Manual Therapy Journal - Volume 9, Issue 1, Pages 1-58 (February 2004)

VOLUME 9 NUMBER 1 PAGES 1–58 FEBRUARY 2004 Editors International Advisory Board Ann Moore PhD, GradDipPhys, FCSP, Cer...

Author: Editors: Ann Moore and Gwen Jull

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VOLUME 9 NUMBER 1 PAGES 1–58 FEBRUARY 2004

Editors

International Advisory Board

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

K. Bennell (Victoria, Australia) B. Carstensen (Frederiksberg, Denmark) S. Durrell (London, UK) S. Edmondston (Perth, Australia) J. Endresen (Flaktvei, Norway) L. Exelby (Biggleswade, UK) J. Greening (London, UK) C. J. Groen (Utrecht,The Netherlands) A. Gross (Hamilton, Canada) W. Hing (Auckland, New Zealand) S. King (Glamorgan, UK) B.W. Koes (Amsterdam,The Netherlands) D. Lawrence (Lombard, IL, USA) D. Lee (Delta, Canada) L. Ma¡ey-Ward (Calgary, Canada) J. McConnell (Northbridge, Australia) S. Mercer (Dunedin, New Zealand) E. Maheu (Saint-Laurent, Canada) D. Newham (London, UK) L. Ombregt (Kanegem-Tielt, Belgium) N. Osbourne (Bournemouth, UK) M. Paatelma (Jyvaskyla, Finland) N. Petty (Eastbourne, UK) H.J.M.Von Piekartz (Wierden,The Netherlands) A. Pool-Goudzwaard (The Netherlands) M. Pope (Aberdeen, UK) G. Rankin (London, UK) M. Rocabado (Santiago, Chile) D. Shirley (Lidcombe, Australia) V. Smedmark (Stenhamra, Sweden) W. Smeets (Tongeren, Belgium) R. Soames (Leeds, UK) P. Spencer (Barnstaple, UK) P. Tehan (Victoria, Australia) M. Testa (Alassio, Italy) M. Uys (Tygerberg, South Africa) P. van Roy (Brussels, Belgium) B.Vicenzino (St Lucia, Australia) M.Wallin (Spanga, Sweden) A.Wright (Winnipeg, Canada) M. Zusman (Mount Lawley, Australia)

Gwendolen Jull PhD, MPhty, Grad Dip ManTher, FACP Department of Physiotherapy University of Queensland Brisbane QLD 4072, Australia Editorial Committee Karen Beeton MPhty, BSc(Hons), MCSP MACP ex o⁄cio member Department of Allied Health Professions—Physiotherapy University of Hertfordshire College Lane Hat¢eld AL10 9AB, UK Je¡rey D. Boyling MSc, BPhty, GradDipAdvManTher, MAPA, MCSP, MErgS Je¡rey Boyling Associates Broadway Chambers Hammersmith Broadway London W6 7AF, UK Darren A. Rivett PhD, MAppSc (ManiPhty) GradDip ManipTher, BAppSc (Phty) Discipline of Physiotherapy Faculty of Health The University of Newcastle Callaghan, NSW 2308, Australia Kevin P. Singer PhD Centre for Musculoskeletal Studies Department of Surgery The University of Western Australia, Royal Perth Hospital Level 2, MRF Building, 50 rear, Murray Street Perth,WA 6000, Australia Clive Standen MA, DO UNITEC Auckland, New Zealand Raymond Swinkels MSc, PT, MT (Book Review editor and NVMTex o⁄cio member) Ulenpas 80 5655 JD Eindoven The Netherlands

Visit the journal website at http://www.elsevierhealth.com/journals/math

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Editorial

The International Federation of Orthopaedic Manipulative Therapists The International Federation of Orthopaedic Manipulative Therapists (IFOMT) was formed in 1974 by an international group of leading manipulative physiotherapists. They perceived a need for an international forum of and for Manual Therapists at which ideas could be exchanged, information could be disseminated and collaborative work could be set up. The importance of ﬁrm links with the world body of Physiotherapists led to the granting of subgroup status by WCPT (World Confederation of Physical Therapists) in 1978. IFOMT became the ﬁrst subgroup of WCPT at a time when only a few countries recognised physiotherapy as an independent profession, and when manipulation, in a number of countries, was practised solely by the medical profession. The subgroup status lent credence to manipulation as an integral part of the physiotherapist’s scope of practise. Through the initial years of the federation there was lively debate as to the membership process, and indeed if there should be membership or not. It was agreed that the development of post-graduate/post-qualifying educational programs in the ﬁeld of Manual Therapy (MT) and associated areas should be a signiﬁcant role of IFOMT. To that effect a Standards Document was developed, mainly through the hard work of Mr. Gregory Grieve. Currently, a group applying for membership has ﬁrstly to submit its educational program for the scrutiny of the IFOMT Standards Committee (SC). The application papers are then sent to the executive committee together with the report from the SC. The voting in of new member groups takes place at the General Meeting of IFOMT every four years. The IFOMT Standards Document is reviewed on a regular basis to reﬂect the developments within the practice of MT and the ever increasing evidence base that now exists. Stringent entry requirements to an organisation naturally means that the membership growth is tempered. It does however demonstrate that as an international body IFOMT is setting standards of education, clinical practice and research and that the need for further clinical specialisation is recognised. IFOMT is 1356-689X/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S1356-689X(03)00130-9

prepared to grow more slowly in order to foster the worldwide continuous development of the clinical application of MT of a high standard. In September 2001 IFOMT held its ﬁrst Strategic Planning meeting with a majority of its Member Organisations (MOs) and Registered Interested Groups (RIGs) present. The vision statement for IFOMT was agreed as ‘‘Worldwide promotion of excellence and unity in clinical and academic standards for manual/musculoskeletal physiotherapists’’. Five main areas of development were identiﬁed: * * * * *

Resources. Advocacy and Communication. Education. Academic Standards. Research and Evidence Based Practice.

The Vehicle through which this work is taking place is via the development of a website. At the beginning of 2004, on the launch of this website (www.ifomt.org), IFOMT will be able to provide information regarding: * *

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post graduate courses in MT, research that is ongoing and that which is recently published in peer reviewed journals, links to research engines such as PEDro, pubmed, Cochrane etc. peer reviewed, referenced clinical guidelines, developed by Mos, names of experts within ﬁelds related to MT, who are familiar with the educational standards of IFOMT, and who are willing to help established, or newly formed MT groups, to develop their educational programs, events related to MT such as courses and conferences in, e.g., neurosciences, policy statements relating to the practise of MT.

There will be direct linking to the websites of all the IFOMT MOs, to WCPT and to other Sub-Groups of WCPT, e.g. IPPA, IFSP and IOPTWH.

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The permanent features of the web site will include the history of IFOMT, Mission and Vision statements, membership categories and criteria and the Standards Document. There will be news items relating to individual MOs but of relevance to the larger MT community. In this way, IFOMT hopes to achieve a high level service both for those already working in this ﬁeld of Physiotherapy, and those who are just starting off. The international community of Physiotherapy has a huge variation of educational traditions and systems. This is inevitably reﬂected in the membership of any World organisation. By bringing many varied course programs on clinical, theoretical and research topics together for viewing on one site we hope to serve the variation in needs. In addition the resource centre will contain names of experts in a variety of areas of physiotherapy, from a background of diverse educational systems and geographical regions. This will make it possible to access manpower resources for all regions of the world, should colleagues wish to seek assistance with the setting up and development of MT education, at all levels. We feel that demonstrating and publicising the level of activity and the exciting developments in MT and associated ﬁelds will stimulate a growing desire to be a part of it all. The most immediate way of doing this is to

attend an IFOMT conference. The outstanding quality of expertise that is demonstrated through the lectures and the pre and post congress courses guaranties all those attending to have something to take back home with them. There will be something that will either modify clinical practise, to the beneﬁt of their patients, or topics to investigate further either by focused reading or by research in the laboratory or in the clinic. The IFOMT conference has in the past also seen the beginning of much successful collaboration across geographical boundaries. This is quite apart from the general feeling of partaking in something bigger than the every day working environment. The next IFOMT conference will be held in March 21–26, 2004, in Cape Town, South Africa. The website for further information is: www.uct.ac.za/depts/pgc I would urge you to book soon. If you want to ﬁnd out more about the organisation, there will be a presidential forum at the conference to which all are welcome. Any person requiring more information about IFOMT should contact the Secretariat of IFOMT, on: [email protected] Agneta Lando (President of IFOMT)

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Masterclass

Rehabilitation of pelvic ﬂoor muscles utilizing trunk stabilization Ruth Sapsforda,b,* b

a Mater Misericordiae Hospital, South Brisbane 4101, Qld., Australia School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane 4072, Qld., Australia

Received 1 August 2003; accepted 14 October 2003

Abstract The pelvic ﬂoor muscles (PFM) are part of the trunk stability mechanism. Their function is interdependent with other muscles of this system. They also contribute to continence, elimination, sexual arousal and intra-abdominal pressure. This paper outlines some aspects of function and dysfunction of the PFM complex and describes the contribution of other trunk muscles to these processes. Muscle pathophysiology of stress urinary incontinence (SUI) is described in detail. The innovative rehabilitation programme for SUI presented here utilizes abdominal muscle action to initiate tonic PFM activity. Abdominal muscle activity is then used in PFM strengthening, motor relearning for functional expiratory actions and ﬁnally impact training. r 2003 Elsevier Ltd. All rights reserved.

1. Introduction Ten years ago musculoskeletal physiotherapists would not have considered the pelvic ﬂoor muscle (PFM) complex when treating patients with low back pain or sacroiliac joint (SIJ) dysfunction and physiotherapists teaching PFM exercises for the treatment of stress urinary incontinence (SUI) discouraged the use of the abdominal muscles. These beliefs are now changing. Research has led to an increased understanding of the synergy between the abdominal and PFM and in fact all the muscle groups surrounding the abdominal capsule. The PFM are now considered to have the dual function of providing trunk stability (Richardson et al., 1999) and contributing to continence and elimination of both bladder and bowel. The synergy of the abdominal and PFM presents the opportunity for a different approach to the rehabilitation of pelvic ﬂoor (PF) dysfunction, which may improve clinical outcomes. Five to seven year follow up of women with urinary incontinence after vaginal delivery indicates that the beneﬁt of initial conservative intervention, such as a PFM strengthening programme, is not maintained (Wilson et al., 2002). Clinicians dealing with PF function believe that cognitive PFM *Address for correspondence. 44 Glen Road, Toowong 4066, Qld., Australia. Tel./fax: +61-7-3870-7596. E-mail address: [email protected] (R. Sapsford). 1356-689X/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S1356-689X(03)00131-0

exercise should be performed pre-, peri- and postpartum and for the rest of life (Chiarelli et al., 2003). Those who have had to exercise therapeutically for any condition will attest to the tedious nature of an ongoing programme. Pain and limited movement are great motivators, but most people anticipate that general activity will then maintain function. In many women who have had vaginal deliveries general activity does maintain PFM function without any speciﬁc PFM exercises (Gordon and Logue, 1984). Why does this not happen in all women? This paper aims to outline the synergies between the PFM and the abdominal muscles during function and dysfunction and suggest an approach to rehabilitation for the most common problems.

2. The pelvic ﬂoor as a musculoskeletal unit The PF is a musculoskeletal unit and like similar units has passive, neural and active subsystems of control (Panjabi, 1992). The fascias of the passive subsystem are thickened into ligaments, but they do not resemble strong articular ligaments. The degree of movement of these fascial layers is variable and depends on the extent of stretch associated with vaginal deliveries. This stretch caused by parturition can be compounded by regular straining at stool (Spence-Jones et al., 1994). Genetic variation in the composition of connective tissue can

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also contribute to increased extensibility (Vierhout and Terlouw, 2001). The neural subsystems of control rely on differing sensory feedback from the abundant muscle spindles within the antigravity PFM. Slow or rapid stretch of the spindles will generate, via gamma efferent motor nerves, a slow sustained or a dynamic brief muscle activation. These neural responses can be disturbed in women who have had vaginal deliveries. Eighty per cent of women undergoing their ﬁrst vaginal delivery have evidence of denervation and reinnervation of pubococcygeus (PC), the main PFM (Allen et al., 1990). Neurological damage has also been shown in the external anal sphincter (EAS) following vaginal delivery (Snooks et al., 1984; Sultan et al., 1994). Some women experience loss of awareness of bladder fullness, and can lose a large volume of urine without warning in the ﬁrst couple of days after delivery. This neurological deﬁcit usually resolves within the ﬁrst week. However reﬂex inhibition from local trauma can cause ongoing deﬁcits in muscle recruitment even when the pain has subsided. A similar scenario may occur in men who have had prostatectomies. The role of the active subsystem is to maintain continence and provide organ support against gravity at rest and with slow, rapid and unpredictable loading. These functions require the ability to act prior to increases in intra-abdominal pressure (IAP) (Constantinou and Govan, 1982). The PFM also contribute to elimination, sexual response, IAP and lumbo-pelvic stability. Local pain may cause inhibition of local muscles, but may also delay the timing of contraction. This can lead to loss of bladder control. The contribution of the PFM to IAP and trunk stability can be explained by its feedforward activation in response to trunk perturbation, resulting from rapid arm movement (Hodges et al., 2002). The PFM respond in a similar manner to the other components of the local muscle system including the transversus abdominis (Hodges and Richardson, 1996), the diaphragm (Hodges et al., 1997) and the deep ﬁbres of lumbar multiﬁdus (Moseley et al., 2002).

