of these two subjects were removed from the data. In the remaining subjects, the consistent amplitude of the M responses was tested using a oneway analysis of variance (ANOVA). Thus, for each subject, the H reflex data set was accompanied by M responses of consistent amplitude. The amplitude of these H reflexes was then compared across the four experimental conditions using a two-way ANOVA with replication. A post hoc Tukey test was used to reveal any significant differences across the four experimental conditions.
RESULTS It was expected that the tape would facilitate the lower fibres of trapezius. For this to occur, the peakto-peak amplitude of the H reflex would increase. In fact, the trapezius H reflex decreased in amplitude with application of tape. Figure 3 illustrates a typical result. Here, the under tape had little effect. However, the application of rigid tape inhibits the trapezius reflex. Upon removal of the tape, the trapezius H reflex amplitude returns to near baseline levels. As illustrated by the stability of the M response, these Manual Therapy (2003) 8(1), 37–41
40 Manual Therapy
Fig. 3FThe effect of tape upon the amplitude of the trapezius H reflex in one subject. The M response amplitude is stable throughout the experimental procedure (diamonds). The amplitude of the H reflex decreases with the application of the rigid Endura Sports tape (squares).
changes occur independently of the effectiveness of the stimulus. Averaging the results from all 16 subjects in which the M response was stable gives the population data (Fig. 4). This reveals that the application of the under tape produced a mean decrease of 4% of the amplitude of the H reflex, while the application of the rigid tape produced a mean decrease of 22%. This 22% inhibition was not sustained when the tape was removed. In fact, on average the H reflex immediately returned to within 2% of the baseline activity upon removal of the tape (see Fig. 4). A two-way ANOVA with replication reveals that these changes in H reflex amplitude across the four conditions reached significance (Po0.001). In addition, a post hoc Tukey test reveals that the H reflex amplitudes compared across all conditions were significantly different from each other (Po0.05). Consequently, application of the under tape inhibited trapezius activity, the additional application of rigid tape inhibited trapezius further and finally the removal of the tapes removes this inhibition, although the activity did not quite return back to pre-tape levels.
DISCUSSION The results of this study show that taping the skin overlying the trapezius muscle, as performed in this study, inhibits its reflexes. This effect does not last, as upon removal of the tape the trapezius reflex returned Manual Therapy (2003) 8(1), 37–41
Fig. 4FThe mean amplitude of the H reflex across four different conditions (7the average SEM for each condition; n=16). The amplitude of the H reflex decreased significantly with the application of tape. Upon removal of the tape, the H reflex returned to near baseline amplitude. The * indicates a significant result (Po0.05).
to within 2% of the pre-tape amplitude. This result is surprising in view of the fact that taping is thought to facilitate the lower fibres of trapezius. However, a review of the literature suggests that this belief is based upon case studies, course notes, clinical experience and anecdotal claims (McConnell 1994; Host 1995; Mottram 1997; Morrissey 2000). Irrespective of clinical observations, the results of this study clearly shows that taping inhibits the H reflex. However, while this result is not in doubt the present experiments shed no light on the mechanisms involved. Consequently, the mechanisms involved are # 2003 Elsevier Science Ltd. All rights reserved.
Tape and lower fibres of trapezius 41
open to speculation. For example, one way by which this inhibition may have occurred may be due to an alteration of the length of the muscle when tape is applied under tension. Thus, if the muscle was held in a shortened position by the tension of the tape, a reduction in tonic muscle spindle activity may result. This would reduce the spindle afferent input upon the trapezius motoneurone pool, which may lead to its inhibition. A small, though significant inhibition of the trapezius H reflex did occur with the application of the under tape, which was not applied under tension. This suggests that mechanisms other than those evoked by changes in muscle length may also be involved. Cutaneous afferents are well known to affect reflex activity (Jenner & Stephens 1982). These afferents have both facilitatory and inhibitory effects upon local motoneurone pool excitability. Although there is little understanding of the effect of local cutaneous afferents upon the activity of trapezius, the inhibitory effects observed here could be explained on the basis of cutaneous effects being produced by laying the tape upon the skin. Another possible mechanism may be related to the subject’s subjective reduced sense of effort in contracting trapezius with the application of tape. Thus, the presence of the tape increases afferent input, which may lead to a corresponding decrease in volitional drive to the motoneurone pool from descending pathways. This might effectively change the motor ‘set’. In conclusion, the results of this investigation suggest that we must reconsider the presumption that taping along the length of a muscle tends to facilitate whereas taping across the length of the muscle inhibits it. However, whatever the mechanism, the results of these experiments should be taken in the context that these were normal healthy subjects, i.e. without shoulder pathology, nor were they in pain.
# 2003 Elsevier Science Ltd. All rights reserved.
Although the effect of tape upon these normal subjects was clearly inhibitory, it may be the case that tape has a different effect in subjects with shoulder pathology. Thus, further examination of these issues should be explored in order to understand the underlying mechanisms of its effect.
Acknowledgements This work was supported by the Wellcome Trust, grant number 054895. C.M.A. is a recipient of a postgraduate training bursary from the Arthritis Research Campaign.
References Alexander CM, Harrison PJ 2002 The bilateral reflex control of the trapezius muscle in humans. Experimental Brain Research 142(3): 418–424 Host H 1995 Scapular taping in the treatment of anterior shoulder impingement. Physical Therapy 75: 803–812 Jenner JR, Stephens JA 1982 Cutaneous reflex responses and their central nervous pathways studied in man. Journal of Physiology 333: 405–419 Krause HR, Bremerich A, Herrmann M 1991 The innervation of the trapezius muscle in connection with radical neck-dissection. An anatomical study. Journal of Craniomaxillofacial Surgery 19: 87–89 McConnell J 1994 The McConnell approach to the problem shoulder. Course Notes. McConnell Institute, Marina Del Ray, CA McNair PJ, Heine PJ 1999 Trunk proprioception: enhancement through lumbar bracing. Arch Phys Med Rehabil 80: 96–99 Morrissey D 2000 Proprioceptive shoulder taping. Journal of Bodywork and Movement Therapies 4(3): 189–194 Mottram SL 1997 Dynamic stability of the scapula. Manual Therapy 2(3): 123–131 Simoneau GG 1997 Changes in ankle joint proprioception resulting from strips of athletic tape applied over the skin. Journal of Athletic Training 32: 141–147 Tobin S, Robinson G 2000 The effect of McConnell’s vastus lateralis inhibition taping technique on vastus lateralis and vastus medialis obliquus activity. Physiotherapy 86(4): 173–183 Turner 1996 Rehabilitation of the sporting shoulder. Physiotherapy in Sport XIX: 6–11 Williams P, Warwick R, Dyson M, Bannister L 1989 Gray’s Anatomy, 36th edn. Churchill Livingstone, London, Ch 7, p 1081
Manual Therapy (2003) 8(1), 37–41
Manual Therapy (2003) 8(1), 42–45 1356-689X/03/$ - see front matter # 2003 Elsevier Science Ltd. All rights reserved. doi:10.1054/math.2002.0473
Clinical note
The effect of postoperative ataralgesia by manual therapy after pulmonary resection F. Hirayama*, Y. Kageyama*, N. Urabe*, H. Senjyuw *Department of Thoracic Surgery, Numazu City Hospital, Japan, wDepartment of Physical Therapy, The School of Health Sciences, Nagasaki University, Japan
SUMMARY. Muscle therapy, a form of manual therapy, was applied to control pain persisting for more than 1 week following posterolateral thoracotomy, and its efficacy for the alleviation of pain was investigated. Eight patients who underwent posterolateral thoracotomy and lung resection for cancer (n = 7) or emphysema (n = 1) received manual therapy to incised muscles and the muscles inserting into the ribs in the affected area for an average of 17 days postoperatively. Pressure-friction and stretching techniques were used. Treatment was continued until the intensity of the pressure-friction technique reached a level at which the patient complained of pain and a decrease in muscle tone was detected. Treatment was performed once a week for 3 weeks. Pain severity was measured using a visual analog scale (VAS) (0–10). Before the first treatment, the VAS was set at 10, and changes of the score were observed before and after the treatment as well as over time. After three sessions, all patients showed a decrease in pain from 10 to an average of 1.9 (range 1.3–2.6). Manual therapy was therefore found to be effective for pain control after posterolateral thoracotomy. r 2003 Elsevier Science Ltd. All rights reserved.
severe pain after posterolateral thoracotomy (Benedetti et al. 1997). Manual therapy is used for the normalization of muscle contraction and for increasing range of motion, and its efficacy has been demonstrated following orthopaedic surgery and in diseases of the central nervous system (Craig & Yoichiro 1997; Bang & Deyle 2000; Deyle et al. 2000). However, the application of manual therapy in the general thoracic field has not been reported. The authors assumed that shortening of the incised muscles was one cause of pain after posterolateral thoracotomy. In the present study, a physiotherapist (PT) used the pressure–friction technique and the stretching technique to treat the injured muscles in the extended position with the patient in a comfortable posture. This muscle therapy, a form of manual therapy, was found to be effective in eight patients with postoperative pain that had persisted despite several attempts at pain control via other methods.
INTRODUCTION Most patients have frequent episodes of postoperative pain after undergoing major operations such as lung resection or esophagectomy via a posterolateral thoractomy (Griffith et al. 1995). Because of limitation of movement of the arms and thoracic cage in an attempt to prevent pain, shortening of the muscles and secondary restriction of range of motion may occur. The pain is not always completely controlled by epidural anaesthesia or by administration of opiates or anti-inflammatory agents. Transcutaneous electrical nerve stimulation (TENS) (John 1990; Robinson 1996) also shows no analgesic effect on Received: 7 February 2002 Revised: 1 June 2002 Accepted: 16 July 2002 Fumi Hirayama PT, Department of Thoracic Surgery, Numazu City Hospital, Japan, Yoshihiko Kageyama MD, Department of Thoracic Surgery, Numazu City Hospital, Japan, Norikazu Urabe MD, Department of Thoracic Surgery, Numazu City Hospital, Japan, Hideaki Senjyu PhD, Department of Physical Therapy, The School of Health Sciences, Nagasaki University, Japan. Correspondence to: FH, Department of Thoracic Surgery, Numazu City Hospital, Hideaki Senjyu 550 Harunoki, Higashishiiji, Numazu, Shizuoka 410-0302, Japan. Tel: 81 55 924 5100; Fax: 81 55 924 5133; E-mail:
[email protected]
MATERIALS AND METHODS Patients: The patients studied at the Department of Thoracic Surgery of Numazu City Hospital comprised eight patients with persistent wound pain at 14 days postoperatively from among 45 patients who 42
Manual therapy after pulmonary resection Table 1.