3. Co-activation of the abdominal and pelvic ﬂoor muscles Recent research has monitored electromyographic (EMG) activity in the PFM and abdominal muscles during voluntary activity (Sapsford et al., 2001; Neumann and Gill, 2002). With a maximal voluntary contraction of the PFM, monitored by digital vaginal palpation of PC, all the abdominal muscles, transversus abdominis (TrA) obliquus internus (OI), obliquus externus (OE), and rectus abdominis (RA) were activated. The response in RA was minimal. Changes in passively maintained positions of the lumbar spine varied the proportion of EMG in the abdominal

muscles, particularly the obliques. In lumbar ﬂexion the OE showed the greatest activity, whereas in lumbar extension TrA produced the dominant response (Sapsford et al., 2001). When only a gentle PFM contraction was performed TrA produced the dominant response irrespective of lumbar spine position. Conversely when various abdominal isometric manoeuvres were performed, increasing abdominal muscle EMG activity resulted in increasing EMG activity in PC and EAS (Sapsford and Hodges, 2001). Co-activation of the PFM and the deep ﬁbres of lumbar multiﬁdus has been observed clinically (Richardson et al., 1999), but no studies conﬁrming this coactivation have been found.

4. Pelvic ﬂoor muscles The PFM are divided into three layers. Superficial—bulbospongiosus, ischiocavernosus and superﬁcial transverse perinei muscles and the external anal sphincter. Intermediate—intrinsic urethral sphincter, deep transverse perinei, and in females, compressor urethrae and the urethrovaginal sphincter (DeLancey, 1990). Deep—levator ani comprising puborectalis (PR), pubococcygeus (PC) and iliococcygeus, and ischiococcygeus, also known as coccygeus. Fibres between PC and the vagina have also been described (DeLancey, 1990). The PFM are the only transverse load bearing muscle group in the body. Biopsy samples taken from PC in asymptomatic females showed between 67% and 76% slow twitch ﬁbres (Gilpin et al., 1989). Continuous tonic PFM activity has been demonstrated at rest in lying, sitting and standing (Vereeken et al., 1975; Deindl et al., 1993). This continuous tonic activity makes these muscles ideally suited to antigravity support. The external anal sphincter also exhibits tonic activity, which is responsible for approximately 15% of anal resting pressure. While PFM activity has been assessed during cognitive and functional activation using a range of modalities it has been shown that automatic functional responses do not necessarily mirror voluntary activation (Deindl et al., 1994; Wijma et al., 1991). Functional tasks such as lifting, nose blowing, laughing, coughing, sneezing, and valsalva (a forced expiratory effort against a closed glottis) recruit the PFM with the abdominal muscles to increase IAP, generate an expiratory force and maintain continence. In all of these tasks the PFM complex must ensure urethral and anal closure before the increase in IAP if continence is to be maintained. Nose blowing, coughing, sneezing and laughing recruit the same PFM, diaphragmatic and abdominal muscle patterns, but with variations in strength and power. See Figs. 1–4 for diagrammatic

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Fig. 1. Breathing at rest. (A) In quiet inspiration, the diaphragm descends and the abdominal wall moves anteriorly. (B) In quiet expiration, the diaphragm ascends and the abdominal wall moves posteriorly. Reproduced with permission of C P Sapsford.

Fig. 2. Nose blowing. (A) With inspiration for nose blow, diaphragmatic descent and abdominal wall movement are similar to that in quiet breathing. (B) With blowing, the abdominal wall pulls in and the PFM are contracted. Increased force in blowing requires stronger muscular effort. Reproduced with permission of C P Sapsford.

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Fig. 4. Sneezing. (A) Inspiratory effort in sneezing is probably similar to that in coughing. (B) Sneezing requires a faster and stronger recruitment of abdominal and PFM muscles than coughing. Reproduced with permission of C P Sapsford.

female problem, with vaginal delivery considered the catalyst in most cases (Viktrup, 2002). Women who have had elective caesarean sections are at less risk of dysfunction in the short term (Snooks et al., 1984; Viktrup, 2002), but in the longer term are still vulnerable (MacLennan et al., 2000). However (SUI) does occur in nulliparous women during high impact activities and with sneezing and coughing, though with a much lower prevalence than in parous women (Bo et al., 1994; Nygaard et al., 1994). It is after radical prostatectomy for cancer of the prostate that men may experience ongoing SUI. Changes in abdominal muscle activity have not been investigated in those with PFM dysfunction.

5. Pelvic organ control Urinary continence depends on both tonic and phasic PFM activity. These contribute to *

* *

Fig. 3. Coughing. (A) Inspiratory effort before a cough requires rapid diaphragmatic descent, and the abdomen often moves further forward. (B) With coughing, the abdomen pulls in hard, PFM are contracted strongly and the diaphragm is forced higher. Reproduced with permission of C P Sapsford.

representation of these muscles during inspiratory and expiratory actions. Studies of PFM function have generally been undertaken in females, as PF dysfunction is predominantly a

a stable bladder during ﬁlling and coughing (Mahony et al., 1977); a urethral closing pressure at rest > bladder pressure; an increase in urethral closing pressure that precedes and is greater than the rise in IAP with effort and impact activities.

Support of the uterus, cervix and vagina is provided by both fascia and muscle. The upper vagina rests above the rectum and both are positioned over the levator plate with the cervix close to the coccyx. Increases in IAP press the pelvic organs against the supporting muscle (Berglas and Rubin, 1953). Both tonic and phasic PFM activity contribute to this support. Anal continence depends on both tonic and phasic PFM activity to achieve *

a sensory awareness of rectal ﬁlling that triggers increasing EAS activation.

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6 *

anal closing pressure that is greater than rectal pressure when rectal contents are present.

PF dysfunction can occur in either the urethrovesical, uterovaginal or anorectal systems and frequently in more than one at the same time (Maglinte et al., 1999). Disturbances and deﬁciencies in PFM activity can be associated with the conditions listed below, though it is important to be aware that other factors, such as fascial laxity and smooth muscle dysfunction, are also involved. Varying degrees of anterior vaginal wall laxity occur after vaginal delivery. Greater fascial stretching occurs with a more prolonged second stage of labour, or frequent straining to evacuate. However only a small proportion of cases of vaginal laxity develop into symptomatic vaginal prolapses (Samuelsson et al., 1999).

6. Disturbances in pelvic organ function Poor tonic support is likely to be a factor in the following conditions: * *

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Urinary frequency—increased daytime voiding. Urinary urgency—a sudden compelling desire to void, with inability to defer. Urinary seepage—can be an insensitive loss—leading to dampness during upright activities. Vaginal prolapse—a suprapubic or vaginal heaviness/ dragging, with or without a palpable vaginal ‘lump’.

Inadequate tonic support and strength contributes to the following: *

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Stress urinary incontinence—involuntary leakage of urine with effort, exertion or impact. Urge urinary incontinence—involuntary leakage associated with urgency. Obstructed defaecation (type B)—the inability to empty the rectum even with straining, due to lack of rectal support.

may affect PFM tonic activity and the timing of its phasic recruitment during functional activities. Acute low back pain (LBP) has been found to alter the motor control of the lumbar multiﬁdus and TrA (Hides et al., 1994; Hodges and Richardson, 1996). LBP may be the trigger which reduces tonic PFM support in a number of conditions such as prolapse, urinary frequency, SUI, urgency, urge incontinence (Eisenstein et al., 1994). SIJ dysfunction also interferes with the stability system of the trunk. Urinary urge incontinence has been reported in this condition, and resolved when the SIJ pain was relieved (Dangaria, 1998; O’Sullivan et al., 2001).

7. Stress urinary incontinence SUI is the most common type of urinary dysfunction in younger women. Vaginal delivery is recognized as the predominant cause (Viktrup, 2002), but not all sufferers develop this condition immediately postpartum. Some women develop it many years after childbearing has been completed. Others experience SUI prior to pregnancy, and its occurrence during pregnancy can be partially attributed to the hormones relaxin and progesterone. Conservative management of SUI by rehabilitation of the PFM is advocated as a primary intervention. This approach has no adverse effects and has been shown to be effective in mild-to-moderate cases of urine loss (Bo et al., 1999). Treatments have generally focussed on increasing PFM strength. However, there are a number of fascial and muscle deﬁciencies that contribute to SUI. Understanding this pathophysiology may also assist in determining the optimum conservative rehabilitation strategies and the likely outcome from muscle rehabilitation. *

Overactive PFM and non-release of PFM have been implicated in the following conditions: *

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Voiding dysfunction—hesitancy in commencing ﬂow, slow or interrupted stream, incomplete emptying. Dyspareunia and vaginismus—painful penetration during coitus. Obstructed defaecation (type A)—sometimes referred to as anismus—inability to release the anus to evacuate rectal contents. Perineal and perianal pain—muscle pain that tends to be worse in sitting, or in actively sustained lumbar ﬂexion postures.

Considering that the PFM is part of the local muscle system of trunk stability, deﬁcits in other local muscles

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Low urethral closing pressure at rest - o 20 cm H2O— can be due to changes in tissue quality with age, lack of oestrogen, neuropathy and scar tissue. This is termed intrinsic sphincter deﬁciency, and may be manifested in seepage incontinence when upright as well as loss with effort. Resting urethral pressure has not been improved by PFM strengthening programmes (Bo et al., 1999). Deficient urethral and bladder neck support: The urethra is supported by the anterior vaginal wall which has fascial attachments to PC. Fascial stretch allows excessive vaginal movement in a dorsal and caudal direction during increases in IAP. The urethrovesical angle widens and the bladder neck descends and opens allowing ingress of urine (Schaer et al., 1995). In some women urethral closure with coughing is maintained but urine loss with impact activities such as running or repeated jumping occurs. Paravaginal fascial tears can also result in lack of

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vaginal support. These can only be remedied by surgery (Maher, 2003). Deficient PFM tonic activity: The ability to sustain a prolonged PFM hold is reduced in women with SUI in comparison with nulliparous women, and resting tonic activity can be absent (Deindl et al., 1994). Prolonged moderate exercise almost exclusively relies on slow twitch ﬁbres. Tonic muscle activity may be a precursor to effective phasic recruitment during effort activities such as lifting and running. Delay in PFM recruitment: PFM activity during increases in IAP may not be generated at the right time. In an EMG study of nulliparous women with SUI on physical exertion and coughing, it has been noted that the urethral pressure drops to zero at the instant of the cough yet the urethral sphincter and PC muscles were recruited with coughing. This ﬁnding of zero urethral pressure may indicate either a delay in muscle recruitment or muscle strength that is inadequate to hold against the IAP (Bo et al., 1994). Asymmetrical PFM contraction: Unilateral recruitment of the PFM may occur with voluntary effort, or only when coughing (Deindl et al., 1994). Partial peripheral neuropathy can occur with vaginal delivery, but unilateral recruitment with coughing indicates a neural deﬁcit. Voluntary PFM activity is controlled by the motor cortex (Blok et al., 1997a). However it is the pons, without any connection to the motor cortex, which controls the automatic aspects of micturition (Blok et al., 1997b). PFM weakness: Muscle strength is generally weaker in women presenting with SUI than in asymptomatic subjects (Gunnarsson and Mattiasson, 1999). However greater PFM strength does not necessarily result in continence (Hextal et al., 1999). Diaphragmatic breathing increases abdominal anteroposterior diameter with inspiration and the resultant stretch on the abdominal muscles may enhance their contraction force during a cough (Van Lunteren et al., 1989). A strong isometric abdominal contraction develops a strong PFM contraction (Sapsford and Hodges, 2001). Global abdominal muscle holding that may occur with LBP (Richardson et al., 1999) restricts the precontractile abdominal stretch that generally occurs during the inspiratory effort of a cough. A similar effect occurs if the abdominal wall is very lax and the diaphragm is low at rest. In these patients even quiet inspiratory effort requires upper rib cage elevation. This may affect the recruitment of the abdominal muscles and consequently the PFM during a cough. Compression of the upper rib cage and lateral widening of the lower rib cage occur in coughing. In tetraplegics upper rib cage compression is effected by the clavicular portion of pectoralis major, but lower lateral rib cage widening is deﬁcient (Estenne and DeTroyer, 1990).

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Weak abdominal muscles: The effectiveness of coughing relies on the generation of adequate intrathoracic pressure to expel the irritant as the glottis open. Intrathoracic pressure is usually generated by rib cage compression and the increase in IAP by contraction of TrA and the OE muscles. However in tetraplegics, who have no abdominal muscle innervation, the abdominal wall bulges out as they cough (Estenne and DeTroyer, 1990). This bulge is due to transmitted pleural pressure, as the diaphragmatic EMG activity does not differ from that in healthy subjects during coughing (Estenne and Gorini, 1992). A similar bulging of the abdominal wall is noted in many women with SUI as they cough. It can occur even during nose blowing, especially in a slumped supported position when there is no pretensioning of the abdominal muscles. Weak abdominal muscles can allow this to happen, but the mechanism of upper rib cage elevation for inspiratory effort may also be a factor. When the abdominal wall is bulged in this manner there is decreased activity in the PFM (Sapsford and Hodges, 2001). Figs. 5 and 6 show changes in muscle recruitment in patients with SUI.