43
Patients characteristics
No.
Sex
Age
1 2 3 4 5 6 7 8
F M F M F F M F
34 70 51 48 70 73 51 64
Disease
Surgery
Lung cancer Pneumothorax, emphysema Lung cancer Lung cancer Lung cancer Lung cancer Lung cancer Lung cancer
Right lower lobectomy Wedge resection Left lower lobectomy Right upper lobectomy Right lower lobectomy Left lower lobectomy Right upper lobectomy Right upper lobectomy
Postoperative days to first treatment 10 10 6 17 24 54 6 11
M = male, F = female.
from April 1999 to March 2000 underwent posterolateral thoracotomy at the level of the fifth or sixth rib for lung cancer or persistent pneumothorax (Table 1). They included three males and five females with a median age of 57.4 years. Treatment: From an average of 17 days postoperatively, manual therapy was started at a frequency of once a week, and three sessions were performed. The muscles treated were serratus anterior and latissimus dorsi, which were cut during surgery, as well as rectus abdominis, external oblique, and pectoralis major, which were attached to the ribs affected by thoracotomy. At the time manual therapy was applied, eight patients were receiving oral analgesics, NSAID. Positioning of the patient: Appropriate positions were selected so that the muscles treated were placed on a slight stretch and the patient’s posture was comfortable. Treatment techniques: The pressure–friction technique, which is used most frequently to improve muscle tone and muscle oedema, and the stretching technique (for evaluation of changes in muscle tone) were applied. The pressure–friction technique involved application of the friction so that the thumbs reached the deepest point when pressure was applied to a fixed position on the patient. The two forces of pressure and friction were applied continuously using a smooth action. The minimum intensity at which the patient felt pain was generally used as a guide for the amount of pressure applied. The final decision was made on the basis of information obtained by assessment of the response at the sites where pressure was applied during treatment (changes of muscle tone and reduction of oedema), as well as the systemic response (autonomic responses such as sweating and piloerection). Therefore, the pressure applied cannot be expressed quantitatively. Before, during, and after manual therapy, extensibility of the injured muscles was examined by passive movement up to the limit of motion for the related joint, so that the effects of therapy could be evaluated. Rectus abdominis, external oblique, and serratus anterior: Initially, the patient was placed in the supine position with cushioning from the lower lumbar spine to the buttock region. The rectus abdominis, external oblique and serratus anterior muscles were elongated # 2003 Elsevier Science Ltd. All rights reserved.
by extension of the lumbar spine and flexion of the shoulder to 1801 on the operated side. When the subject was unable to achieve 1801 shoulder flexion, cushions were placed near the head of the patient, the arms were placed on the cushions and the shoulder position at which the patient showed no increased muscle tone due to pain was selected. Then, the PT applied the pressure-friction technique to the stiff muscles using the thumbs (Figs. 1 and 2). The rectus abdominis and external oblique muscles showed induration and pain when pressure was applied near their pelvic insertions, especially along the inner border of the anterior superior iliac spine. Since the serratus anterior showed the greatest sensitivity to pressure among the treated muscles,
Fig. 1FTreatment of rectus abdominis and external oblique.
Fig. 2FTreatment of serratus anterior. Manual Therapy (2003) 8(1), 42–45
44 Manual Therapy
pressure was applied very lightly to this muscle. Because this muscle was cut during the operation, the technique was not applied for one finger breadth above and below the operative wound. Immediately after the first application of the pressure–friction technique, passive flexion was applied to the shoulder joint using the stretching technique to evaluate the range of motion and resistance. Pectoralis major: Initially, the patient was placed in supine with cushioning from the lower lumbar spine to the buttock region. Pectoralis major was placed on stretch with the lumbar spine in the extended position and the shoulder on the operated side in an intermediate position between internal and external rotations with 901 abduction. Then, the PT applied the pressure–friction technique to the pectoralis major muscle using the thumbs (Fig. 3). The muscle was sensitive to pressure, especially at its attachment to the clavicle. Immediately after the first application of the pressure–friction technique, passive horizontal abduction of the shoulder joint was performed using a stretching technique to evaluate the range of motion and resistance. Latissimus dorsi: Initially, the patient was placed in prone with cushioning of the precordial region. Latissimus dorsi was stretched by lateral flexion of
the upper thoracic spine and by placing the shoulder on the operated side in an intermediate position between internal and external rotations with 901 abduction. The patient’s arms were allowed to hang downwards on either side of the bed. Next, the PT applied the pressure–friction technique to the latissimus dorsi muscle using the thumbs (Fig. 4). Because this muscle was incised during surgery, the technique was not applied for one finger breadth above and below the operative wound. When the technique was applied, this muscle showed the least sensitivity to pressure.
ASSESSMENT A visual analog scale (VAS) (Huskisson 1974) was used to evaluate the severity of pain. The sites of pain were confirmed immediately before application of manual therapy and the pretreatment pain was defined as 10 on the VAS. Immediately after manual therapy, changes of the pain at each site were assessed from the VAS. The changes of pain day by day were also assessed by the patients and recorded once a day until the next treatment.
RESULTS
Fig. 3FTreatment of pectralis major.
Five patients had pain in the precordial region, four had pain in the lateral chest wall, and six had back pain (including patients with pain in more than one region). The course after treatment was similar in all patients. Immediately after manual therapy, a marked reduction in pain was confirmed in the treated regions, but the pain worsened again on days 2 or 3 after treatment, with subsequent alleviation of pain from day 4. When changes in the severity of pain on completion of treatment were assessed using the VAS, a reduction in pain from a VAS of 10 (pretreatment) to a score of 2–4.6 was noted after treatment (Fig 5).
DISCUSSION
Fig. 4FTreatment of latissimus dorsi. Manual Therapy (2003) 8(1), 42–45
The results of this study show the effect of manual therapy for postoperative pain following thoracotomy for lung resection. Transcutaneous electrical nerve stimulation is often effective in reducing postoperative pain, and was effective when used alone to treat mild pain caused by video-assisted thoracoscopy (Benedetti 1997). It also showed an effect when used concomitantly with analgesics for mild-to-moderate pain caused by muscle-sparing thoracotomy or sternotomy (Benedetti 1997). However, it has been reported that TENS is not effective against severe # 2003 Elsevier Science Ltd. All rights reserved.
Manual therapy after pulmonary resection
Fig. 5FReduction in pain with manual therapy (10 = worst, 0 = none).
45
This therapy should be started from 2 weeks after the operation when the incision has healed, and a treatment interval of at least 4 days is considered to be appropriate. The reason for this is that pain actually increased in severity at 2–3 days after manual therapy in most patients, while alleviation of the pain was noted from the fourth day. The authors believe that results of this observational study indicate the need for further investigations in the form of a randomized controlled clinical trial. Acknowledgements
pain caused by posterolateral thoracotomy (Benedetti 1997). The authors have found that one cause of pain after posterolateral thoracotomy is stress on muscles incised during the operation or on muscles attached to the ribs that are affected by thoracotomy. In this series of patients the manual therapy applied was based on the hypothesis that shortening of these muscles was involved in causing such pain. It has been reported that reactions to opioids such as endorphins that suppress pain are deeply involved in pain inhibition. To obtain the analgesic effects of opioids for muscle pain, a physiological response to simulation of the skin and deep tissues is necessary, and intermittent stimulation by manual therapy is effective for inducing this physiological response (Lewis et al. 1980). This therapy not only appears to stimulate the secretion of pain-suppressing substances and thus alleviates pain, but also improves the local circulation (Dawson & Hudlicka 1993), reduces muscle spasm, and helps to normalize muscle contractility. Treatment was performed once a week for a total of three sessions. When the severity of pain expressed on the VAS scale was monitored over time, there was a significant reduction in pain to 2–4.6 after treatment, compared with a score of 10 on the VAS before treatment, suggesting the efficacy of manual therapy.
# 2003 Elsevier Science Ltd. All rights reserved.
We wish to express our sincere thanks to Sue Jenkins, GradDipPhys, PhD, School of Physiotherapy, Curtin University of Technology, Perth, Western Australia, for her editorial assistance.