8. Assessment of pelvic ﬂoor muscle dysfunction The following clinical and subjective tests may help to determine the mechanism causing SUI. *

Firm hand contact over the vagina and perineum can detect vaginal bulging and perineal descent during coughing. This can be detected in standing. The presence of a vaginal prolapse at the introitus may interfere with this. If running and jumping usually result in urinary incontinence, using hand pressure to restrict vaginal descent during a test of repeated

Fig. 5. Stress urinary incontinence—nose blow, cough and sneeze. (A) In patients with SUI who have weak abdominal muscles, the nose blow, cough and sneeze inspiratory effort may be similar to that in healthy subjects. There is often less abdominal wall excursion and more rib cage movement. (B) During the expiratory phase, the abdominal wall bulges forward and the PFM are forced down. Reproduced with permission of C P Sapsford.

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ported sitting, and with resisted lifting and coughing in the upright posture can be recorded in the following manner. Tests can be conducted in other positions. Slump/sit PF Abd ? k

Fig. 6. Inspiratory rib cage elevation in stress urinary incontinence— nose blow, cough and sneeze. (A) When rib cage elevation is used for inspiratory effort before a nose blow, cough and sneeze, the abdominal wall tends to be stretched and drawn in a little, even though the diaphragm descends. (B) With the expiratory effort, the rib cage drops down and the abdominal wall is forced out and the PFM are forced down. Reproduced with permission of C P Sapsford.

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jumping can result in little or no loss. This conﬁrms that vaginal laxity is a factor in incontinence for that patient. However incontinence associated with a weak urethral sphincter mechanism will not change. Poor tonic PFM activity is likely if the tonic hold in TrA is deﬁcient. A sense of vaginal heaviness and urinary urgency may accompany the incontinence. Many of these women note that the abdomen sags when they lean forward in standing, and this may represent lack of an automatic postural hold in TrA. PFM activation and strength are frequently assessed by digital vaginal palpation by experienced PF physiotherapists. An alternative clinical test to conﬁrm the correct activation can be achieved by external hand contact over the vaginal entrance. The patient is asked to contract the PFM by drawing the urethra and vagina closed and towards the head. There should be a drawing in and upward movement of the vaginal entrance and perineum. The patient can also detect this with her hand. A perceived bulging indicates that increased IAP is forcing the pelvic organs and vagina down. This can be due to diaphragmatic descent and breath holding with or without a ﬁrm abdominal wall. A subjective awareness of contraction of abdominal muscle and vaginal tension status (PFM activity) during sitting at rest and with functional tasks can indicate correct or incorrect PFM and abdominal muscle recruitment. Changes in status in both muscle groups, as the patient moves from one sitting position to the next and performs the set tasks, are frequently detected. A hand on the lower abdomen is needed to feel the direction of abdominal wall movement during coughing. Subjective abdominal and vaginal awareness in slumped supported sitting, upright unsup-

Upright/sit PF Abd m m

Resisted lift Coughing PF Abd PF Abd m m k k

Muscle looseness at rest, or a decrease in activity, is indicated by a downward arrow. An increase in activity is indicated by an upward arrow. When the subject is unable to detect the muscle condition an interrogation mark is used. Retesting as treatment progresses will detect subjective changes as muscle function improves. *

*

A diaphragmatic breathing pattern at rest should be conﬁrmed in both lying and sitting. Co-activation of PF and abdominal muscles can be detected by palpating TrA medial to the anterior superior iliac spines (ASIS) during a gentle sustained periurethral hold. It is possible to detect asymmetry in TrA during the periurethral hold. This test should be conducted in lying initially, as the global abdominal muscles can be relaxed thus making TrA changes easier to detect.

9. Treatment of pelvic ﬂoor muscle dysfunction It is important to realise that muscle rehabilitation is not the only strategy used when treating patients with various types of pelvic ﬂoor dysfunction. However it is the aspect covered by this paper. A continence physiotherapist has a full understanding of other interventions that can be used. There are several stages to be undertaken in PFM rehabilitation. Progression from one stage to the next depends on the ability to perform the ﬁrst step before embarking on the next. The status of the abdominal muscles on initial assessment may determine the order of treatment. In patients with strong global abdominal muscle holding, the retraining of a diaphragmatic breathing pattern needs to be the ﬁrst treatment step. 1. Diaphragmatic breathing: The correct breathing pattern should be checked in lying and sitting, both unsupported and supported. Visual feedback using a mirror can be very helpful when sitting. Practice should aim to minimize upper rib cage elevation, though limitations imposed by certain respiratory conditions have to be taken into account. 2. Tonic activation: PFM rehabilitation should begin with tonic activity, as this is often deﬁcient (Deindl et al., 1994). This differs from many other programmes for SUI which focus on strong PFM holds sustained for up to 10 s. As with rehabilitation

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of TrA in patients with LBP (Richardson et al., 1999), retraining of a tonic PFM action involves very gentle and prolonged muscle holds. Some patients need to learn to relax global abdominal muscle activity prior to commencing this approach. Using an independent TrA contraction to gain a PFM co-contraction helps to ensure the very low-level PFM activation required. Use of tactile input medial to ASIS, by both patient and therapist, teaches and conﬁrms the correct abdominal activation. In patients without back pain this reeducation can be commenced in standing. An advantage of this upright position is that the lumbar curve is maintained and the dependent abdominal contents create some tension in the abdominal wall. This tension of the abdominal wall makes it easier to detect the gentle muscle activation required. Patients must be able to report their subjective awareness of the periurethral and/or perivaginal and perianal tensioning response during the independent TrA activation, and/or the release as the abdominal wall is released. This is critical to the success of this approach. If this perineal response is not detected, it may indicate that the PFM are not being recruited and consequent increases in IAP can aggravate many PF conditions. When a patient holds a gentle TrA contraction in standing the patient should also be aware of a suprapubic ﬁrmness radiating from the midline to both sides above the inguinal ligaments. As with muscle activation for lumbar stabilization, TrA must be recruited without respiratory effort or spinal movement (Richardson et al., 1999). Five repetitions up to ﬁve times a day holding for as long as possible can be used as a starting programme. Each abdominal hold should gradually be increased to up to 30 or 40 s and more. At this stage the focus of muscle holding remains abdominal. The action should be progressed from tactile abdominal awareness to ‘thinking just above the pubic bone’ and learning to develop a gentle abdominal ﬁrmness in this region. Use of this gentle action before and during lifting improves the sense of PFM support during the lift. Awareness of perineal tensioning and release with the abdominal activation and relaxation should be checked a few times a day. An alternative method to achieve tonic PFM activity is to use a minimal periurethral PF hold in unsupported upright sitting with a neutral lumbar curve. The desired action is to imagine holding the ﬂow of urine. Hand contact over the lower abdomen can detect an isometric abdominal response. This is a preferable method for those with chronic back problems who tend to recruit global abdominal muscles. However many women have been encouraged to perform strong PFM contractions and must realise the difference with this approach. In

9

patients with current LBP it is advisable to address the back pain before treating the PF problem. While many patients initially over activate the TrA/ PFM co activation, a small degree of OI activity may not be detrimental to PF dysfunction sufferers if there is no back pain. This exercise is then gradually incorporated into daily activities in standing and walking. 3. Muscle strengthening: Once a TrA/PFM co-contraction can be maintained easily with walking for more than 15 s, strength training is added to the tonic work. The TrA ability to hold is tested functionally by palpating the activation and asking the patient to walk. It is important to assess the ease with which the patient walks and to feel the abdominal wall release as they relax. During strength training the patient should palpate TrA and OE muscles. This will help to develop an awareness of abdominal activation. It can be difﬁcult to be aware of an abdominal contraction without this palpation. A gentle lower abdominal action as used for TrA is commenced ﬁrst, then the patient is requested to keep pulling the lower abdomen in towards the spine. The patient should hold hard and then pull up the periurethral PF as far as possible. This can be done in reverse order. The patient should hold this for 3–5 seconds, breathing as the hold is maintained. This action uses TrA and the obliques, but avoids spinal movement thus minimizing RA activity. The principles of strength training should be used to determine the number of repetitions per day, but the therapist should be cognisant of motivational and compliance factors. The amount of internal vaginal movement detected by the patient with the added periurethral lift will vary with the degree of fascial laxity and the strength of the abdominal muscles. Once the abdominal muscles have been strengthened, further elevation with the added PFM activation is often negligible. It is difﬁcult to state how strong the PFM needs to be. This depends on the demands put upon the muscle, and the extent of the fascial laxity. Some women want to be able to run, others wish only to walk. The fascial laxity is very variable but greater laxity requires greater strength to stabilise the musculofascial unit. 4. Functional expiratory patterns: ‘To improve a speciﬁc performance by strengthened musculature, the muscles must be trained with movements as close as possible to the desired movement or actual skill’ (McArdle et al., 1991, p. 465). Thus nose blowing, coughing, sneezing and laughing all need retraining in a similar manner, using a motor relearning approach of deliberate and repeated practice of the necessary sequence of breathing and muscle activation. Nose blowing should be

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commenced ﬁrst as this is a slower pattern and thus easier to master. The patient should be sitting upright, unsupported, in front of a mirror. A diaphragmatic breath increases the antero-posterior diameter of the abdomen. The nose blow is commenced from this full inspiration and incorporates a strong cognitive abdominal pulling in contraction as the nose blowing takes place. The use of a sustained blow gives time to concentrate on the correct pattern of abdominal activation. Once the patient can perform the expiratory pattern, she should be asked to comment on her perceived vaginal response. This nose blow pattern needs to be practised ﬁve or six times repeatedly once or twice a day. It should be performed effectively and consistently before progressing to coughing retraining. As with all expiratory patterns practice is eventually progressed to lying and all sitting and standing postures. The recruitment of the correct pattern is hardest in positions of abdominal laxity e.g. lying, slumped supported sitting and forward lean standing. Coughing requires stronger and faster abdominal muscle activation. In sitting there is some vaginal support from the chair and this gives the patient improved awareness and more conﬁdence that she will not leak urine as she practises. The retraining commences in upright unsupported sitting using the same pattern as for nose blowing. This pattern becomes more effective as the abdominal muscles gain strength. In laughing the abdomino/PFM pattern must be able to be repeated and sustained. Sneezing requires the greatest muscle power and correct timing. Placing the hands around the lower ribs with ﬁngers palpating over the external oblique muscles can aid in detecting the correct lower rib expansion and muscle action. This lateral widening of the lower rib cage with abdominal muscle concentric contraction should occur in all forceful expiratory patterns. The inspiratory phase requires rapid diaphragmatic descent as with coughing. The second phase of the sneeze, the compressive phase, needs to be practised many times with increasing rapidity in front of a mirror. As this is performed, the abdominal wall is seen to pull in and up and the lower rib cage is felt to widen laterally. Further abdominal pulling in occurs in the third or expulsive phase. In all of these expiratory patterns an awareness of vaginal tightening must be reported. 5. Impact activities: After this retraining programme many women will be able to cough and sneeze without loss, but they may not be able to run or do repeated jumping activities such as impact aerobics. In a number of those women excessive bladder neck mobility will require surgery. However for some women this abdominal and PFM tonic and strength

retraining programme does enable them to be continent while they are running. These women begin their impact retraining using tonic TrA holds as they run, initially on soft grass surfaces and if possible, running uphill. Uphill running minimizes the impact force and puts more demands on trunk stability mechanisms with resultant increasing PFM activity. Women gradually extend the distance and the force that they generate. Unpredictable demands on the PF with uneven surface running should be added. They will comment that the TrA hold seems to become automatic as they run. Patients have used this approach for retraining for tennis, netball, and playing soccer with the children. While regular straining at defaecation has not been implicated in isolated SUI, it is a factor in utero-vaginal prolapse and this may have accompanying SUI (SpenceJones et al., 1994). Thus attention to defaecation dynamics should be included for all patients (Markwell and Sapsford, 1995).

10. Conclusion This paper has attempted to review the impact of different aspects of thoraco/abdomino/pelvic muscle functioning on urinary continence and incontinence. Whilst surgery is likely to remain the only successful option for women with extensive PF fascial laxity, implementation of the regimen outlined in this paper provides a different approach to amelioration of mildto-moderate SUI. That one programme of exercise can rehabilitate abdominal and PF muscles, contribute to the prevention of LBP and aesthetically enhance abdominal contours must appeal to many women. There are very few women who do not bemoan their lax abdominal muscles following child bearing and as they get older. That this abdominal laxity has a bearing on PFM function will be new information for many. Motivation and compliance are important considerations in prescribing an exercise programme. If the isometric abdominal work and the retrained functional tasks are incorporated into daily living activities the beneﬁts gained from the initial intervention are more likely to be maintained. Long-term outcomes of treatment of SUI may then improve. This paper has presented new concepts into dysfunction and conservative management of SUI. Rigorous research is needed to prove these concepts before such programmes will be universally accepted.

Acknowledgements The author thanks Susannah Kelley for reviewing the manuscript.

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Viktrup L. The risk of the urinary tract symptoms ﬁve years after the ﬁrst delivery. Neurourology and Urodynamics 2002;21:2–9. Wijma J, Tinga DJ, Visser GHA. Perineal ultrasonography in women with stress incontinence and controls: the role of the pelvic ﬂoor muscles. Gynecologic and Obstetric Investigation 1991;32:176–9. Wilson PD, Glazener C, McGee M, Herbison P, Macarthur C, Grant A. Randomised controlled trial of conservative management of postnatal urinary and faecal incontinence: long term follow-up study. Neurourology and Urodynamics 2002;21:370.

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www.elsevier.com/locate/math

Original article

Doppler studies evaluating the effect of a physical therapy screening protocol on vertebral artery blood ﬂow C. Arnolda,*, R. Bourassaa, T. Langerb, G. Stonehamc a

School of Physical Therapy, University of Saskatchewan, 210-1121 College Drive, Saskatoon, Sask S7N 0W3, Canada b Department of Anatomy, College of Medicine, University of Saskatchewan, Canada c Deptartment of Medical Imaging, College of Medicine, University of Saskatchewan, Canada Received 21 November 2002; received in revised form 22 May 2003; accepted 7 July 2003

Abstract General and isolated cervical positional tests are used to screen for potential vertebro-basilar insufﬁciency (VBI). There is limited research evaluating vertebral artery blood ﬂow in these positions to justify the rationale of progressive mechanical stress occurring to the arteries. The purpose of the study was to determine vertebral artery blood ﬂow in six cervical positions used in clinical practice. A comprehensive cervical assessment was conducted on 22 men and women (mean age 35) with no known vascular pathology. Vertebral artery peak systolic (PS), end diastolic (ED) ﬂow rates and resistive index (RI) were measured using duplex colour Doppler sonography (sampling at C3–C5) in neutral, rotation, extension, combined rotation–extension, combined rotation– extension–traction, deKelyn’s position and a C1–C2 pre-manipulative hold. Results showed there was a signiﬁcant decrease in PS and ED in the contra-lateral artery during the pre-manipulative hold, and a decrease in ED in the contra-lateral artery during rotation. There was no effect of age, gender or mobility restriction on these blood ﬂow changes. The pre-manipulative hold had the greatest response with 34% of the arteries demonstrating a complete cessation of ED ﬂow. In conclusion the pre-manipulative hold and rotation created the greatest mechanical stress to the contra-lateral vertebral artery. These two positions may be useful screening positions to identify individuals at risk for VBI due to inadequate collateral blood ﬂow. r 2003 Elsevier Ltd. All rights reserved. Keywords: Vertebral artery; Doppler; Screening; Cervical movement; Physical therapy

1. Introduction Recent evidence suggests that stroke is linked to manipulation more often than previously reported in individuals less than 45 years of age (Rothwell et al., 2001). The causes of arterial dissection induced by manipulation are not known, however, the most frequently injured site is at C1–C2, likely due to the elongation of the artery occurring at this region during cervical movements (Mann and Refshauge, 2001). The vertebral arteries provide the posterior circulation to the brain and are vital in maintaining brainstem function. Vertebro-basilar insufﬁciency (VBI) is deﬁned as episodes of cerebral or brainstem ischaemia causing symptoms (Grant, 1994). VBI screening tests may detect someone at risk of injury by evaluating collateral ﬂow to *Corresponding author. Tel.: +1-306-966-6575; fax: +1-306-9666588.. E-mail address: [email protected] (C. Arnold). 1356-689X/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S1356-689X(03)00087-0

supply the brain while temporarily occluding one artery. If there is vascular pathology restricting collateral ﬂow, there is a risk of ischaemia occurring during cervical treatment (Rivett et al., 1999). Although there are a variety of screening tests reported, a common test used in Canadian PT practice is a progression of cervical movements proposed to gradually add mechanical stress to the arteries (Canadian Physiotherapy Association Orthopedic Division, 2003–2004a). The purpose of the stress test is to reproduce potential signs or symptoms of VBI in a safe, gradual progression of neck motion. If central neurological signs or symptoms such as nystagmus, dysphasia or hemianopia are reproduced, this warrants immediate referral to a physician for further testing. The reproduction of other signs or symptoms such as dizziness, blurring of vision or nausea, not necessarily originating due to central ischaemia, indicates the need to carry out further differentiation tests (Meadows, 1999). The order may vary with different practitioners, however common

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movements utilized in the stress test are: cervical rotation, extension, combined rotation and extension and adding traction to the combined extension–rotation position (Arnold, 2003; Canadian Physiotherapy Association Orthopedic Division, 2003–2004a). Achieving full available range of motion is an important component of the test, as well as including both upper and lower cervical motion. Each position should be held for at least 10 s or until symptoms arise, with a minimum of 10 s resting time before progressing to the next movement (Aspinall, 1989; Meadows, 1999; Australian Physiotherapy Association, 2000). Some clinicians advocate the use of a deKleyn’s or Wallenberg’s position where the head is extended and rotated over the end of the bed (Carey, 1995); however, others suggest that the additional stress of the head hanging over the end of the bed as well as the safety concern if the client loses consciousness makes this position potentially dangerous (Meadows, 1999). Alternatively, combined rotation and extension can be achieved by lordosing the cervical spine with the head remaining on the bed. This position is more likely to be used during treatment. There have been no studies comparing vertebral blood ﬂow in this alternative position to deKleyn’s position. If the graduated stress test is negative and the therapist decides manipulation is the technique of choice, a ﬁnal test prior to manipulation would be a pre-manipulative hold (PMH). This is a sustained hold of the manipulative position for a minimum of 10 s and released for 10 s, to ensure that no potential VBI symptoms are reproduced. (Aspinall, 1989; Australian Physiotherapy Association, 2000). A recent literature review (Mann and Refshauge, 2001) reported that in 16 out of 20 Doppler studies, there was diminished blood ﬂow in the contra-lateral artery during cervical rotation whether extension was added or not. However, it is difﬁcult to reach a consensus from these studies, as there are considerable differences in methodology. Sole use of continuous wave Doppler ultrasound questions conclusions regarding ﬁndings of ‘‘complete occlusion’’ as the artery cannot be directly visualized (Licht et al., 1998). Limited descriptions of neck position make it unclear if full range of motion was achieved, active or passive movement was tested or if movements were performed in sitting or supine. Only 6 studies have included a sample with symptoms of VBI; two of these used the same sample (Thiel et al., 1994; Cote et al., 1996) and only two identiﬁed the clinical test used to determine VBI (Thiel et al., 1994; Rivett et al., 1999). These two studies report conﬂicting results, one ﬁnding a signiﬁcant decrease in blood ﬂow for both symptomatic participants and a control group and the other found no change in blood ﬂow. In studies of healthy populations with and without neck pain, but with no VBI symptoms, the majority has found diminished blood ﬂow in the

contra-lateral artery with rotation or combined extension–rotation. However, a recent study examining the reliability of Doppler ultrasound has questioned results from two of these studies (Johnson, 2000). Other positions in the stress test sequence, including extension, the addition of manual traction and the PMH in the upper cervical spine has limited research with no consensus on the capability of these positions to detect VBI symptoms indicative of occlusive risk (Grant, 1994; Thiel et al., 1994; Li et al., 1999; Mann and Refshauge, 2001). The purpose of this study was: (1) to measure blood ﬂow velocity in the contra- and ipsi-lateral vertebral arteries during a stress test sequence commonly used in Canadian PT clinical practice, (2) compare blood ﬂow changes in a full deKleyn’s position compared to a modiﬁed extension–rotation position with the head remaining on the bed with and without traction applied, (3) measure blood ﬂow in a PMH at C1–C2 and (4) pilot the ability to measure ﬂow in these positions in a healthy population with no known vascular pathology prior to conducting the sequence on a symptomatic population.

2. Method Prior to the study, two pilot Doppler tests were conducted to ensure that the ultrasound technologist would be able to locate and sample the artery in all positions. The technologist was a qualiﬁed, experienced ultrasonographer. Participants were recruited by advertisements at university and health care facilities. This study was approved by the University of Saskatchewan Ethics Committee and informed consent was obtained prior to the PT assessment. Exclusion criteria included any contraindication to manipulation such as: osteoporosis, anti-coagulant medication, signiﬁcant cardiac or neurological disease, inﬂammatory joint disease, ligamentous instability, malignancy, a positive VBI screening test or recent fractures. Other conditions (for example known inner ear conditions or marked postural hypotension) that may mimic signs or symptoms of VBI as well as any history of heart disease or vascular pathology were also excluded. Unless there was a severe restriction to physiological range of motion, participants with a history of neck pain or injury were included in order to represent the population that would be typically seen in a clinical situation. All participants were screened by telephone interview and questioned regarding symptom history, medications and vascular disease. Following the interview, the same PT who would be conducting the movement progression with the Doppler test assessed participants. The PT had 24 years of clinical experience and advanced training in manual and manipulative therapy. The PT assessment included a detailed history, VBI screening tests and a thorough

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examination of the cervical spine. Physiological range of motion was evaluated by observing active movement in sitting and applying passive over pressure at end range. Biomechanical range of motion was assessed at each cervical segment. Physiological and segmental biomechanical restrictions were graded by the PT as mild, moderate or severe. The same PT re-evaluated and conﬁrmed the grading category just prior to the Doppler test. Physiological restrictions were generalized to the whole cervical spine. Biomechanical restrictions were classiﬁed into cranio-vertebral restrictions (any restriction at atlanto-occipital joints, C0–C1, or atlanto-axial joints, C1–C2) or mid-to-lower cervical spine restrictions (any restriction at joints C2–C7). The Doppler test was conducted within 1 week following the PT assessment. The participant was positioned supine on the table with no pillow 5–10 min prior to the test to allow for a period of haemodynamic stabilization. Heart rate was measured in the resting position in supine as radial pulse rate for 30 s and blood pressure using a standard cuff and stethoscope. Representative Doppler spectral waveforms were obtained in supine with the spine in a neutral position from both the right and left vertebral arteries using a 7 MHz probe on a duplex Doppler ultrasound machine with colour ﬂow imaging (ATL 3000 HDI). The same qualiﬁed technician performed all Doppler scans and the same PT performed all movement progressions. The sampling region was with the probe in the midportion of the extra cranial segment of the vertebral artery (approximately C3–C5). Sampling of PS (peak systolic velocity, cm/s), ED (end diastolic velocity, cm/ s), and RI (resistive index, peak systolic–end diastolic/ peak systolic) were recorded in each position for both ipsi- and contra-lateral arteries using the same order of sampling for each test. Decreases in PS and ED are indicative of decreased blood ﬂow due to occlusion or narrowing of the artery more distal to the site of measurement. A high RI signiﬁes increased resistance to ﬂow distal to the sampling site with a maximum possible value of 1.0. Scanning was performed from the ipsi-lateral anterior aspect of the sternocleidomastoid muscle at an angle of less than 60 . With more extreme neck positioning, (i.e. rotation) scanning was still performed from an anterior approach, but often required locating the ultrasound probe more medially on the sternocleidomastoid muscle when rotation was toward the side of the artery being interrogated. Colour Doppler was utilized when needed to assist in locating the vertebral artery. The position was held as long as necessary to obtain a sample in both arteries. All positions were held for at least 25 s and no sampling was initiated until the position had been held for 10 s. Subjects were rested in a neutral position on the bed for 10 s before re-positioning for the next movement test. Subjects were asked to report any symptoms during

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and after each test movement and were observed for neurological signs. For each of the positions, full available end range passive movement was obtained. The movement sequence (performed in both directions) was: (1) cervical rotation (rot), (2) extension with the head supported on the bed (ext), generated by lordosing the mid and lower cervical spine and extending the upper cervical spine, (3) combined rotation and extension (rot–ext) as in # 2, (4) adding manual traction to the cervical spine while sustaining #3 (rot–ext–tr), (5) a deKleyn’s test (deK) with the subject positioned at the end of the bed (level with the third thoracic vertebrae) in order that the head could hang over the edge in full rotation–extension, supported by the PT and (6) a pre-manipulative hold (PMH) at the atlanto-axial joint complex positioned in cranio-vertebral side ﬂexion combined with contralateral rotation down to and including C1–C2, with

Fig. 1. First movement progression: Rotation.

Fig. 2. Second movement progression: extension induced by lordosing the spine with maximal upper cervical extension.

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Fig. 3. Third movement progression: combined extension and rotation.

Fig. 6. Pre-manipulative hold C1–C2.

measured. A radiologist reviewed all scans following testing to provide a qualitative assessment for artery pathology or abnormal discrepancy in arterial diameters.

3. Data management and analysis

Fig. 4. Combined extension and rotation with longitudinal traction.

SPSS version 11.0 was used for statistical analysis. Paired samples t-tests were used to determine any signiﬁcant differences (Po0.05) for resting Doppler samples, pre- and post-BP and HR measurements. Because there was no difference between left and right artery ﬂow in neutral, all arteries were pooled (n=44) for the analysis of position change. (Individual blood ﬂow changes for left and right arteries were also evaluated, with similar results to the pooled data, therefore just the pooled results are presented in this paper.) Changes in PS, ED and RI values for all arteries (contra-lateral to movement sequence and ipsi-lateral to movement sequence) during the stress test sequence were compared using a general linear model repeated measures analysis. A Bonferroni correction was used for multiple comparisons for each relative change in PS, ED and RI from neutral to each position (corrected Po0.05). Age, gender and mobility restriction were entered as co-variates to determine if these factors inﬂuenced blood ﬂow changes.