References Bang MD, Deyle GD 2000 Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. Journal of Orthopaedic & Sports Physical Therapy 30(3): 126–137 Benedetti F, Amanzio M, Casadio C, Cavallo A, Cianci R, Giobbe R, Mancuso M, Ruffini E, Maggi G 1997 Control of postoperative pain by transcutaneus electrical nerve stimulation after thoracic operations. Annals of Thoracic Surgery 63: 773–776 Craig BN, Yoichiro T 1997 Myotherapy: A new approch to the treatment of muscle pain syndrome. The Journal of Manual and Manipulative Therapy 5: 87–90 Dawson JM, Hudlicka O 1993 Can changes in microcirculation explain capillary growth in skeletal muscle? International Journal of Experimental Pathology 74(1): 65–71 Deyle GD, Henderson NE, Matekel RL, Ryder MG, Garber MB, Allison SC 2000 Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee: A randomised, controlled trial. Annals of Internal Medicine 132(3): 173–181 Griffith PF, Jean D, Robert JG, Clement AH, Martin FM, Harold CU 1995 Thoracic Surgery. Churchill Livingstone, Edinburgh, ch 1, pp 116–117 Huskisson EC 1974 Measurement of pain. The Lancet 9: 1127–1131 John JB 1990 The Management of Pain, Vol II, 2nd edn. Lea & Febiger, Philadelphia, pp 1852–1853 Lewis JW, Cannon JT, Liebeskind JC 1980 Opioid and nonopioid mechanisms of stress analgesia. Science 208: 623–625 Robinson AJ 1996 Transcutaneous electrical nerve stimulation for the control of pain in musculoskeletal disorders. Journal of Orthopaedic & Sports Physical Therapy 24(4): 209–226
Manual Therapy (2003) 8(1), 42–45
Manual Therapy (2003) 8(1), 46–51 1356-689X/03/$ - see front matter # 2003 Elsevier Science Ltd. All rights reserved. doi:10.1054/math.2002.0472
Professional issue
Spinal manipulation for low-back pain: a treatment package agreed by the UK chiropractic, osteopathy and physiotherapy professional associations E. Harvey,* A. K. Burton,w J. K. Moffett,z A. Breen,} in collaboration with the UK BEAM trial team*z *Department of Health Sciences, University of York, York, UK, wSpinal Research Unit, University of Huddersfield, Queensgate, Huddersfield, UK, zInstitute of Rehabilitation, University of Hull, Hull, UK, }Institute for Musculoskeletal Research and Clinical Implementation, Anglo-European College of Chiropractic, Bournemouth, Dorset, UK, zMedical Research Council (MRC) General Practice Research Framework (GPRF) at the MRC Clinical Trials Unit, Stephenson House, London, UK
SUMMARY. Trials of manipulative treatment have been compromised by, amongst other things, different definitions of the therapeutic procedures involved. This paper describes a spinal manipulation package agreed by the UK professional bodies that represent chiropractors, osteopaths and physiotherapists. It was devised for use in the UK Back pain Exercise And Manipulation (UK BEAM) trialFa national study of physical treatments in primary care funded by the Medical Research Council and the National Health Service Research and Development Programme. Although systematic reviews have reported some beneficial effects of spinal manipulation for low-back pain, due to the limited methodological quality of primary studies and difficulties in defining manipulation, important questions have remained unanswered. The UK BEAM trial was designed to answer some of those questions. Early in the design of the trial, it was acknowledged that the spinal manipulation treatment regimes provided by practitioners from the three professions shared more similarities than differences. Because the trial design specifically precluded comparison of the effect between the professions, it was necessary to devise a homogenous package representative of, and acceptable to, all three. The resulting package is ‘pragmatic’, in that it represents what happens to most people undergoing manipulation, and ‘explanatory’ in that it excludes disciplinespecific variations and other ancillary treatments. r 2003 Elsevier Science Ltd. All rights reserved.
INTRODUCTION Current guidelines for the management of low-back pain have been produced in at least 11 countries. Since the numerous national low-back pain guidelines development groups used largely the same body of scientific evidence, a consistent recommendation is that patients have early access to physical treatments and should be encouraged to return to normal activities as soon as possible (Koes et al. 2001). There is some heterogeneity, however, in the recommendations on manipulation (Koes et al. 2001). For instance, the UK, US, New Zealand, Swiss, German, Danish and Swedish guidelines recommend manipulation as an option in the initial weeks of an episode. However, the Dutch, Australian and Israeli guidelines do not recommend manipulation for acute low-back pain, and the Dutch and Danish guidelines suggest it is a useful therapeutic option for chronic back pain. The reason for the discrepancies seems to
Received: 30 January 2002 Revised: 22 May 2002 Accepted: 8 July 2002 Emma Harvey, BSc, PhD, Research Fellow and UK BEAM Trial Manager, Department of Health Sciences, Alcuin College, University of York, York, UK A Kim Burton, PhD, DO, Research Director and UK BEAM National Clinical Coordinator, Spinal Research Unit, University of Huddersfield, Queensgate, Huddersfield, UK. Jennifer Klaber Moffett, MSc, PhD, MCSP, Deputy Director and UK BEAM National Clinical Coordinator, Institute of Rehabilitation, University of Hull, Hull, UK. Alan Breen, DC PhD, Research Director and UK BEAM Trial Working Group, Institute for Musculoskeletal Research and Clinical Implementation, Anglo-European College of Chiropractic, Bournemouth, Dorset, UK. The UK BEAM trial team, Medical Research Council (MRC) General Practice Research Framework (GPRF) at the MRC Clinical Trials Unit, Stephenson House, London, UK Correspondence to: EH, Baines Wing, School of Health Care Studies, University of Leeds, Leeds LS2 9JT, UK. E-mail:
[email protected] 46
Spinal manipulation for low-back pain
be related to the interpretation of the evidence, and in particular, the way that chronicity is defined. Systematic reviews of the evidence on manipulation There have been a number of systematic reviews of the effectiveness of manipulation for low-back pain. Koes et al. (1991) carried out a blinded review of 38 studies and concluded that, although some results were encouraging, there was a need for further trials to establish the effectiveness of manipulation. Shekelle et al. (1992) carried out a meta-analysis combining data from nine trials and concluded that manipulation could increase the rate of recovery from acute uncomplicated low-back pain. However, they reported there were insufficient data to provide evidence for the effectiveness of manipulation in more chronic cases. The Agency for Health Care Policy and Research (1994) report from the US, based on four meta-analyses and 12 additional randomized trials, came to the same conclusion about acute low-back pain as Shekelle et al. (1992). They also reported that the evidence to support the use of manipulation for radiculopathies or longer standing back pain was inconclusive. Thereafter, a systematic overview of reviews by Assendelft et al. (1995) was critical of the general standard of reviews; nevertheless nine of the ten best reviews, as judged by methodological criteria, reported positive effects of manipulation. Van Tulder et al. (1996a) reported a systematic review of 11 different interventions for acute back pain. They concluded there is limited evidence from 16 trials for the effectiveness of manipulation when compared with a placebo, but no clear evidence that it was more effective than physiotherapy or drug therapy. In another systematic review of 14 different interventions for chronic back pain they identified nine trials of manipulation (van Tulder et al. 1996b). They concluded that there was strong evidence for manipulation being more effective than a placebo and moderate evidence that it was more effective than usual care in general practice, analgesics, bed rest and massage. However Koes et al. (1996), updating Koes et al. (1991b), concluded that the resulting evidence was still equivocal because of the variable quality of the trials. All the reviewers agreed on the need for further research in this field. Although on balance there is evidence to suggest that people with back pain may derive modest benefit from spinal manipulation, there is no clear evidence from the published trials as to whether such treatment should be given early or late (Koes et al. 1991b; Shekelle et al. 1992). The only substantial pragmatic trial involving manipulation in the UK was mounted by the Medical Research Council to compare chiropractic management in its traditional private setting, with fast-tracked # 2003 Elsevier Science Ltd. All rights reserved.
47
(1-week availability) hospital outpatient management, for episodes of at least 1-month duration (Meade et al. 1990; 1995). It served to raise the intensity of the scientific debate about manipulation and inform the research agenda. It was also one of two trials to suggest that there might be long-term benefit from manipulation (Koes et al. 1992; Croft 1997), although its design was subsequently questioned (Assendelft et al. 1991). Therefore, despite previous trials of manipulation therapy for back pain, there remained major uncertainties about the role of treatments in clinical practice in the UK. One serious problem in interpreting the evidence is that reports often do not make it clear exactly what manipulative procedures have been given to patients, over what period of time, and whether other elements of care (such as advice on activity and exercise) were included. Furthermore, there are substantial problems in mounting such trials: people with back pain usually do not have a clear diagnostic label; doctors, practitioners and manipulators use different clinical paradigms; it is not generally possible to identify homogeneous groups of sufferers; and indications for specific physical treatments are difficult to define. For these and other reasons, many of the previous trials have been subject to methodological problems (Koes et al. 1995).
Manipulation in the UK Spinal manipulation has been practised for many years by a variety of practitioners. In the mid-1990s, two of the main professional groups in the UKFchiropractic and osteopathyFwere formally recognized by Acts of Parliament that established systems of regulation analogous to those of the General Medical Council. Also in the UK, the similarities between chiropractors and osteopaths are probably much greater than their differences; in particular a broadly common type of manipulation underlies both treatment approaches. It was therefore agreed that it would be unnecessary (and almost certainly impossible in view of the large sample size that would be needed) to compare the effectiveness of the two approaches in the current state of knowledge. UK general practitioners commonly refer patients with back pain to physiotherapists working in the National Health Service. The majority of those physiotherapists practicing hands-on therapy in the UK use passive mobilization techniques (Foster et al. 1999). McKenzie exercises, which can include manipulation for a small proportion of sufferers, are often advocated, but there are only a few fully trained McKenzie physiotherapists in the UK. A minority of physiotherapists attend post-registration courses and Manual Therapy (2003) 8(1), 46–51
48 Manual Therapy
specialise in manual therapy, including high-velocity thrusts, often referred to in the profession as ‘Grade Vs’. The range of techniques used by these specialist physiotherapists are probably similar in many respects to those used by chiropractors and osteopaths, although the use of high-velocity thrust techniques is considerably less frequent. Traditionally, the three professions have seen themselves (and each other) as quite separate entities with little common ground philosophically. However, despite differences in the extent of use of certain manipulative techniques and exercise, there is anecdotal evidence that some measure of commonality exists in terms of the management approach to back pain. Indeed, it seems possible that within-profession differences may be greater than typical betweenprofession differences. The term manipulation covers a bewildering array of manual techniques and terminologies that can confuse other health professionals (Breen et al. 2000). However, these can be broken down into three general areas: techniques directed primarily at soft tissue structures (muscle, ligament, fascia, etc.); techniques that are intended to articulate joints through physiological ranges of movement; and techniques that involve application of a high-velocity, low-amplitude thrust with the intention of creating cavitation of a synovial joint. The precise manner in which each technique will be delivered does vary between professions, but the greatest source of variance is probably the perceived needs of the patient. Individual practitioners also develop specific preferences and skills according to their own experience. In addition to manual techniques, practitioners will make variable use of exercises and advice; the between-profession variation here again may be substantial. A further source of variation within-profession is the number of treatment sessions; most practitioners will deliver a number of treatments to a back pain patient over a period of weeks rather than rely on a single procedure. Any attempt to mount a trial of manipulative treatment needs to take account of the above sources of variation when defining the nature and content of the ‘manipulation’ under test. Whilst it would be possible to control the variance by testing the value of, say, a single manual technique applied by practitioners from a single discipline, this tells us little about the way manipulation is used in practice. Conversely, simply testing the uncontrolled use of manipulation will lose any semblance of the homogeneity needed to draw valid and useful conclusions from the result of a trial. Thus, what is required is a package that defines in advance the range of techniques permitted, the timing of delivery, and the accompanying advice. One such approach is described below. Manual Therapy (2003) 8(1), 46–51
The UK BEAM trial The spinal manipulation approach for low-back pain is currently being evaluated in a national, multicentre trial in 14 UK centres. The UK Back pain Exercise And Manipulation (UK BEAM) trial is funded by the Medical Research Council and the National Health Service (NHS) Research and Development Programme (UK BEAM 2002). In this trial, all eligible patients who had simple mechanical lowback pain for at least 4 weeks were randomized between the spinal manipulation package and GP management. Those randomized to spinal manipulation were also randomized between NHS premises and manipulators’ own private premises (the same practitioner delivered treatments in both settings in each area). Each participant (patient) recruited was also randomized between the Back to Fitness progressive exercise package (Klaber Moffett & Frost 2000) and GP management. Therefore, some participants received both the spinal manipulation and exercise treatments. In addition, all members of GP surgery staff were invited to training in the ‘active management’ of back pain (that is, advice to avoid bed rest and return to normal activities as soon as possible) (Underwood et al. 2002) and encouraged to give participants copies of The Back Book (Roland et al. 1996).