4. Results Fig. 5. Full deKleyn’s position.

digital pressure on C1–C2 just short of manipulative thrust (Figs. 1–6). Following the test procedure, the subject rested in supine with no pillow. Heart rate, blood pressure and a neutral, resting Doppler scan of both arteries were re-

4.1. Subjects There were 14 females and 8 males, mean age 35710.5 years. Table 1 outlines demographic information and ﬁndings from the PT assessment for the 22 participants. There were six subjects reporting a history of potential VBI symptoms such as dizziness, blurring of

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vision and headaches, but symptoms were not reproduced in the VBI stress test sequence conducted during the PT assessment.

17

baseline values. There were no artery pathologies identiﬁed by the radiologist and any minor discrepancies in arterial diameters were equally distributed across left and right arteries.

4.2. Blood flow responses in neutral 4.3. Blood flow responses during the stress test sequence There were no signiﬁcant differences (P>0.05) between mean neutral blood ﬂow values before and after the testing sequence (PS pre-test neutral mean=56.5 cm/s712.3, post-test=58.6 cm/s715.0; ED pre-test neutral mean=18.4 cm/sec75.0, posttest=18.2 cm/sec74.5). Although there was a small decrease in post-test pulse rate (3 bpm, Po0.05), there were no signiﬁcant differences in pre- and post-test resting BP. In order to account for sources of variability in neutral haemodynamics, the means for pre- and posttest neutral PS, ED and RI were used as the resting

The artery was visualized in all positions on both ipsiand contra-lateral sides. The means and standard deviations for PS, ED and RI for neutral and the six different neck positions for all 44 arteries can be found in Table 2. Figs. 7–9 depict mean change scores occurring in contra- and ipsi-lateral arteries for PS, ED and RI during the stress test sequence. There were signiﬁcant changes in mean blood ﬂow (corrected Po0.05) during the test sequence. The most consistently signiﬁcant drop in blood ﬂow and increase

Table 1 Subject demographics and ﬁndings from the physical therapy assessment n

PT assessment ﬁndings Symptoms reporteda Vascular stress test ﬁndingsb Physiological mvt. Restrictionsc Biomechanical mvt. Restrictions (c-v)d Biomechanical mvt.restrictions (m-l)e History of neck pain History of neck injury

No Neg. None None None No No

16 22 15 14 10 14 17

n Yes Pos. Mild Mild Mild Yes Yes

n

6 0 4 5 7 8 5

Moderate Moderate Moderate

n

3 2 3

Severe Severe Severe

0 1 2

a

Subjective reports of potential VBI symptoms such as dizziness, blurring of vision. Presence of any central ischaemia signs or symptoms during a progressive vascular stress test, Negative indicates no signs or symptoms reproduced. c Active physiological movement. d Passive movement testing at atlanto-occipital and atlanto-axial joints. e Passive movement testing at mid-lower cervical spine. b

Table 2 Mean values for PS, ED, RI for all arteries grouped by movements in the contra- and ipsi-lateral directions in relation to the artery

Contralat. artery (n=44) PS Mean SD ED RI

Ipsilat. artery (n=44) PS Mean SD ED RI

Neutral (mean of two tests)

Rot.

Ext

57.6 (12.6) 18.3 (4.3) 0.68 (0.06)

51.9 (18.8) 14.8 (7.4) 0.74 (0.12)

61.2 (13.8) 18.5 (5.5) 0.70 (0.08)

57.6 (12.6) 18.3 (4.3) 0.68 (0.06)

62.3 (22.0) 18.3 (7.0) 0.71 (0.10)

61.2 (13.8) 18.5 (5.5) 0.70 (0.08)

Rot-ext

Rot-ext-tr

DeK.

PMH

57.2 (9.5) 18.7 (4.3) 0.67 (0.06)

59.3 (16.0) 18.2 (5.1) 0.70 (0.08)

63.4 (17.3) 18.5 (5.4) 0.70 (0.07)

38.4 (22.8) 8.1 (7.4) 0.82 (0.15)

60.9 (14.8) 17.8 (6.5) 0.71 (0.09)

62.9 (22.8) 17.6 (7.6) 0.73 (0.10)

63.1 (24.0) 17.0 (7.4) 0.74 (0.10)

65.3 (21.6) 22.7 (8.4) 0.66 (0.09)

rot.=rotation, ext.=extension, rot–ext.=combined rotation and extension, rot–ext–tr=combined rotation, extension and traction, deK.=deKleyn’s position, PMH=pre-manipulative hold. Signiﬁcant difference compared to neutral, Po0.05 (bonferroni correction for multiple comparisons).

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18 70 65 60

cm/s

55 PS: contra-lateral artery

50

PS: ipsi-lateral artery

45 40 35 30 neutral

rot.

ext.

rot-ext rot-ext-tr deK.

PMH

25 23 21 19 17 15 13 11 9 7 5 K

PM H

de

xt ro t-e xt -tr

t.

t-e

ex

ro

ne

ro t.

ED-contra-lateral artery ED-ipsi-lateral artery

ut ra l

cm/s

Fig. 7. Changes in mean peak systolic ﬂow for the stress test sequence in the contra- and ipsi-lateral arteries.

Fig. 8. Changes in mean end diastole ﬂow for the stress test sequence in the contra- and ipsi-lateral arteries.

0.85 0.8 0.75

contralateral ipsilateral

0.7 0.65 0.6 neutral

rot.

ext.

rot-ext rot-exttr

deK

PMH

Fig. 9. Changes in mean resistive index for the stress test sequence in the contra- and ipsi-lateral arteries.

in RI occurred in the contra-lateral arteries for the PMH and rotation. Mean PS decreased signiﬁcantly in the contra-lateral artery for the PMH, ED decreased and RI increased signiﬁcantly for both rotation and the PMH. RI also increased signiﬁcantly in ipsi-lateral arteries for ext–rot–traction and deKleyn’s. Mean values for ED increased signiﬁcantly in the ipsi-lateral arteries for PMH only. Extreme responses to each test position for contra- and ipsi-lateral movements were also considered based on percent change values. As this was a healthy population, it is expected that the majority of responses would lie within the 95% conﬁdence limits. However, rotation and PMH had the greatest number of extreme responses. Seven of the 44 tests for ED contra-lateral

rotation were more than two standard deviations below the 0% change line. The tendency for reduced ﬂow in the contra-lateral artery during the PMH was the most obvious deviation from normal variability, with 23 of the 44 tests below the 95% conﬁdence limit for PS and 16 for ED. Of those 16 arteries, 15 demonstrated a complete cessation of blood ﬂow during ED. When age, gender and mobility restrictions were considered as co-variates in the repeated measures analysis, the statistical change in mean blood ﬂow response remained unchanged. As well, no correlations were found between position change scores and BP, presence of any symptom history or neck pain. Although the majority of individuals with substantial decreases in PS and ED in the contra-lateral artery during the PMH were graded as having full craniovertebral mobility, there were 3 subjects with limited cranio-vertebral mobility who had a complete cessation of ED in this position. In other words, signiﬁcant decreases in blood ﬂow during the C1–C2 PMH occurred despite restricted motion at the upper cervical spine.

5. Discussion It is apparent that not all individuals at risk of injury or death during a cervical manipulation can be adequately screened. The causes and precipitating factors are still not clear enough to provide clinicians with a sensitive screening protocol. We are unable to make conclusions regarding the sensitivity of the stress test sequence to identify individuals with vascular pathology as our sample consisted of healthy men and women. However, by determining the pattern of blood ﬂow changes that occur during the test, it provides evidence which cervical positions mechanically stress the vertebral arteries. If there is compromise of collateral ﬂow, there is a greater risk of brain ischaemia when the neck is placed in a position where the patent artery is mechanically stressed (Rivett et al., 1999). It is also possible that if there is a pre-existing weakness or predisposition to embolize, the position that stresses the arterial wall causing cessation of ﬂow may be the position more likely to tear the artery or slough a thrombus or atherosclerotic plaque, although this is yet to be proven (Mann and Refshauge, 2001). This study evaluated a sequence of cervical movements used in PT practice to screen for VBI. No other studies have evaluated blood ﬂow both ipsi-laterally and contra-laterally throughout this stress test sequence to determine if blood ﬂow changes reﬂect that the artery is being progressively stressed. The ﬁndings from this study support that only full range cervical rotation and the PMH at C1–C2 stressed the vertebral arteries sufﬁciently to demonstrate reduction of blood ﬂow.

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One of the limitations of this study, similar to other Doppler studies, is the lack of knowledge of ultrasound reliability, particularly when measuring in more extreme neck positions such as rotation and extension. The reliability of Doppler sampling is very dependent on the skill of the technologist to accurately locate and identify the arteries. Consistency of measurement in a neutral position was conﬁrmed by repeating this test following the movement progression. However, with the neck in extreme positions, it becomes more difﬁcult for the technologist to locate the vertebral artery. We did not perform a reliability test of these positions, however we did address this limitation by using technically advanced equipment, a highly skilled technologist and sampling at a region where the artery is more easily visualized extra cranially at C3–C5. Although one could argue that measuring at the mid cervical spine is less sensitive than measuring speciﬁcally at the site of proposed artery stretching, (C1–C2), there is support that duplex Doppler measurements at the mid cervical region are accurate in identifying pathology at any level of vertebro-basilar circulation (Nicolau et al., 2000). We were able to consistently visualize and sample both vertebral arteries at this level in all positions. This study used advanced duplex ultrasound technology with colour ﬂow imaging. Previous studies reporting the effect of cervical movements have used ultrasound equipment with several technical limitations, the most important being poor localization of the vertebral artery (Johnson, 2000). The sophistication of colour ﬂow imaging increases the ability to locate and verify accurate sampling. The only two positions that consistently demonstrated blood ﬂow changes indicative of distal narrowing occurring higher up in the cervical spine were rotation and the PMH. The contra-lateral vertebral artery is elongated by approximately 5 mm during cervical rotation (Sim et al., 2000) with 50–90% of cervical spine rotation attributed to movement at the atlanto-axial joint (Mercer and Bogduk, 2001). Thus, the vertebral artery is more vulnerable to shear and tensile forces where it exits C2 and runs vertically and laterally to C1 due to the degree of movement at this region (Goel et al., 1988). In order to gain maximal speciﬁc end of range motion of C1–C2 for the PMH, the cervical spine was positioned above and below C1–C2 with physiological coupling of side ﬂexion toward the opposite side of the rotation. This is a manipulative position used in PT practice when locking is necessary (Canadian Physiotherapy Association Orthopedic Division, 2003–2004b). By producing unilateral anterior or posterior gliding motion of the atlas on the axis, maximal stress is proposed to occur to the vertebral artery as a ﬁnal progressive test (Aspinall, 1989). Other studies have compared blood ﬂow in neutral before and after manipulation and have found no signiﬁcant change

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(Licht et al., 2000), however, to the authors’ knowledge, no other studies have measured vertebral artery blood ﬂow during a simulated hold of a cervical manipulation. We found that the drop in both systolic and diastolic velocities were sufﬁcient to totally occlude ﬂow in one artery for several subjects and decrease the ﬂow by greater than 50% for the majority of the sample. The PMH as compared to any other position tested produced the greatest mechanical stress to the contralateral vertebral artery. This may be due to the isolation of maximal motion speciﬁcally at the region where the artery is most vulnerable to tensile forces. The order of movement progression was the same for all subjects. This method was chosen in order to more closely reﬂect what is done in clinical practice, gradually adding further stress to the arterial system. However, because the PMH was the last movement in the sequence for all subjects and demonstrated the greatest ﬂow decrease, it is not completely clear if the order of testing may have affected the results. Because blood ﬂow quickly returned to pre-test values when measured again immediately after the PMH, one would not expect there to be a latent effect. In fact, the second most occlusive position was rotation, which was the ﬁrst movement in the sequence. Nonetheless, in order to determine the possible effect of testing order, a subsequent study is currently being conducted with random variation of test positions. Despite the consistent observation of occlusion of one artery during the PMH, there was only one subject who reported any symptoms potentially indicative of ischaemia. Transient dizziness was reported at the beginning of the hold and then following the release of the position. In this case, ED did drop to 0 and PS dropped by 65%. Cessation of ﬂow is generally not a risk to the brain, because there are other pathways that will allow circulation to the brainstem, cerebellum, and posterior cerebrum. In fact, we frequently observed increases in ﬂow rates in the ipsi-lateral vertebral artery during the PMH. This pattern was not consistently observed in any other position. If an individual presented with pathology in one artery, the PMH by stressing the patent artery, may signiﬁcantly compromise posterior circulation to the brain. One would expect ischaemic symptoms to present in this situation. The combined position of extension–rotation did not occlude vertebral artery ﬂow in this study. In fact, mean blood ﬂow tended to return to or increase slightly above resting values. This position has been proposed to stress the artery to a greater extent than rotation and extension performed separately (Carey, 1995; Canadian Physiotherapy Association Orthopedic Division, 2003– 2004a). The ﬁndings from this study would support the opposite: rotation alone mechanically stressed the contra-lateral vertebral artery more than combined extension–rotation, whether in a full deKleyn’s