THE UK BEAM SPINAL MANIPULATION PACKAGE The UK BEAM spinal manipulation package was developed by three members of the UK BEAM Working Party, representing chiropractic, osteopathy and physiotherapy. The starting point was consultation (correspondence and face-to-face meeting) with a group of representatives appointed by the British Chiropractic Association (BCA), the Chartered Society of Physiotherapy (CSP) and the General Council and Register of Osteopaths (GCRO). (Negotiations with the CSP were delegated to the special interest groupFthe British Association of Chartered Physiotherapists in Manipulation (BACPIM).) The combined group strongly recommended that the manipulation arm of the trial not be based on the intervention’s use in isolation, but on a package of care that reflected the holistic nature of their approaches. The UK BEAM Working Party developed such a package, based on a previously described model for osteopathic management of low-back pain (McClune et al. 1997). This model was refined, using an iterative process, to take account of the needs and practices of the three professions, and to place it in the context of the research project. The revised draft was re-submitted to representatives of each professional body, and circulated to opinion leaders and # 2003 Elsevier Science Ltd. All rights reserved.
Spinal manipulation for low-back pain
officials among the three professions. In addition, the trial design and the package were offered to professional newsletters and conferences. Whilst direct contact between the research team was limited to two appointed representatives from each profession, they in turn discussed the matter openly with various colleagues. Following detailed feedback and appropriate further refinement, a package of care emerged that was acceptable to all concerned. It defines a common core of manipulative practice that omits some lesser-used modalities, yet permits enough flexibility in both assessment and treatment to be representative of all three professions. It is ‘pragmatic’ in that it represents what happens to most people undergoing manipulation, and ‘explanatory’ in excluding confounding variations (Schwartz & Lellouch 1967). The assumption underlying the package was that participants would have ‘simple mechanical backache’, with or without referred leg pain (Royal College of General Practitioners 1999). Practitioners were free to exclude from manipulative treatment any participant who was found at their assessment to be unsuitable for manipulation. As all participants had previously been pre-screened for inclusion, the number of participants excluded at this point was low. Trial procedures Fourteen trial centres were established across the UK (two feasibility study sites and 12 main trial sites). For reasons of homogeneity, and to accommodate the then imminent legislation concerning osteopathy and chiropractic, manipulators were invited to participate from the membership lists of the BCA, the GCRO and BACPIM. In general, in each centre there were two main manipulators, each with a backup from the same profession to cover any absences. (In some larger centres, extra main and back-up manipulators were recruited.) As far as possible, representatives were recruited from the three professions to provide a balance of professions across the UK. On occasions, this ideal was modified to reflect the local availability of practitioners. In the end, there were 12 main osteopaths, seven main chiropractors and nine main physiotherapists (each with one or more back-up). Although the elements of the package were familiar to practitioners, the package was described in full prior to the trial and a detailed manual was provided. In addition, practitioners attended familiarization sessions in which the principles of the trial and the manipulation package were presented and discussed. Practitioners were asked to commit themselves to the ‘active’ philosophy of the trial. To avoid participants receiving different information from different professionals, practitioners were also asked to confine # 2003 Elsevier Science Ltd. All rights reserved.
49
explanation to the proposed treatment, and to avoid offering specific diagnoses and commenting on other health professions. When a participant was randomized to their care, the practitioner was notified by letter and asked to make the initial appointment. The notification letters would instruct practitioners to carry out the treatments in either their own premises, or in NHS premises hired on their behalf (usually a room in a local general (family) practice, equipped with a suitable treatment table). Further treatments were scheduled according to the practitioner’s usual practice. Practitioners were asked to complete a simple treatment record for each session with each participant. At the end of treatment, they completed a discharge form, giving the reason for the end of treatment (e.g. participant recovery, end of maximum number of sessions). Practitioners were asked to notify the trial team immediately of any potential adverse events following treatment. On average, each manipulator in the trial received about 30 participants randomized to his or her care during the 12-month recruitment period. Half were allocated to private premises and the other half to NHS premises.
Spinal manipulation package For individual participants, the package comprised a series of scheduled sessions with the same practitioner. The first session, lasting 30–50 min, included an ‘assessment’ (case history and appropriate clinical examinations and tests), ‘explanation’ (description of the proposed treatment, but not a discipline-specific diagnosis) and ‘treatment’ (the administration of one or more elements from the treatment package). Subsequent sessions, lasting about 20 min, focussed on the administration of elements from the treatment package. At the discretion of the practitioner, a maximum of eight sessions could be spread over the intervention period of 12 weeks (or 6 weeks in the case of participants randomized to receive both manipulation and exercise). For example, it was permissible to schedule four sessions over the first 2 weeks and two sessions over the next 2 weeks, keeping two sessions in reserve for the remaining 8 weeks.
The elements The package comprised two groups of ‘elements’ Fmanual and non-manual. Each main element listed below is followed by a subgroup of ‘techniques’, some of which are discipline-specific. The practitioner was confined to using only the techniques listed, but had free choice of which to use when. All patients were Manual Therapy (2003) 8(1), 46–51
50 Manual Therapy
expected to receive the first two manual elements and verbal advice at each treatment session, and most were expected to receive a high-velocity thrust procedure at least once during the overall treatment period. The frequency of use of each element depended on the practitioners’ assessment of the participants’ needs. (The target for the use of thrust techniques was 75% of all participants randomized to spinal manipulation, at some stage during their treatment. It was expected that the use of exercises would be a minor part of the package.) Use of special treatment tables, for example chiropractic or swingleaf, was permitted. The manual elements were: K
K
K
Soft tissue techniques: cross-fibre stretch, longitudinal stretch, direct pressure, deep friction; neural mobilization. Articulatory techniques (mobilizations): lowthrough high-amplitude passive movements of lumbar spine and sacroiliac joints (and necessarily hips); flexion, extension, rotation, side-bending, manual traction; oscillation. Thrust techniques (‘manipulations’): high or low velocity; low amplitude; direct or leverage; directed at central lumbar, zygapophysial or sacroiliac joints; unilateral or bilateral; at one or more locations.
The non-manual elements were: K
K
Exercises: passive flexion and extension, active side bending, active trunk rotation, passive or active hip joint stretching, abdominal or lumbar strengthening and neural mobilization. Advice (in line with the RCGP guidelines and The Back Book (Roland et al. 1996)Fsee Table 1).
(i) In respect of activity: advocate continuance of leisure activities, work activities and performance of daily tasks (and do not prescribe bed rest or work absence); analgesics are allowed but not encouraged. (ii) In respect of psychosocial issues: give generally positive messages and advocate benefits of activity (with avoidance of emotive language and concepts). Excluded procedures were: K
K
High-velocity thrusts to the neck (cervical manipulation with a rotary component) taking the neck beyond its normal physiological range, because there would be a very small chance of serious adverse effects (Assendelft et al. 1996). Printed educational material, so as to avoid possible contradiction with the active management approach.
Manual Therapy (2003) 8(1), 46–51
Table 1. Key patient advice points (taken from the Royal College of General Practitioners 1996 ‘Clinical guidelines for the management of acute low-back pain’)* Simple backache Give positive messages There’s nothing to worry about. Backache is very common No sign of any damage or disease. Full recovery in days or weeksFbut may vary No permanent weakness. Recurrence possibleFbut does not mean re-injury Activity is helpfulFtoo much rest is not. Hurting does not mean harm Nerve root pain Give guarded positive messages No cause for alarm. No sign of disease Conservative treatment should sufficeFbut may take a month or two Full recovery expectedFbut recurrence possible Possible serious spinal pathology Avoid negative messages Some tests are needed to make the diagnosis Often these tests are negative The specialist will advise on the best treatment Rest or activity avoidance until appointment to see specialist *Patient Booklet: The above messages can be enhanced by an educational booklet given at consultation. The Back Book is an evidence-based booklet developed for use with these guidelines.
K
K K
Modalities: acupuncture, bed rest, biofeedback, electrotherapy and ultrasound. Appliances: lumbar corsets, belts and strapping. X-rays: practitioners were asked to refer the participant back to the general (family) practitioner if an X-ray was considered essential.
Examples of how the package could be used As examples of how use of the package was envisaged, the following three general categories of participant were considered appropriate: acute, subchronic and chronic. Table 2 indicates the choice of elements that might typically be used: it was not prescriptive.
CONCLUSION The UK BEAM spinal manipulation package was developed for the treatment of simple mechanical low-back pain and was accepted by the three professions who perform this treatment in the UK. It defines a common core of manipulative practice while permitting enough flexibility in both assessment and treatment to be representative of all three professions. It is the outcome of a successful, strenuous attempt to overcome inter-disciplinary barriers in order to enable the value of ‘manipulation’, as typically practised in the UK, to be tested scientifically. In practice, the UK BEAM trial team encountered minimal problems in recruiting representatives from the three professions to deliver spinal # 2003 Elsevier Science Ltd. All rights reserved.
Spinal manipulation for low-back pain
51
Table 2. Examples of how the manipulation package could be used Low-back pain type
Soft tissue
Articulatory
Thrust
Exercises/activities
Acute
Paraspinal crossfibre, inhibition
Small amplitude
Short leverage or direct
Encourage walking; neural mobilization
Advice
Limit aggravating factors; encourage work/sport as soon as possible; reduce fear of future Subchronic Cross-fibre, Larger amplitude Normal leverage Spinal exercises; encourage Early uptake of sport or work; stretching, friction or direct general exercise/activity; neural ergonomic advice; promote mobilization positive attitudes Chronic Stretching Larger amplitude Normal leverage Spinal exercises; encourage Progressive uptake of sport; or direct daily walking and exercise; reduce fear-avoidance; neural mobilization promote positive attitudes
manipulation treatments to trial participants, and received few reports of problems using the package. The package is offered as a template for use in the context of further pragmatic trials in the UK or elsewhere. Full trial results are expected towards the end of 2002. Acknowledgements The trial is funded by the UK Medical Research Council and National Health Service Research and Development Programme.
References Agency for Health Care Policy and Research 1994 Acute low-back problems in adults. Clinical Practice Guideline, Vol. 14. US Department of Health and Human Services, Rockville, MD. Assendelft WJJ, Bouter LM, Kessels AGH 1991 Effectiveness of chiropractic and physiotherapy in the treatment of low-back pain: A critical discussion of the British randomised clinical trial. Journal of Manipulative and Physiological Therapeutics 14: 281–286 Assendelft WJJ, Bouter LM, Knipschild PG 1996 Complications of spinal manipulation: A comprehensive review of the literature. The Journal of Family Practice 42: 475–480 Assendelft WJJ, Koes BW, Knipschild PG, Bouter LM 1995 The relationship between methodological quality and conclusions in reviews of spinal manipulation. Journal of the American Medical Association 274: 1942–1948 Breen A, Carrington M, Collier R, Vogel S 2000 Communication between general and manipulative practitioners: A survey. Complementary Therapies in Medicine 8: 8–14 Croft P 1997 Low back pain. In: Stevens A, Raftery J (eds) Health Care Needs Assessment II. Radcliffe, Oxford Foster N, Thompson K, Baxter G, Allen J 1999 Management of nonspecific low back pain by physiotherapists in Britain and Ireland. Spine 24: 1332–1342 Klaber Moffett J, Frost H in collaboration with the UK BEAM Trial Team 2000. Back to fitness programme: The manual for physiotherapists to set up the classes. Physiotherapy 86: 295–305 Koes BW, Assendelft WJJ, van der Heijden GJMG, Bouter LM 1996 Spinal manipulation and mobilisation for low back pain: An updated systematic review of randomised clinical trials. In: van Tulder MW, Koes BW, Bouter LM (eds) Low Back Pain in Primary Care: Effectiveness of Diagnostic and Therapeutic Interventions. Institute for Research in Extramural Medicine, Amsterdam Koes BW, Assendelft WJ, van der Heijden GJMG, Bouter LM, Knipschild PG 1991 Spinal manipulation and mobilisation for back and neck pain: A blinded review. British Medical Journal 303: 1298–1303
# 2003 Elsevier Science Ltd. All rights reserved.
Koes BW, Bouter LM, van der Heijden GJMG 1995 Methodological quality of randomised controlled trials on treatment efficacy in low back pain. Spine 20: 228–235 Koes BW, Bouter LM, van Mameren H, Essers AHM, Verstegen GMJR, Hofhuizen DM, Houben JP, Knipschild PG 1992 Randomised clinical trial of manipulative therapy and physiotherapy for persistent back and neck complaints: Results of one year follow-up. British Medical Journal 304: 601–605 Koes BW, van Tulder MW, Ostelo R, Burton AK, Waddell G 2001 Clinical guidelines for the management of low back pain in primary care: An international comparison. Spine 26: 2504–2514 McClune T, Clarke R, Walker C, Burton K 1997 Osteopathic management of mechanical low back pain. In: Giles LGF, Singer KP (eds) The Clinical Anatomy and Management of Back Pain Series, Volume 1: Clinical Anatomy and Management of Low Back Pain. Butterworth-Heinemann, Oxford, pp. 358–368 Meade TW, Dyer S, Browne W, Frank AO 1995 Randomised comparison of chiropractic and hospital outpatient management for low back pain: Results from extended follow up. British Medical Journal 311: 349–351 Meade TW, Dyer S, Browne W, Townsend J, Frank AO 1990 Low back pain of mechanical origin: Randomised comparison of chiropractic and hospital outpatient treatment. British Medical Journal 300: 1431–1437 Roland M, Waddell G, Klaber Moffett J, Burton K, Main C, Cantrell E 1996 The Back Book. The Stationery Office, London Royal College of General Practitioners 1996, 1999 Clinical Guidelines for the Management of Acute Low back Pain. Royal College of General Practitioners, London (www.rcgp.org.uk) Schwartz D, Lellouch J 1967 Explanatory and pragmatic attitudes in clinical trials. Journal of Chronic Diseases 20: 637–648 Shekelle PG, Adams AH, Chassin MR 1992 Spinal manipulation for low back pain. Annals of Internal Medicine 117: 590–598 UK BEAM 2002 Trial summary available at: http:// www.york.ac.uk/healthsciences/centres/trials/ukbeam/ ukbeam.htm Underwood M, O’Meara S, Harvey EL for the UK BEAM Trial Team 2002 The acceptability to primary care staff of a multidisciplinary training package on acute back pain guidelines. Family Practice (in press) van Tulder MW, Koes BW, Bouter LM 1996a Conservative treatment of acute low back pain: A systematic mega-review of 81 randomised clinical trials of 11 interventions. In: van Tulder MW, Koes BW, Bouter LM (eds) Low Back Pain in Primary Care: Effectiveness of Diagnostic and Therapeutic Interventions. Institute for Research in Extramural Medicine, Amsterdam van Tulder MW, Koes BW, Bouter LM 1996b Conservative treatment of chronic low back pain: A systematic mega-review of 80 randomised clinical trials of 14 interventions. In: van Tulder MW, Koes BW, Bouter LM (eds) Low Back Pain in Primary Care: Effectiveness of Diagnostic and Therapeutic Interventions. Institute for Research in Extramural Medicine, Amsterdam
Manual Therapy (2003) 8(1), 46–51
Manual Therapy (2003) 8(1), 52–53 1356-689X/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved. doi: 10.1054/math2002.0493
Letters to the editors
Control subjects in whiplash studies Sterling et al. (2002) studied a group of chronically distressed whiplash patients, known to score high on somatization scales on the SCL-90-R (Moog et al. 2002), and compared them to a control group consisting of healthy volunteers. They find that whiplash patients report more pain with maneuvers that involve the upper limb and shoulder region. Sterling et al. decide to label this as ‘hyperalgesic responses’, later referred to as central hypersensitivity. There is no gold standard for the identification of this phenomenon, and no known site for its origin. Koelbaek Johansen et al. (1999) have previously made the same assumption that if one finds that chronically distressed patients give a different pain interpretation and response to a physical stimulus, then there must be some hypersensitivity of a central origin. Perhaps there is, but is it because of physical derangement, injury, or simply psychological distress? As in previous works of this type (KoelbaekJohansen et al. 1999), Sterling et al. have failed to adequately control for the fact that whiplash subjects are psychologically distressed (Ferrari 2001). There is a body of literature showing that if one selects healthy subjects, then make them anxious and distressed, physical stimuli will be perceived differently and recorded as a more-noxious stimulus than when the same subjects are not distressed (Levine et al. 1982; Barsky 1986, 1992; Robin et al. 1987; Barsky et al. 1988). Clearly, the healthy subjects of these experiments have no disorder prior to the distress and yet will appear to have the very phenomenon Sterling et al. reproduced. Moog et al. (2002) have recently shown that the group of whiplash subjects reporting pain with noxious stimuli used affective pain descriptors more frequently than those who did not report stimulus-induced pain, and had significantly higher affective but not sensory pain descriptor scores on the short form McGill Pain Questionnaire. It is clear that the presence of psychological distress may be just as valid an explanation for the findings of Sterling et al. (2002). The study design used by Sterling et al. cannot test for the cause or mechanism of central sensitization or hypersensitivity, as their control group was wholly inappropriate to address this important question. We suggest, that the standard in this type of research has already been set and should be followed carefully (Carragee et al. 2000). Carragee et al. accomplished this in a study examining for responses to a noxious stimulus in chronic spinal pain. To explain, Carragee et al. wanted to examine the responses to the noxious stimulus of discography
(known to be painful to some extent even in healthy subjects). Discography tends to be painful in chronic low back pain patients, and the question is whether or not the physical cause of the back pain is the cause of the response to discography, or whether the psychological distress of back pain patients is the predictor of the discography response, independent of chronic pain. Carragee et al. chose three groups as control subjects: (1) healthy subjects with no low back pain and no psychological distress, (2) subjects with chronic neck pain, but no low back pain, and (3) subjects with chronic anxiety or other chronic psychological distress, but no pain. As expected, the chronic low back pain patients reported more severe and diffuse pain with the injection much more often than the healthy subjects. What was unexpected was the 43% of the subjects with chronic neck pain but no low back pain also reported more severe and diffuse low back pain with the lumbar disc injection. This could mean that chronic neck pain patients with no low back pain share some common lesions with chronic low back pain patients. To eliminate the factor of chronic pain, one looks at the response of the psychologically distressed subjects without pain: 83% had a response just like that of the chronic low back pain patients. Thus, the independent predictor of the painful response to lumber discography is not the presence or absence of chronic pain, nor necessarily the presence or absence of tissue pathology. It is the presence or absence of psychological distress that causes what should be a mildly painful stimulus to be registered as more severe and more diffuse (i.e. symptom amplification). That is what the chronic low back pain, chronic neck pain, and psychologically distressed subjects without chronic pain have in common. How does one interpret the results of Sterling et al.? Certainly, without a proper control group included in the study it is difficult. Finally, one must once and for all put Elvey to rest, as well as the 19th century notion of nervous (brachial) irritation as a cause for the inexplicable (Ferrari et al. 2002). While it is understandable that we wish to provide some logical explanation for symptoms to patients, we do not believe that labelling subjective, non-specific symptoms as brachial plexus irritation is helpful. Diagnosing any brachial plexus lesion using non-specific symptoms as brachial plexus irritation is unhelpful. Diagnosing any brachial plexus lesion using non-objective data but rather on the basis of symptoms and/or manoeuvres which reproduce those symptoms is only valid and objective if research has already shown the symptoms 52
Letters to the editors 53
to be specific, and the physical examination manoeuvres to correlate with other objective measure (i.e. not relying on the symptoms themselves) as a gold standard for the diagnosis. Surely, if we have no objective measurements to make in these patients, it does not mean one should discount their symptoms, but one should not be so pressed for a diagnosis that one confuses those rare cases of objectively provable thoracic outlet syndrome and brachial plexopathy with patients whose symptoms remain unexplained, or for which there may be many possible explanations yet to be defined. The brachial plexus test of Elvey was developed by first manipulating cadaver’s arms until one could find a manoeuvre that stretched the nerves of the brachial plexus (Quintner 1989). Elvey could have just as easily suggested that this manoeuvre placed the glenohumeral capsule in a certain stretched position, arguing that nerves supplying the capsule are stretched in a specific way leading to arm paresthesiae. As Ferrari et al. (2002) have pointed out, we would then today be using the glenohumeral capsular test of Elvey as a basis for these same symptoms. The way Elvey designed the test by only viewing what the manoeuvre did to the brachial plexus and not other tissues and to then say this manoeuvre, when it exacerbates a symptom indicates a brachial plexus lesion is of course tautological. Again, the clinical specificity of the so-called brachial plexus test of Elvey or other similar manoeuvres has never been studied with regards to how often the sign appears in people with clear evidence of brachial lesions vs other diagnoses. In an area, filled with controversy, such as whiplash, we need more objective and carefully controlled studies before labelling patients with various disorders and pathology.