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C. Arnold et al. / Manual Therapy 9 (2004) 13–21

position or with the head remaining on the bed. Previous studies have reported conﬂicting results for deKleyn’s position (Thiel et al., 1994; Li et al., 1999) and there have been no previous studies measuring blood ﬂow in the alternative position, inducing rotation and extension with the head remaining on the bed. We found no consistent blood ﬂow response in either of these positions. It is possible that when attempting to combine full extension with rotation, it is difﬁcult to achieve full physiological rotation. If rotation is the primary movement found to reduce arterial ﬂow, the addition of extension may actually diminish the stress to the contralateral artery. From the results of this study, we propose that combining extension and rotation is not a necessary progression to further stress the artery if rotation alone has already been tested. A recent screening protocol recommends rotation as a minimal testing position to screen for those with symptoms (Australian Physiotherapy Association, 2000). Previous research demonstrating equal reduction of blood ﬂow in both rotation and combined rotation–extension adds further support that screening both positions may not be necessary (Rivett et al., 1999). A progression of the extension–rotation position is the addition of manual traction in order to add further stress to the artery without dropping the head over the end of the bed. There is limited knowledge of the effect of traction on blood ﬂow. Cadaveric studies have found that traction signiﬁcantly increases the stress on the arteries, however it is not clear if the same force is being applied manually in vivo (Brown and Tatlow, 1963; Rivett, 1997). Our ﬁndings suggest that manual traction applied to the cervical spine while it is in an extended and rotated position does not add any additional stress to the artery. There was never cessation of ﬂow observed with extension alone. This movement induced combined extension at both lower and upper cervical regions with the head on the bed. Despite reports of vascular injuries occurring in an extended position (Wouter, 2001) only one study has found decreased blood ﬂow with cervical extension (Li et al., 1999). It is unlikely that cervical extension places notable stress upon the healthy vertebral artery. Our ﬁnding of no effect of mobility restriction on blood ﬂow changes is clinically important. It appears that mild to moderate movement restriction at the cranio-vertebral joints does not provide a protective effect to limit stretching of the contra-lateral artery. Signiﬁcant drops in blood ﬂow occurred for three individuals in the PMH even in the presence of craniovertebral movement restrictions. No other studies have attempted to quantify segmental movement restrictions and measure the relationship to blood ﬂow changes. It is possible that over time the vertebral artery adapts to movement restrictions resulting in the same degree of

arterial stretching occurring at the individual’s limitation of range, similar to end range stretching of a fully mobile spine. Further study with a larger sample of biomechanical segmental restrictions would assist in understanding the effect of degree of movement on vertebral artery stretching. Developing a screening protocol that is known to mechanically stress at least one vertebral artery should assist to evaluate the ability of collateral ﬂow to maintain brainstem function. This study concludes that full range physiological rotation and a PMH at C1–C2 should provide sufﬁcient mechanical stress to reproduce observable symptoms to screen out individuals with unilateral pathology. For individuals with speciﬁc history of positional symptom reproduction, other movements may need to be employed. It should also be noted that due to the dramatic change in blood ﬂow observed in the PMH, clinicians need to be cautious using this position particularly for individuals with history that may pre-dispose them to increased risk of arterial dissection and those with symptoms that may suggest VBI or inhibited collateral ﬂow. Further study is still required to verify if these positions can reproduce symptoms that would alert the practitioner to possible risk.

Acknowledgements We would like to acknowledge the contributions of Dean MacMillan for his technical expertise and John Berzolla for his assistance with this study. We also gratefully acknowledge Physiotherapy Foundation of Canada; Continuous Research Fund, School of Physical Therapy, University of Saskatchewan for the ﬁnancial support.

References Arnold CM. Clinical practice of vertebral artery screening tests by physical therapists in Saskatchewan. Physiotherapy Canada 2003;55(1):41–52. Aspinall W. Clinical testing for cervical mechanical disorders which produce ischaemic vertigo. Journal of Orthopaedics & Sports Physiotherapy 1989;11(5):176–82. Australian Physiotherapy Association. Clinical guidelines for premanipulative procedures for the cervical spine. Australian Physiotherapy Association, Victoria, Australia; 2000. Brown BSJ, Tatlow TWF. Radiographic studies of the vertebral arteries in cadavers. Radiology 1963;81:80–8. Canadian Physiotherapy Association Orthopedic Division: Diploma of advanced manual and manipulative physiotherapy, Level I Manual Draft 3; May 2003–2004a. Canadian Physiotherapy Association Orthopedic Division: Diploma of advanced manual and manipulative physiotherapy, Level 4/5 Manual Draft; May 2003–2004b.

ARTICLE IN PRESS C. Arnold et al. / Manual Therapy 9 (2004) 13–21 Carey PF. A suggested protocol for the examination and treatment of the cervical spine: managing the risk. Journal of Canadian Chiropractic Association 1995;39:35–9. Cote P, Kreitz B, Cassidy D, Thiel H. The validity of the extension– rotation test as a clinical screening procedure before neck manipulation: a secondary analysis. Journal of Manipulative and Physiological Therapeutics 1996;19(3):159–64. Goel V, Clark C, Gallaes K, Liu Y. Moment–rotation relationships of the ligamentous occipito-atlanto-axial complex. Journal of Biomechanics 1988;21(8):673–80. Grant R. Vertebral artery concerns: pre-manipulative testing of the cervical spine. In: Grant R, editor. Physical therapy of the cervical and thoracic spine. 2nd ed. Churchill Livingston, New York: 1994. p. 145–66. Johnson C, Grant R, Dansie B, Taylor J, Spyropolous P. Measurement of blood ﬂow in the vertebral artery using colour duplex Doppler ultrasound: establishment of the reliability of selected parameters. Manual Therapy 2000;5(1):21–9. Li YK, Zhang YK, Lu CM, Zhong SZ. Changes and implications of blood ﬂow velocity of the vertebral artery during rotation and extension of the head. Journal of Manipulative and Physiological Therapeutics 1999;22(2):91–5. Licht PB, Christensen HW, Hoilund CP. Is there a role for premanipulative testing before cervical manipulation? Journal of Manipulative and Physiological Therapeutics 2000;23(3):175–9. Licht PB, Christensen HW, Hojgaard P, Hoilund-Carlsen PF. Triplex ultrasound of vertebral artery ﬂow during cervical rotation.

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Journal of Manipulative Physiological Therapeutics 1998;21(1): 27–31. Mann T, Refshauge K. Causes of complications from cervical spine manipulation. Australian Journal of Physiology 2001;47:255–66. Meadows, J. Orthopedic differential diagnosis in physical therapy: a case study approach. New York: McGraw-Hill: 1999. p. 167–77. Mercer S, Bogduk N. Joints of the cervical vertebral column. Journal of Orthopaedics & Sports Physics Therapy 2001;31(4):174–82. Nicolau C, Gilabert R, Chamorro A, Vazquez F, Bargallo N, Concepcio B. Doppler sonography of the intertransverse segment of the vertebral artery. Journal of Ultrasound Medicine 2000;19:47–53. Rivett D, Sharples K, Milburn P. Effect of pre-manipulative tests on vertebral artery and internal carotid artery blood ﬂow: a pilot study. Journal of Manipulative and Physiological Therapeutics 1999;22(6):368–75. Rivett D. Preventing neuro-vascular complications of cervical spine manipulation. Physical Therar Reviews 1997;2:29–37. Rothwell D, Bondy S, Williams I. Chiropractic manipulation and stroke: a population-based case-control study. Stroke 2001;32(5):1054–60. Sim E, Vaccaro A, Berzlanovich A, Pienaar S. The effects of staged static cervical ﬂexion-distraction deformities on the patency of the vertebral arterial vasculature. Spine 2000;25(17):2180–6. Thiel H, Wallace K, Donat J, Yong HK. Effect of various head and neck positions on vertebral artery blood ﬂow. Clinical Biomechanics 1994;9:105–10. Wouter S. Spontaneous dissection of the carotid and vertebral arteries. New England Journal of Medicine 2001;344(12):898–906.

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www.elsevier.com/locate/math

Original article

Inter- and intraexaminer reliability in palpation of the ‘‘primary respiratory mechanism’’ within the ‘‘cranial concept’’ P. Sommerfelda,c,d,*, A. Kaidera, P. Kleinb a

Department of Medical Computer Sciences at the University of Vienna, Austria b Research Unit for Manual Therapies, Free University of Brussels, Belgium c Biomechanics, Research Methods and Clinical Subjects at the Wiener Schule fur . Osteopathie, Austria d Biomechanics and Osteopathic Techniques at the Osteopathieschule Deutschland, Germany Received 11 February 2003; received in revised form 11 July 2003; accepted 6 August 2003

Abstract Inevitable subjectivity makes interexaminer reliability of manual assessment procedures a special matter of concern. The cranial concept (CC), one aspect of osteopathy, deals with very subtle changes that have to be palpated. One of the main principles of the CC is the primary respiratory mechanism (PRM), which is hypothesized to be a palpable physiological phenomenon that occurs in rhythmic cycles, called ﬂexion- and extension-phase, which are independent from cardiac and respiratory rates. Palpation of the PRM is one of the ﬁrst steps in assessment within the CC. An inter- and intraexaminer reliability study design for repeated measures was used in this study. Forty nine healthy subjects were palpated simultaneously twice, once at the head and once at the pelvis. PRM-frequency (f), the mean duration of the ﬂexion phase and the mean ratio of ﬂexion- to extension-phase were used as the main outcome measures. Inter- and intraexaminer reliability and correlations to the respiratory rates were analysed for all three parameters. Inter- as well as intraexaminer agreement could not be described beyond chance agreement, as the range within the 95% limits of agreement (e.g. for f=6.6 cycles/90 s) for all cases resembled the total range of values (e.g. for f=7 cycles/90 s) that were produced. A signiﬁcant effect of the examiners’ respiration was found for both examiners at the pelvis (P=0.004 for one examiner, P o0.0001 for the other examiner), and for one examiner only at the head (P=0.0017). No correlation could be found for the subjects’ respiratory rates. In conclusion, PRM-rates could not be palpated reliably and under certain conditions were inﬂuenced by the examiners’ respiratory rates. These results do not support the hypotheses behind the PRM. The role of PRM palpation for clinical decision making and the models explaining the PRM should therefore be rethought. r 2003 Elsevier Ltd. All rights reserved. Keywords: Palpation; Primary respiratory mechanism; Cranial concept; Osteopathy; Interexaminer reliability; Intraexaminer reliability

1. Introduction The cranial concept1 (CC), originally introduced and developed by W.G. Sutherland (1873–1954) (A.S. Sutherland and A.L. Wales, editors, 1998) and H.I. Magoun (1951, reprint, 1997), can be regarded as part of the osteopathic approach in manual medicine.

*Corresponding author. Karl Bodingbauerstabe 23/4, Korneuburg 2100, Austria. Tel.: +43-2262/63-993. E-mail address: [email protected] (P. Sommerfeld). 1 Different terms like craniosacral osteopathy, biodynamic cranial osteopathy, craniosacral therapy, etc. are more or less describing the same. 1356-689X/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S1356-689X(03)00099-7

Despite criticisms within and from outside the osteopathic community, its publicity is increasing (Abehsera, 2001). The physiological aspect of the CC is built on two main hypotheses: (1) The idea of mobility within the osseous and membranous structures of the skull, the hypothesis of cranial mobility. (2) The ‘‘primary respiratory mechanism’’ (PRM), an autonomous rhythmic phenomenon inherent to every living organism, independent of thoracic respiration and cardiac pulse. The cyclic changes of the PRM are represented by an expanding phase called ﬂexion and a contracting phase called extension.

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Cranial mobility as well as the physiological basis of the PRM is still a matter of discussion (Klein and Burnotte, 1985; Ferre! and Barbin, 1990; Rogers and Witt, 1997; Green et al., 1999; Klein, 2002; Hartman and Norton, 2002) and due to methodological deﬁciencies investigations that tried to prove the existence of the PRM (Baker, 1971; Frymann, 1971; Mitchell and Pruzzo, 1971; Michael and Retzlaff, 1975; Retzlaff et al., 1976a, b, 1978; Tettambel et al., 1978; Upledger and Karni, 1979; Rommeveaux, 1992; Oleski et al., 2002) have to be regarded critically. A recent study (Adams et al., 1992) only mentions cranial mobility, being due to cardiac and thoracic respiratory rhythmic inﬂuences. Several physiological models try to explain the PRM such as the hypothesis of cerebral motility (Sutherland, 1998), the ‘‘muscle reaction model’’ (Upledger and Vredevoogd, 1994), the ‘‘pressurestat model’’ (Upledger, 1994), the ‘‘tissue pressure model’’ (Norton, 1991) or the ‘‘entrainment hypothesis’’ (McPartland, 1997). The CC says that these rhythmic changes make the osseous and membranous structures of the cranium and in consequence the fascial system of the entire body move in certain patterns, which can be palpated (Upledger and Vredevoogd, 1994; Becker, 1997; Sutherland, 1998). The movements or changes induced by the PRM are thought to be very small. So the observation of that phenomenon is taking part near the limits of tactile perceptible events (Upledger and Vredevoogd, 1994) and requires special training as already stated by Sutherland himself (Sutherland, 1990, 1994, 1998). In this context several authors report that palpation of the PRM is easier at the parietals, the squamous part of the occipital bone, the greater wings of the sphenoid bone and the sacrum (Upledger and Vredevoogd, 1994; Liem, 1998; Sutherland et al., 1998). Together with observation, percussion and auscultation, palpation can be regarded as one of the main tools for structural diagnosis in manual medicine (Greenman, 1996). Interexaminer reliability of palpation within the CC has rarely been assessed. In an early paper, nearly perfect interexaminer reliability for different ﬁndings during an assessment of the cranial system is reported (Upledger, 1977), but these results are misleading because of inadequate statistical analysis. According to Alley (1983), reliability studies prior to 1983 suffer methodological and statistical deﬁciencies. Inter- and intrarater reliability for the palpation of the PRM has recently been assessed by different authors (WirthPattullo and Hayes, 1994; Norton, 1996; Hanten et al., 1998; Rogers et al., 1998; Moran and Gibbons, 2002). This study aimed to assess the agreement within two examiners concerning the palpation of the PRM as described in the CC referring to the following hypothesis: If the PRM represents a physiological phenomenon whose effects occur as presumed by the CC and if

23

further on these effects can be reliably palpated by trained persons, then clinical relevant intra- and interexaminer agreement with respect to the assessment of the cycles of the PRM should be reached by two trained examiners palpating one subject simultaneously and repeatedly within a short time interval. In addition, the PRM cycles should not show any dependency on examiners’ and subject’s respiratory rates.