References Barsky AJ 1986 Palliation and symptomatic relief. Archives of Internal Medicine 146: 905–909 Barsky AJ, Goodson JD, Lane RS, Cleary PD 1988 The amplification of somatic symptoms. Psychosomatic Medicine 50: 510–519 Barsky AJ 1992 Amplification, somatization, and the somatoform disorders. Psychosomatics 33: 28–34 Carragee EJ, Tanner CM, Khurana S, Hayward C, Welsh J, Date E, Truong T, Rossi M, Hagle C 2000 The rates of false positive lumbar discography in select patients without low back complaints. Spine 25: 1373–1381 Ferrari R 2001 Wilplash and symptom amplification. Pain 89: 293–302 Ferrari R, Bohr T, Wilbourn AJ 2002 Neurogenic thoracic outlet syndrome in whiplash injury Journal of Spinal Disorders 15: 334–335 Koelbaek Johansen M, Graven-Nielsen T, Schou Olesen AS, Arendt-Nielsen L 1999 Generalised muscular hyperalgesia in chronic whiplash syndrome. Pain 83: 229–234 Levine JD, Gordon NC, Smith R, Fields HL 1982 Post-operative pain: Effect of injury and attention. Brain Research 234: 500–504 Moog M, Quinter J, Hall T, Zusman M 2002 The late whiplash syndrome: a psychophysiological study. European Journal of Pain 6: 283–294. Quintner J 1989 A study of upper limb pain and paraesthesiae following neck injury in motor vehicle accidents: Assessemnt of the brachial plexus tesnion test of Elvey. British Journal Rheumatology 28: 528–533 Robin O, Vinard H, Vernet-Maury E, Saumet JL 1987 Influence of sex and anxiety on pain threshold and tolerance. Functional Neurology 2: 173–179 Sterling M, Treleaven J, Jull G 2002 Responses to a clinical test of mechanical provication of nerve tissue in whiplash associated disorder. Manual Therapy 7: 89–94
O. Kwan E-mail address:
[email protected]
Manual Therapy (2003) 8(1), 52–53
r 2003 Elsevier Science Ltd. All rights reserved.
Manual Therapy (2003) 8(1), 54–55 1356-689X/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved. doi: 10.1054/math.2002.0494
Letters to the editors continued
Response to Drs Kwan and Friel somatisation disorder by ICD-9 coding. All of these patients had a chronic pain syndrome’. Furthermore, five of the six subjects (83%) complained of pain with discography, a very small sample upon which to base an argument of psychogenesis. Nonetheless, this finding is understandable when one considers that all those in the third group were experiencing chronic pain of some description (not precisely detailed in the original paper, except to say that it was not low back pain). These patients might be expected to show evidence of hypersensitivity to all painful stimuli as a result of changes that have taken place in central nociceptive pathways. This phenomenon, rather than their psychological status, could explain their enhanced sensitivity to discography. With respect to the brachial plexus test, Drs Kwan and Friel suggest in an unfortunate way that ‘one must once and for all put Elvey to rest’. They are quite correct in saying that the brachial plexus test is not a specific test of nerve tissue mechanosensitivity as it could provoke pain from a number of other potentially painful tissues. Readers will be well aware of the debate surrounding the use of this test (Coppieters & Butler 2001; Di Fabio 2001). However in our paper we advised examiners to use caution when interpreting this test due to the generalized hypersensitive responses that were seen in our whiplash patients. Drs Kwan and Friel suggest that the gold standard for diagnosis of a brachial lesion involves correlation between physical examination manoeuvres and other objective measures. We totally agree with this and have stated in our paper—‘It is suggested that a clinical diagnosis of nerve tissue mechanosensitivity in WAD should not rest on nerve provocation tests in isolation but involve a more thorough examination process.’ Contrary to Drs Kwan and Friels statement that we ‘labelled subjective non-specific symptoms as brachial plexus irritation’, we found only 25% of our cohort had their arm reproduced by the brachial plexus test which we proposed as being suggestive of irritated nerve tissue. This figure is less than that of Ide et al. (2001) who found 38% of their whiplash cohort showed signs of brachial plexus irritation using Tinel sign. We note that Drs Kwan and Friel also acknowledge that thoracic outlet syndrome and brachial plexopathy may indeed occur in some patients – exactly what our results suggest. As Drs Kwan and Friel point out brachial plexus irritation is a ‘19th century notion’. Nevertheless, they should not dismiss this concept out of hand as current neurobiological research supports the
Drs Kwan and Friel make the claim that hyperalgesic responses to physical examination in whiplash patients, which are well documented in an increasing numbers of recent studies (Koelbaek-Johansen et al. 1999; Curatolo et al. 2001; Moog et al. 2002; Sterling et al. 2002a), constitute what they call ‘symptom amplification’ as a result of psychological distress. Despite their persistence on this matter, Drs Kwan and Friel are yet to produce scientifically valid evidence in whiplash subjects to support their argument. One reason for this is because basically their hypothesis is untestable—unless it is possible to separate the mind from all physiological mechanisms within the body. Whilst we acknowledge that psychological distress has an important role to play in those with persistent symptoms, the evidence to date in whiplash research (not of other pain syndromes) would suggest that psychological distress occurs as a consequence of ongoing pain and disability (Radanov et al. 1996; Gargan et al. 1997) and that psychological distress alone is not solely responsible for the persistence of symptoms. Drs Kwan and Friel have failed to grasp the main findings of our study. Firstly, the whiplash patients did not only report higher levels of pain but demonstrated a greater loss of elbow extension, which we hypothesized to be a hyperalgesic motor response. We clearly acknowledged that the brachial plexus test is a clinical test but are encouraged by similar finding of Curatolo et al. (2002) who showed hypersensitive flexor withdrawal responses in the lower limbs of whiplash subjects, tested with electrical stimulation. Furthermore, the whiplash subjects in our study did not respond as a homogenous group. Whilst all subjects showed hypersensitive responses to a degree, those with arm pain reproduced by the brachial plexus test demonstrated greater sensitivity. If psychological distress alone was the primary reason for these findings, more uniform responses would be found. Drs Kwan and Friel suggest that our control group (healthy volunteers) was inappropriate. They make reference to a study by Carragee et al. (2000) but in so doing fail to accurately present the factual details and have thereby misled readers. Drs Kwan and Friel cite this study as including three groups ‘(1) healthy subjects with no back pain and no psychological distress, (2) subjects with chronic neck pain but no low back pain, and (3) subjects with chronic anxiety or other psychological distress, but no pain’. We wish to point out that in Carragee et al.’s study, the third subject group in fact comprised ‘individuals with 54
Letters to the editors 55
hypothesis that mechanical irritation of peripheral nerves can render them highly mechanosensitive. This is thought to be due to sensitization of C-fibres in continuity, producing ectopic discharge with little or no neuronal degeneration such that nerve conduction remains intact (Eliav et al. 1999, 2001). Such a pathophysiological basis for pain and other positive sensory symptoms has yet to be shown to follow whiplash type injuries, but circumstantial evidence from cadaver studies (Taylor & Taylor 1996) along with clinical studies (Ide et al. 2001) would suggest it might be a likely scenario in at least some patients with chronic symptoms – a pertinent point of our study. Whilst Drs Kwan and Friel are yet to provide evidence to support their hypothesis that symptoms and responses in WAD are due to ‘symptom amplification’ and psychological distress, we have evidence to the contrary to refute their hypothesis. In another study we have shown that motor system dysfunction in whiplash patients occurs soon after injury and persists independently of the subjects’ psychological distress (in this case their beliefs about fear of movement and reinjury measured with the TAMPA scale) (Sterling et al. 2002b). We are finding similar results with sensory disturbances and psychological distress. We do not deny that those whiplash patients with persistent symptoms demonstrate psychological distress; indeed our studies show that they do. However to dismiss all physical findings, particularly those of hypersensitivity as being merely ‘symptom amplification’ is reminiscent of that certainty with which poorly understood symptoms such as persistent pain were once deemed by some to be ‘psychogenic’ (Weintraub 1988). Cognitive neurobiological research has greatly advanced our knowledge since those days; the challenge before us is to develop adequate early medical and rehabilitation protocols to prevent the development of chronic WAD. M. Sterling G. Jull Australia E-mail address:
[email protected]
r 2003 Elsevier Science Ltd. All rights reserved.