2. Materials and methods 2.1. Subjects Forty-nine symptom-free voluntary subjects (n=49) with a mean age of 37.4577.52 (min=19; max=61) were assessed. Thirty-four were female, 15 male. The subjects were recruited from the student body of the Vienna School of Osteopathy as well as from acquaintances of the students. Subjects who had undergone severe trauma, surgery and current acute pain in the area of the cranium, the spine and the pelvis as well as current and past neurological diseases were excluded. The subjects were informed about the procedure during the measurements as well as the fact that no treatment would take place. 2.2. Materials The palpatory ﬁndings of both examiners were recorded via two foot switches. In order to get the examiners blind, the switches were muted using forklight barriers. The signals from the switches were recorded directly as digital units ‘‘on’’ and ‘‘off’’. The recording of the respiratory rates of the examiners and the subjects was carried out by strain gauges (Measurements Groups Type: N2A-06-S153R- 35B), glued to metal bows, which were attached to the individuals by a non-elastic belt fastened around the thorax. For further processing, the measured signals were ampliﬁed and sent to an analogue-digital converter (ELV Elektronik AGs; measuring module type M232) connected to a PC via a serial interface. The time-related resolution was 500 ms. The software was written in LabWindowss CVI 16 Bit-Version 4.0.1. Each single measurement could be started, ended and selectively stored, showing starting time and the measured time period for further analysis. 2.3. Examiners Two examiners took part in this study. Both had graduated from the Vienna School of Osteopathy. For 2 years, they had participated in a postgraduate project in co-operation with the Osteopathic Centre for Children (London), where the main emphasis for clinical work

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was based on the principles of the CC. At the time of the study, both have undergone about 300 h training in cranial techniques and theory and had 7 years of clinical experience behind them. They could therefore be considered as experts in the cranial approach to treatment. 2.4. Procedure For the measurements two treatment couches were used. While the examiners were palpating one of the subjects, the next subject was already lying on the other table. So sufﬁcient relaxation of the subjects could be guaranteed for palpation. During palpation the subject was lay supine. One practitioner was seated at the head, palpating the cranium, the other one at the side near the pelvis, palpating the sacrum. In order to blind the examiners, a curtain was hung down from the ceiling at about the middle of the treatment coach. Belts with the integrated metal bows for the recording of respiratory rates were ﬁxed to the examiners’ and the subject’s chests. Afterwards the correctness of the signals was checked. The examiners were told to press the foot switch as soon as they felt the beginning of a ﬂexion-phase and let go at the beginning of the extension-phase of the PRM. So the palpated PRM appeared as a rectangular wave on the display. The measurement period lasted over 90 s. This time period seemed to be long enough to obtain sufﬁcient opportunity to determine and compare the frequency of the PRM-rates and short enough to avoid early fatigue of the examiners. The examiners could use their own hand-holds and had about 1 min to become orientated. Both examiners used known standard holds. Each examiner palpated each subject twice, once at the head and once at the pelvis. The position for the ﬁrst measurement was randomized. Breaks were taken after eight subjects.

irregular (Lockwood and Degenhardt, 1998). Thus f, MDF and RF/E would enable differentiated possibilities in data analysis and future interpretation. The three dependent variables were tested with regard to systematic differences under various conditions. For this, including the random factor subject, a four-way analysis of variance (ANOVA) (Kirk, 1982) was used. The dependent variables f, MDF and RF/E were tested separately with regard to the factors location (L), examiner (O) and examination-time (T). Interrater reliability was tested by using the 95% limits of agreement as described by Bland and Altman (1986): Mean difference71.96 standard deviation of the differences. Possible interactions between palpatory ﬁndings and respiratory rates of subjects and examiners were tested. In this case, analysis of covariance models (Kirk, 1982) was used. Besides the factors subject, examiner, location and time, the respiratory rates were tested as covariables in the models. These analyses were carried out separately for the independent variables f, MDF and RF/E. If interactions were present, the respective factors were analysed separately for each examiner (A,B) or location (P,C). The correlations between the three summary measures and the respiratory rates were additionally described using Pearson’s correlation coefﬁcient (r).

3. Results The palpated PRM-frequencies ranged from 2.3 (SD 0.8) to 3.6 (SD 0.8) cycles/min (see Fig. 1). For MDF we could ﬁnd values ranging from 8.0 (SD 4.3) to 10.6 (SD 4.1) s. Due to skewed distribution the values for RF/E have been log10 transformed and ranged from –0.15 (SD 0.22) to 0.09 (SD 0.16). ANOVA analysis showed a signiﬁcant inﬂuence of the examiner (Po0.0001) as well as a signiﬁcant interaction between examiner and location (Po0.0001) could be found for the variable f.

2.5. Statistical analysis

*

*

*

PRM-Frequency (f), which means the number of ﬂexion-phases in 60 or 90 s; mean duration of the ﬂexion-phases per examination (MDF); mean ratio of the lengths of the ﬂexion- to extensionphase per examination (RF/E).

The researchers decided to determine these three summary measures because the distribution between ﬂexion- and extension-phase can be expected to be

10 9 8 f [cycles in 90 sec]

The independent variables were: examiner A and B, examiner location pelvis (P) and cranium (C) and measurements T1 (ﬁrst measurement) and T2 (second measurement). The palpated PRM-rates were described by the three dependent variables:

7 6 5 4 3 2 1 L O T

P A T1

P A T2

P B T1

P B T2

C A T1

C A T2

C B T1

C B T2

Fig. 1. Boxplot of the palpated PRM-rates (f) under the different conditions for location (L) pelvis (P) and cranium (C), examiner (O) A and B and examination-time (T) T1 and T2. The whiskers show the 95% range, the box represents 50% of the measured values.

ARTICLE IN PRESS P. Sommerfeld et al. / Manual Therapy 9 (2004) 22–29 Table 1 Results of the analysis of interexaminer agreement using the 95% limits of agreement (Lts) MDiff A B

SD A B

95% Lts Low

PRM-frequency (f) C 49 P 49 T1 49 T2 49

1.65 0.06 0.88 0.84

1.70 1.66 1.59 1.45

Mean duration flexion-phases (MDF) C 48 1.12 5.02 P 49 0.93 4.28 T1 49 0.17 5.26 T2 49 0.33 4.27 Mean ration flexionC 49 P 49 T1 49 T2 49

to extension-phase (RF/E) 0.17 0.41 0.13 0.28 0.12 0.37 0.8 0.35

4.99 3.32 3.99 3.68

8.71 9.33 10.48 8.04

0.97 0.57 0.84 0.77

n

Factor

MDiff P C

SD P C

95% Lts

High 1.68 3.20 2.24 2.00

10.95 7.46 10.13 8.70

0.63 0.51 0.60 0.61

Mdiff—mean difference, Low—lower limit, High—higher limit, SD— standard deviation, A, B—examiners, C—examiner location cranium, P—examiner location pelvis, T1—ﬁrst measurement, T2—second measurement.

For MDF the analysis showed no signiﬁcant effect for L and O, for RF/E a systematic tendency for signiﬁcant lower mean values for examiner A as for B (P=0.005) could be found. The data for inter- and intrarater agreement are summarized in Tables 1 and 2 and Fig. 2. For all three summary measures f, MDF and RF/E the range within the 95% limits of agreement for interexaminer agreement resembles the total range of ascertained values (see the bar-diagram in Fig. 2). The expected intrasubjective difference within the 95% limits of agreement can be seen in Table 2. As before, the ranges are quite as large as 95% of the total range of ascertained values for the respective parameters (see the bar-diagram in Fig. 2). The analysis of possible effects of the respective examiner’s respiratory rate (REO) and the subject’s respiratory rate (RESU) on the palpated PRM showed the following results: For both examiners a signiﬁcant effect of the examiner’s own respiratory rate could be observed at the pelvis with P=0.004 for examiner A (REA) and with Po0.0001 for examiner B (REB) on the dependent variable f. At the head, the effect was signiﬁcant for examiner B only (P=0.0017). No signiﬁcant inﬂuence of the RESU on f could be found. For the dependent variable MDF, as for f, a signiﬁcant effect of REO has been found at the pelvis (P=0.0276). At the head, no signiﬁcant effects could be observed (P=0.8918). For the dependent variable RF/E no signiﬁcant effects of the examiners’ as well as the subjects’ respiratory rates could be found (P>0.05).

Low PRM-frequency (f) A 49 B 49

1.02 5.57

High

1.55 1.38

2.01 3.28

4.05 2.14

Mean duration flexion-phases (MDF) A 49 1.79 4.94 B 49 0.36 2.42

11.48 4.39

7.90 5.11

0.79 0.50

0.86 0.29

Mean ration flexion- to extension-phase (RF/E) A 49 0.03 0.42 B 49 0.11 0.20

Mdiff—mean difference, Low—lower limit, High—higher limit, SD— standard deviation, A, B—examiners, C—examiner location cranium, P—examiner location pelvis, T1—ﬁrst measurement, T2—second measurement.

Difference [f in cycles per 90 sec]

n

Table 2 Results of the analysis of intraexaminer agreement using the 95% limits of agreement (Lts)

Range [f in cycles per 90 sec]

Factor

25

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

4,05 3,20 2,24

2,14

1,68

2,00

1,02 -0,06

-0,57

-0,88

-0,84

-1,65 -2,01 -3,32

-3,28 -3,99

-3,68

-4,99

A-B/C

A-B/P

P-C/A (A intra)

P-C/B (B intra)

A-B/T1

A-B/T2

Range within the 95% limits of agreement 8 7

95% Range of ascertained values

7,0 6,6

6,6 6,0

6 5

6,0

6,2

6,0 5,4

6,0

5,6

6,0

5,0

4 3 2 1 A-B/C

A-B/P

P-C/A (A intra)

P-C/B (B intra)

A-B/T1

A-B/T2

Fig. 2. Graphical presentation of the results for inter- and intraexaminer agreement for examiner A and B at the pelvis (P) and the cranium (C) for the palpated PRM-rates (f). The upper diagram shows the 95% limits of agreement. The bar-diagram below shows the range within the 95% limits of agreement in comparison with the 95% range of ascertained data (dark bars).

To describe the strengths of the effects detected in the analysis of covariance, correlation coefﬁcients were estimated. At the pelvis, a moderate correlation between REO and f could be described with r=0.42 (P=0.0024) for examiner A and r=0.58 (Po0.0001) for B. For examiner B, moderate correlation with regard to MDF could be observed with r= 0.55 (Po0.0001). The negative coefﬁcient indicates that the examiner palpated shorter ﬂexion-phases when her respiratory rate

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P. Sommerfeld et al. / Manual Therapy 9 (2004) 22–29

increased. All other correlations for the location pelvis produced low values. At the head moderate correlation could only be found for examiner B with r=0.45 (P=0.0012) for f and r= 0.57 (Po0.0001) for MDF.