References Carragee E, Tanner C, Khurana S, Hayward C, Welsh J, Date E, Troung T, Rossi M, Hagle C 2000 The rates of false-positive lumbar discography in select patients without low back symptoms. Spine 25(11): 1373–1381 Coppieters M, Butler D 2001 In defence of neural mobilisation. Journal of Orthopaedic and Sports Physical Therapy 31: 520–521 Curatolo M, Petersen-Felix S, Arendt-Nielsen L, Giani C, Zbinden A, Radanov B 2001 Central hypersensitivity in chronic pain after whiplash injury. Clinical Journal of Pain 17: 306–315 Curatolo M, Banic B, Petersen-Felix S, Andersen O, Radanov B, Villeger P, Arendt-Nielsen L 2002 Preliminary electrophysiological evidence for central hypersensitivity in whiplash pain and fibromyalgia. Abstacts 10th World Congress on Pain, San Diego, USA Di Fabio E 2001 Neural mobilisation: the impossible. Journal of Orthopaedic and Sports Physical Therapy 31: 224–225 Eliav E, Benoliel R, Tal M 2001 Inflammation with no axonal damage of the rat saphenous nerve trunk induces ectopic discharge and mechanosensitivity in myelinated axons. Neuroscience Letters 311: 49–52 Eliav E, Herzberg U, Ruda M, Bennett G 1999 Neuropathic pain from an experimental neuritis of the rat sciatic nerve. Pain 83: 169–182 Gargan M, Bannister G, Main C, Hollis S 1997 The behavioural response to whiplash injury. The Journal of Bone and Joint Surgery (Br) 79: 523–526 Ide M, Ide J, Yamaga M, Takagi K 2001 Symptoms and signs of irritation of the brachial plexus in whiplash injuries. The Journal of Bone and Joint Surgery (Br) 83: 226–229 Koelbaek-Johansen M, Graven-Nielsen T, Schou-Olesen A, Arendit-Nielsen L 1999 Muscular hyperalgesia and referred pain in chronic whiplash syndrome. Pain 83: 229–234 Moog M, Quintner J, Hall T, Zusman M 2002 The late whiplash syndrome: A psychophysical study. European Journal of Pain 6: 283–294 Radanov B, Begre S, Sturzenegger M, Augustiny K 1996 Course of psychological variables in whiplash injury – a 2-year follow-up with age, gender and education pair-matched patients. Pain 64: 429–434 Sterling M, Treleaven J, Edwards S, Jull G 2002a Pressure pain thresholds in chronic whiplash associated disorder: Further evidence of altered central pain processing. Journal of Musculoskeletal Pain 10: 69–81 Sterling M, Jull G, Vizenzino B, Kenardy J, Darnell R 2002b Development of motor system dysfunction following whiplash injury. Pain, in press. Taylor J, Taylor M 1996 Cervical spinal injuries: An autopsy study of 109 blunt injuries. Journal of Musculoskeletal Pain 4: 61–79 Weintraub M 1988 Regional pain is usually hysterical. Archives of Neurology 45: 914–915
Manual Therapy (2003) 8(1), 54–55
Manual Therapy (2003) 8(1), 56–57
Book reviews All aspects of this section are concept or model based and there is no evidence-based information. Unfortunately, there is no new information included in this section, but only existing information about for example palpation and non-palpatory approaches. The second section ‘Treatment and Discharge’ consists of eight chapters, which give an overview of all the components and guidelines for existing massage treatments. The chapters are well organized with clear pictures. Overall, it is a well organized and clear book about Outcome Based Massage. It is a pity that there is a lack of evidence-based information. For those interested in massage it gives a good overview of all existing techniques. For students in physical therapy a must, but I would not recommend it for manual therapists.
Clinical reflexology: a guide for health professionals. P.A. Mackereth, D. Tiran. 2002. 1st edn. Churchill Livingstone. 210pp. Price: d19.99. ISBN: 044 307 1209. The interest in complementary therapies, and especially reflexology, is growing rapidly in health care. This book, ‘Clinical reflexology’, addresses a broad range of issues associated with reflexology. The first part of the book deals with the key themes of reflexology such as theories, education, rules of reflexology, professionalism, research, healing, the therapeutic relationship, and safe and effective practice. The second part deals with the application of reflexology in specialist clinical areas such as pregnancy and childbirth, neonatal care, learning disabilities, mental health care, and palliative care. The book intends to be a basis for the critical development and integration of reflexology within conventional health care by formulating guidelines for the development of reflexology, by challenging the ‘rules’ of reflexology, and by reviewing the available research critically. For those therapists who treat patients according to reflexology and believe it is an effective treatment, this book may be a guide to developing reflexology further. Those who doubt its effectiveness, will not change their opinion. ‘That reflexology actually does something is undoubted, although the effects may not necessarily be immediately perceived by the client or therapist. On some occasions it may be the client’s relatives who recognize that they are more relaxed. Even the family dog may react differently to the client post-treatment!’ (Page 8). Texts like these cannot convince the critical reader.
Jan Pool, PT, MT Epidemiologist VU University Medical Centre Amsterdam The Netherlands doi:10.1054/math.2002.0490 Massage therapyFthe evidence for practice. Grant Jewel Rich. 2002. Mosby. 212pp. Price: d22.95. ISBN: 0723432171. The opening two chapters of this book give an overview of research planning in the field of massage therapy. The editor acknowledges the pitfalls and limitations of such research, both now and in the past, but successfully offers positive solutions for continuing to develop evidence-based practice. There is reference to governing bodies within the USA which may not be so relevant to manual therapists elsewhere. The book in then divided into three sections: massage research on various conditions, massage across the life-span and massage and the workplace. Each section contains several original research reports from different authors. These reports are very readable and generally of high quality. I would recommend this text for the reader who has a special interest in the use of massage therapy in a particular field but would not recommend it for those who are seeking a review of the literature on massage therapy. This book may be criticized for being an odd collection of evidence from many different specialities and fields, but it is a text that is easy to dip in and out of. It is very important that such evidence is presented and shared so that evidence-based practice in therapy grows. I would recommend this as a resource text for libraries.
Pieter Ubele Dijkstra, PT, MT, PhD Clinical Epidemiologist Department of Rehabilitation University Hospital Groningen Groningen, The Netherlands doi:10.1054/math.2002.0491 Outcome based massage. Carla-Krystin Andrade, Paul Clifford. 2001. 1st edn. Lippincott Williams & Wilkins. 373pp. ISBN: 0781717434. As mentioned in the preface the goal of Outcome-Based Massage is to provide both a conceptual framework and a concrete methodology for using massage techniques to achieve specified clinical outcomes. This book is well organized with section objectives included and with clear figures, scheme’s and boxes referring to the text. In the first section ‘Client Examination and Treatment Planning’ are three chapters, which give an overview of the concept, the clinical reasoning process and a review of the selected concept with regard to the client examination and the massage treatment.
John Hammond, PhD St. George’s Hospital Medical School, London, UK doi:10.1054/math.2002.0489 56
Book reviews 57
Positional release techniques. L. Chaitow. 2002. 2nd edn. Churchill Livingstone. 215pp. Price: d37.95. ISBN: 044307081 In his second edition of Positional Release Techniques (PRT) Leon Chaitow is successful in making this approach more understandable, and in a more popular way than the first, 1997 edition. PRT, based on the traditional Osteopathic approach, is, as Chaitow mentions ‘an indirect noninvasive, non-interventionist, passive and gentle approach. It ‘allows’ change to emerge, rather than forcing it to do so’. The book with a total of 215 pages explains the history, extends the nomenclature and theoretical constructs of PRT and describes a variety of techniques which come from different manual therapeutic backgrounds such as osteopathy, chiropractic and physiotherapy. As a signal of integration and consensus from different professions, this experienced author has invited two other authors (E. Wilson and D. Morrissey) with physiotherapeutic background to write a chapter of the book. They attempt to write a general chapter about respectively, Brian Mulligan’s Mobilisation with Movement and unloading and facilitat-
ing taping, which, as the author describes, are strongly linked with the underlying concepts of PRT. The twocoloured drawings of most of the techniques are a good visual assistance. Furthermore, a CD ROM is included in which the complete text of the book and most techniques are demonstrated. This is an advantage because some of the techniques are not described in detail in the text (hand position, method and position of the therapist). It is a pity that this eclectic dominantly creative ‘tissue’ technique book is not linked in with the actual knowledge of pain mechanisms, which could be a very worthwhile addition and add an extra dimension. Alas: the references of Chaitows chapters about the background of muscle pain and dysfunction (Chapters 2,3,4,5) have not been updated since the last edition. In general, it is a book which presents a fundamental reflection of a popular tissue approach, which is clear to read and especially useful for clinicians who want to (re)learn new skills. Harry J.M. von Piekartz, MSc, Pht, MT doi:10.1054/math.2002.0488
Manual Therapy (2003) 8(1), 56–57
Manual Therapy (2003) 8(1), 59–62 doi:10.1054/math.2002.0495
Subject index for Volume 7 Physiotherapy for Respiratory and Cardiac Problems, 178 Positional Release Technique, from a Dynamic Perspective, 112 Practical Research, A Guide for Therapists, 177 Reflective Teaching and Learning in the Health Professions, 60 Brachial plexus provocation test (BPPT), responses to clinical test of mechanical provocation of nerve tissue in whiplash-associated disorder, 89
A
Accessory movement, determination of R1 with force movement curves from spinal assessment machine (SAM), 39 Achilles tendon, tendinopathy of (masterclass), 121 Ankle, bibliography, radiology, 229 Arthritis, bibliography, 50 Articular cartilage, bibliography anatomy, 50 arthritis, 50 cartilage, 52 gene therapy, 56 imaging, 55 injury, 54 mechanics, 54 repair, 57 surface, 57 surgery, 58 Athletes, thoracic pain in collegiate runner (case report), 168
C
Cartilage, bibliography, 52 Central nervous system hypersensitivity, responses to clinical test of mechanical provocation of nerve tissue in whiplash-associated disorder, brachial plexus provocation test (BPPT), 89 Central sensitization, ‘non-specific’ pain and manual therapy (review), 80 Cervical lateral glide mobilization technique, for cervicobrachial pain syndrome (CBPS), effectiveness of, 31 Cervical spine bibliography, radiography, 231 cervical lateral glide mobilization technique for cervicobrachial pain syndrome (CBPS), effectiveness of as treatment for, 31 cervical SNAGs: A biomechanical analysis (review), 71 mechanical neck disorders, randomized trials to assess effectiveness of manual therapy (review), 131 survey of attitudes and patterns of practitioners performing cervical spine manipulation, 10 see also Neck Cervicobrachial pain syndrome (CBPS) effectiveness of manipulative physiotherapy for treatment of, 31 randomized clinical trial of manual therapy for, 95 Clinical measurement, of medial/lateral orientation of the patella, inter-tester reliability of, 163 Clinical practice are manipulative therapy approaches the same? (editorial), 63 biopsychosocial theory, conceptual models for implementing into (masterclass), 2 musculoskeletal therapists’ multifaceted role and influences on treatment outcomes (editorial), 119 practitioners performing cervical spine manipulation, attitudes and patterns of, 10
B
Back pain mobilization with movement for low back pain, use and effects of for, survey, 206 repetitive movement in recalcitrant pain (masterclass), 183 sacroiliac joint movement as guide to management of unilateral back pain (masterclass), 215 Biopsychosocial theory, conceptual models for implementing in clinical practice (masterclass), 2 Book reviews Anatomy and Human Movement, 234 Anatomy Trains, 113 The Cranio-cervical Syndrome, 59 Craniofacial Dysfunction and Pain, 59 The Hand: Fundamentals of Therapy, 113 Human Movement: An introductory Text, 112 Injection Techniques in Orthopaedic and Sports Medicine, 178 Integrating Complementary Therapies in Primary Care: A Practical Guide for Health Professionals, 114 Low Back Pain: A Symptom-based Approach to Diagnosis and Treatment, 112 Multidisciplinary Approaches to Breathing Pattern Disorders, 178 Neurological Physiotherapy, 177 Neuromusculoskeletal Examination and Assessment, A Handbook for Therapists, 59 Pain, A Textbook for Therapists, 113 59
60 Manual Therapy
what is a suitable dosage of physical therapy treatment? (editorial), 181 Clinical practice guideline, on the use of manipulation or mobilization in the treatment of adults with neck disorders (review), 193 Cochrane database, bibliography, 173
Loading, response of posteroanterior lumbar stiffness to, 19 Low back pain see Back pain Lower limb, bibliography, 110 Lumbar posteroanterior responses, repeated loading and, 19 Lumbar spine, bibliography, radiography, 231
D
Deloading tape, thoracic spine pressure pain thresholds, effect of soft tissue deloading tape in asymptomatic subjects, 150 E
Elbow, bibliography, radiography, 232 Electromyographic muscle activity, taping and, in scapular rotators in healthy shoulders, 154 F
Foot, bibliography, radiology, 229 Force displacement curves, with Spinal Assessment Machine: Manual examination of accessory movements to find R1, 39 Forebrain-mediated sensitization, of central pain pathways: ‘Non-specific’ pain (review), 80 G
Gene therapy, articular cartilage, bibliography, 56 H
Hip, bibliography, radiology, 230 Hyperalgesic responses, to clinical test of mechanical provocation of nerve tissue in whiplash-associated disorder, brachial plexus provocation test (BPPT), 89 I
Imaging Achilles tendinopathy (masterclass), 121 bibliography articular cartilage, 55 musculoskeletal, 108 radiology, 229 Mulligan’s mobilization with movement for thumb: MRI to evaluate positional fault hypothesis (case report), 44 Injury, articular cartilage, bibliography, 54 K
Knee, bibliography, radiology, 229 L
Leg pain, repetitive movement in recalcitrant pain (masterclass), 183 Manual Therapy (2003) 8(1), 59–62
M
Magnetic resonance imaging (MRI), Mulligan’s mobilization with movement for thumb: MRI to evaluate positional fault hypothesis (case report), 44 Manipulation are manipulative therapy approaches the same? (editorial), 63 cervical spine manipulation, attitudes and patterns of practitioners performing, 10 cervicobrachial pain syndrome (CBPS), effectiveness of manipulative physiotherapy for treatment of, 31 Manipulation Association of Chartered Physiotherapists (MACP), Course Approval Board of, 222 mechanical neck disorders clinical practice guideline on use of to treat adults with (review), 193 randomized trials to assess effectiveness of (review), 131 thoracic pain in collegiate runner (case report), 168 Manipulation Association of Chartered Physiotherapists (MACP), Course Approval Board of, 222 Measurement, medial/lateral orientation of patella, inter-tester reliability of clinical measurement of, 163 Mechanical neck disorders clinical practice guideline on use of manipulation or mobilization to treat adults with (review), 193 randomized trials to assess effectiveness of manual therapy (review), 131 Mobilization mechanical neck disorders clinical practice guideline on use of to treat adults with (review), 193 randomized trials to assess effectiveness of (review), 131 thoracic pain in collegiate runner (case report), 168 Mobilization with movement acute locked thoracic spine: treatment with modified SNAG (case report), 103 cervical SNAGs: A biomechanical analysis (review), 71 for spinal conditions (masterclass), 64 for thumb: MRI to evaluate positional fault hypothesis (case report), 44 use and effects of in low back pain management, survey, 206
Subject Index 61
Movement diagrams, with Spinal Assessment Machine: Manual examination of accessory movements to find R1, 39 Mulligan concept acute locked thoracic spine: Treatment with a modified SNAG (case report), 103 application of in management of spinal conditions (masterclass), 64 cervical SNAGs: A biomechanical analysis (review), 71 mobilization with movement for thumb: MRI to evaluate positional fault hypothesis (case report), 44 Musculoskeletal system, bibliography, 108 N
Neck mechanical neck disorders clinical practice guideline on use of manipulation or mobilization to treat adults (review), 193 randomized trials to assess effectiveness of manual therapy (review), 131 see also Cervical spine Nerve trunk pain, cervical lateral glide mobilization technique for cervicobrachial pain syndrome (CBPS), effectiveness of, 31 O
Outcomes, musculoskeletal therapists’ multifaceted role and influences on treatment outcomes (editorial), 119 P
Pain, central sensitization of (review), 80 Palpation sacroiliac anatomical landmarks by, errata (letter), 115 scapular position assessment by skin surface palpation, validity of, 26 Patella, medial/lateral orientation of, inter-tester reliability of clinical measurement of, 163 Peripheral nerve trunk pain, cervical lateral glide mobilization technique for cervicobrachial pain syndrome (CBPS), effectiveness of, 31 Positional fault hypothesis, Mulligan’s mobilization with movement for thumb: MRI to evaluate positional fault hypothesis (case report), 44 Posteroanterior lumbar stiffness, response of to repeated loading, 19 Posture, scapular position assessment by skin surface palpation, validity of, 26 Pressure pain thresholds, thoracic spine, effect of soft tissue deloading tape in asymptomatic subjects, 150 R
Repetitive movement, in recalcitrant chronic low back and leg pain (masterclass), 183
Resistance, determination of R1 with force movement curves from spinal assessment machine (SAM), 39 S
Sacroiliac joint anatomical landmarks by palpation, errata (letter), 115 bibliography, radiology, 231 joint movement in as guide to management of unilateral low back pain (masterclass), 215 Scapular position, skin surface palpation as indicator of, 26 Scapular rotators, taping and electromyographic muscle activity in, 154 Shoulder bibliography, radiography, 232 taping and electromyographic muscle activity in scapular rotators in healthy shoulders, 154 Spinal assessment machine (SAM), manual examination of accessory movements to find R1, 39 Spinal mobilizations with limb movements (SMWLMs), Mulligan concept and its application to spinal conditions (masterclass), 64 Spine back pain see Back pain bibliography, radiography, 231 cervical see Cervical spine; Neck lumbar see Lumbar spine Mulligan concept: Application to management of spinal conditions (masterclass), 64 sacroiliac see Sacroiliac joint thoracic see Thoracic spine Sports medicine, thoracic pain in collegiate runner (case report), 168 Stiffness, posteroanterior lumbar, response to repeated loading, 19 Surgery, bibliography, articular cartilage, 58 Surveys cervical spine manipulation, attitudes and patterns of practitioners performing, 10 mobilization with movement techniques in low back pain, 206 Sustained natural apophyseal glides (SNAGs) acute locked thoracic spine: treatment with modified SNAG (case report), 103 Mulligan concept and its application to spinal conditions (masterclass), 64 T
Taping electromyographic muscle activity in scapular rotators in healthy shoulders, 154 thoracic spine pressure pain thresholds, effect of soft tissue deloading tape in asymptomatic subjects, 150 Tendinopathy, of Achilles tendon (masterclass), 121 Manual Therapy (2003) 8(1), 59–62
62 Manual Therapy
Thoracic spine acute locked thoracic spine: treatment with modified SNAG (case report), 103 bibliography, radiography, 231 pressure pain thresholds, effect of soft tissue deloading tape in asymptomatic subjects, 150 thoracic pain in collegiate runner (case report), 168 Thumb, Mulligan’s mobilization with movement: MRI to evaluate positional fault hypothesis (case report), 44 U
Upper limb
Manual Therapy (2003) 8(1), 59–62
bibliography, 110 cervical lateral glide mobilization technique for cervicobrachial pain syndrome (CBPS), effectiveness of, 31 V
Volvo awards, bibliography, 173 W
Whiplash, mechanical provocation of nerve tissue in: Brachial plexus provocation test (BPPT), 89 Wrist, bibliography, radiography, 233