4. Discussion Measuring the perception of the PRM by using a foot switch can produce erroneous values caused by possible difﬁculties in simultaneously palpating and activating the switch. The number of presented measurements (n=98) and the fact that the spread of the ﬁnal values concerning palpated data were between acceptable limits (e.g. 0.7–5.3 cycles/min for f) do support the assumption that these kind of errors can be considered to be small. The examiners themselves neither claimed to have problems in using the foot-switches nor did they subjectively interfere the quality of palpation. We did not test interrater reliability for thoraco-abdominal respiration palpation like Wirth-Pattullo and Hayes (1994) and Norton (1996). Possible inﬂuences of the experimental context on the observers’ concentration cannot be excluded. One of the essential issues in data analysis was the description of inter- and intraexaminer agreement (or reliability). Interclass correlation coefﬁcients (ICC) are frequently suggested for the description of agreement for continuous data (Haas, 1991, 1995; Altman, 1999) and have repeatedly been used for the calculation of interand intraexaminer reliability for the palpation of the PRM (Wirth-Pattullo and Hayes, 1994; Hanten et al., 1998; Rogers et al., 1998; Moran and Gibbons, 2002). As Bland and Altman (1986) state, the interpretation of the comparison between two measures can be misleading, when correlation is mixed up with agreement. So we decided to use a method suggested by these authors, using the 95% limits of agreement (Bland and Altmann, 1986) as explained above. The number of examiners used to conduct this reliability study was minimal (two examiners). But as the probability of treatment effects increases with the number of examiners (i.e. repetition of measurements), it was probably wise to limit their number. As the analysis of interexaminer agreement is more meaningful if the sample size is bigger, the latter was favoured for this project. As mentioned above, the examiners’ degree of experience can be expected to be sufﬁcient. The study was limited to healthy subjects. Nevertheless, inter- and/ or intraexaminer agreement for symptomatic subjects could be better than for asymptomatic subjects. Comparing asymptomatic with symptomatic subjects randomly might provide more speciﬁc information. Unadjustment either by time or by location has to be taken into account for the assessment of inter-

and intrarater agreement. However, this essential problem has to be considered for most reliability study designs. The PRM-frequencies palpated in this study are similar to recent publications (Norton et al., 1992; Wirth-Pattullo and Hayes, 1994; Norton, 1996; Hanten et al., 1998; Rogers et al., 1998; Moran and Gibbons, 2002) and differ to an older publication (Upledger, 1977), which described a faster rhythm ranging from 6 to 12 cycles/min (0.1–0.2 Hz). Several authors have suggested explaining the PRM as an expression of variations of known physiological rhythms like heart rate and respiratory rate (Frymann, 1971; Upledger, 1977; McPartland, 1997; Nelson et al., 2002). Comparing the results (0.04 (SD 0.02) to 0.06 (SD 0.01) Hz) with the frequency spectrum of heart rate variability, they cover the lower part of the lowfrequency spectrum, known as Mayer waves which ranges from 0.04 to 0.15 Hz and seems to be expressed by changes in blood pressure (Camm et al., 1996). Norton et al. (1992) report a mean duration of the ﬂexion phase with 7.7 (SD 1.4) s, the MDF found in this study is longer and ranges from 8 (SD 4.3) to 10.6 (SD 4.1) s. Recent publications (Wirth-Pattullo and Hayes, 1994; Norton, 1996; Hanten et al., 1998; Rogers et al., 1998; Moran and Gibbons, 2002) report low or absent interrater reliability for the palpation of the PRM. Our results are similar. In contrast to the other authors, we described agreement in addition to the palpated f, i.e. for the MDF and the RF/E and used a larger sample size. In neither case, interexaminer agreement could be described beyond chance agreement. For intraexaminer agreement the results differed. Norton (1996) reported signiﬁcant intrarater correlation for the cycle lengths palpated by the same examiner at the head and at the pelvis. Hanten et al. (1998) as well as Moran and Gibbons (2002) found intrarater reliability to be fair to good for palpation of the PRM-rates. We found, like Rogers et al. (1998), intraexaminer reliability to be low. See a summary of published data in Table 3. Previous publications (Upledger, 1977; Wirth-Patullo and Hayes, 1994; Hanten et al., 1998) agreed in ﬁnding low correlations between the palpated PRM-rate and the subjects’ respiratory as well as cardiac rates. This is in agreement with our results concerning the subjects’ respiratory rates. In addition, our results indicate a tendency for the examiners’ respiratory rates to have an effect on the PRM-frequencies palpated at the pelvis. This means that the examiners tend to palpate higher PRM-frequencies and shorter lengths of the ﬂexionphase when their own respiratory rate increases and or decreases. At the head the results for the examiners differ. These results are in agreement with the suggestions of Norton (1991), drawn from the tissue pressure model.

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27

Table 3 Results of published data on inter- and intraexaminer reliability for the palpation of the PRM described by intraclass correlation coefﬁcient (ICC), Pearsons correlation coefﬁcient (r) and range within the 95% limits of agreement (Lts) Publication

Interexaminer

Wirth-Pattullo and Hayes (1994)

ICC= 0.02

P=0.0001

Norton (1996)

rHead= 0.275 rPelvis= 0.296

P=0.115 P=0.089

Hanten et al. (1998)

ICC=0.22

ICC=0.78/0.83

Rogers et al. (1998)

ICCHead=0.08 rHead=0.12 ICCFeet=0.19 rFeet=0.23

ICCHead=0.18/0.26 rHead=0.17/0.27 ICCFeet=0.30/0.29 rFeet=0.30/0.29

Moran and Gibbons (2002)

ICCHead=0.05 rHead=0.17 ICCSacrum= 0.02 rSacrum= 0.035

ICCHead=0.47/0.73

Values of this study a

Intraexaminer

The values indicate the number of cycles/90 s.

Considering the limitations of the study and the fact that neither inter- nor intraexaminer agreement was found for the palpation of the PRM in this study, which is in agreement with similar publications, the following suggestions can be discussed:

*

ICCSacrum=0.65/0.52 Lts=6.0/5.4

LtsHead=6.6a LtsPelvis=6.6a

5. Conclusion

*

r=0.926Po0.001

The PRM could be highly inﬂuenced by the examiner’s mental images in connection with perception. The physiological existence of the PRM cannot be regarded as proven (Green et al., 1999). Echternach (1994) states in this context that under normal conditions clinicians do not try to measure a phenomenon whose existence is unclear. So the use of palpatory ﬁndings, concerning the PRM as means for clinical decision making, should be rethought. The presumption seems possible as there could be found certain inﬂuences of the examiners’ own respiratory rates on the palpatory ﬁndings. The PRM is a phenomenon that is too subtle to be palpated reliably. This contradicts the fundamentals and the development of the CC. In the beginning, the PRM has solely been manually detected. To prove this assumption, the changes induced by the PRM should be scientiﬁcally proven and tests on manual perceptive possibilities should suggest that the threshold for such a perception lies above the measured changes for the PRM. Roppel et al. (1978) report a threshold from about 0.5 to 0.25 mm, whereas mechanical recordings (Frymann, 1971) showed

*

*

*

amplitudes from 0.012 to 0.025 mm. We do not consider here the validity of the reported values for these measurements. The PRM is a metaphysical (vitalistic), not a physiological concept. The frequent use of metaphoric terms like ‘‘breath of life’’ or the ‘‘tide’’ instead of the PRM, which were already introduced by Sutherland himself (Sutherland, 1990, 1998), suggest such an interpretation. If this is so, the physiological models explaining the PRM should be dropped. The PRM is the result of the interaction between known physiological rhythms of the examiner and the subject. In this context, Norton (1991) found that within a computer-model simulated variations especially of the examiner’s heart- and respiratory frequencies had the strongest inﬂuence on changes of the resulting frequency. If this is, so Norton’s work, could explain low interexaminer agreement. The examiners are not skilled enough. In the present study, with regard to the professional experience of the examiners, this argument is not justiﬁed.

This study does not assess the existence of the PRM as a rhythmical phenomenon, neither it is possible to assess the clinical efﬁciency. However, the results presented do not support theories behind the PRM, calling for a physiological autonomous rhythmical event that is manually detectable. The results imply that the PRM cannot be palpated consistently among different examiners as well as within one examiner and under certain conditions the examiner’s respiratory rates seem to have a distinct inﬂuence on what the examiner perceives as

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P. Sommerfeld et al. / Manual Therapy 9 (2004) 22–29

the PRM. What the examiner actually does perceive, remains unclear.

Acknowledgements This study was part of a diploma thesis at the Vienna School For Osteopathy. We want to thank Mr. Ing. Tanzer from the Measurements Groups, who applied the strain gauges as well Mr. Stacher and Mr. DI Dum from the Engeneering School Hollabrunn who built the measuring devices and developed the software. Further we want to thank Mrs. Wagner M.D., D.O. and Mrs. Mandl-Weber Dipl PT, D.O. for being the examiners and ﬁnally Mrs. Diana Pitt D.O., M.Sc. for proofreading.

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Manual Therapy 9 (2004) 30–35

www.elsevier.com/locate/math

Original article

Long-term follow-up of patients with low back pain attending for manipulative care: outcomes and predictors A. Kim Burtona,*, Timothy D. McClunea, Robert D. Clarkea, Chris J. Mainb a

Spinal Research Unit, University of Huddersfield, Queensgate, Huddersfield HD1 3DH, UK b Department of Behavioural Medicine, Hope Hospital, Salford M6 8HD, UK

Received 7 September 2002; received in revised form 26 February 2003; accepted 7 April 2003

Abstract Psychosocial factors are known to act as obstacles to recovery from low back pain, but predictors of longer-term outcomes are not established. An average 4-year follow-up of a cohort of 252 low back pain patients attending for manipulative care was conducted to describe the longer-term course of low back pain, and to identify predictors of outcomes. Clinical and psychosocial data were obtained at baseline. Mailed questionnaires collected self-reported outcomes (pain, disability, recurrence and care seeking). Among the 60% who responded, the statistically signiﬁcant reduction in mean Roland Disability Questionnaire score seen at 1 year did not improve further during follow-up. At the 4-year point, 49% of respondents reported residual disability, and 59% reported at least ‘mild’ pain. Symptom recurrence beyond the 1-year point was reported by 78% of respondents, with half of them seeking further care. Recurrence and care seeking were related to fear avoidance beliefs and duration of presenting symptoms. The disability score at 4-years was statistically signiﬁcantly related to baseline depressive symptoms and higher pain intensity. Low back pain presenting for manipulative care is characterized by high levels of recurrence and care seeking over at least 4-years for many patients. Because psychosocial factors at presentation exert a long-term inﬂuence, they need to be considered by manual therapists. r 2003 Elsevier Ltd. All rights reserved. Keywords: Care seeking; Low back pain; Manipulation; Outcomes; Predictors; Prospective; Psychological; Recurrence

1. Introduction It is axiomatic that low back pain (LBP) continues to pose a problem for clinical management despite very substantial international research efforts. Nevertheless, it has been viewed as a largely self-limiting problem with a favourable prognosis (Indahl et al., 1995; Malmivaara et al., 1995; Royal College of General Practitioners, 1996) , but that view is based largely on the outcome for the presenting spell at a discrete time point (typically at 12 months or sooner). By contrast, if the natural history of back trouble is considered not by reference to the presenting spell but to the lifetime experience, a different picture is suggested. LBP can be seen as a recurring phenomenon during life with varying degrees of pain and/or disability, although an individual spell may follow a short course (Weber and Burton, 1986; Deyo, *Corresponding author. 30 Queen Street, Huddersﬁeld HD1 2SP, UK. Tel.: 01484-535200; fax: 01484-435744.. E-mail address: [email protected] (A.K. Burton). 1356-689X/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S1356-689X(03)00052-3

1993). Within the ranges illustrated by such models are those patients for whom short-term clinical management does not appear to pose a problem, but their longerterm prognosis may be less favourable. This view has been substantiated by a careful review of outcome studies in primary care, with the suggestion that deﬁnitions of acute and chronic based on a single episode are inadequate (Von Korff and Saunders, 1996). Seemingly, the general course of back pain is characterized by variability and change rather than predictability and stability, which may be reﬂected in patterns of care seeking. Back pain patients generally do not consult their family doctor beyond the 3-month point yet a substantial proportion (75%) report continuing pain and/or disability at 1 year (Croft et al., 1998), and whatever improvement occurs during the ﬁrst 2–3 months can be largely unchanged by 12 months (Wahlgren et al., 1997). Whilst studies with a follow-up in excess of 12 months are rare in primary care, studies in other health care settings (such as orthopaedics, group health

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maintenance organizations, and chiropractic) have shown that recurrence of back pain beyond the 1-year point is not unusual (Campbell et al., 1989; Carey et al., 1999). A range of factors has been found to be associated with back pain outcomes. The duration of symptoms preceding the initial visit, and subsequent physical therapy, have been associated with a poorer prognosis (van den Hoogen et al., 1997), whilst a duration of LBP in excess of 3 months before seeking health care has been associated with psychological distress (Waxman et al., 1998). Psychological factors are known to have a substantial inﬂuence on 12-month outcomes. Distress/ depression and heightened somatic concern are strongly implicated in the transition from acute to chronic LBP (Pincus et al., 2002), whilst passive coping strategies and fear-avoidance beliefs are also considered to act as obstacles to recovery (Burton et al., 1995; Vlaeyen and Linton, 2000). The potentially important role of psychological and psychosocial factors in manual therapy has been comprehensively discussed previously (Main and Watson, 1999; Jones et al., 2002), but what remains unclear is precisely which factors are relevant in patients attending for manual therapy, and whether the effects are consistent and constant over time. Our previously reported study of 1-year predictors of LBP outcome in a patient population attending for manipulative care (Burton et al., 1995) presented an opportunity further to explore the above issues. We elected to re-approach our patients with the aim of describing the course of symptoms and care seeking over a longer period in a cohort initially treated with an active management approach that included manipulative treatment. It was hypothesized that: (1) the overall pattern of disability due to low back pain would not change substantially between 1 and 4 years from presentation; (2) patients with a longer duration of symptoms prior to presentation would have a relatively poor longer-term outcome; (3) baseline psychological factors would be predictive of longer-term outcomes.

2. Methods The detailed methodology for the 1-year follow-up period of this survey has been reported elsewhere (Burton et al., 1995), and so needs only to be described brieﬂy here. The location was a private group practice specialising in manipulative (osteopathic) treatment, where sequentially attending patients ðn ¼ 252Þ with a primary complaint of low back pain were enrolled; patients with ‘red ﬂag’ indicators of serious spinal pathology (Royal College of General Practitioners, 1996) were excluded. At presentation, each patient completed a questionnaire to record a detailed history of low back pain, along with a structured clinical

31

examination including clinical measures of back function, and standard orthopaedic tests. An assessment of present pain intensity was recorded using six verbal descriptors ranging from 0=‘no pain’ to 5=‘excruciating’, and a measure of self-reported back-related disability was obtained using the Roland Disability Questionnaire (RDQ), which has a possible score range of 0–24 (Roland and Morris, 1983). Patients also completed a battery of psychosocial instruments that explored a range of psychological parameters, including depressive symptoms, pain coping strategies, somatic perceptions, and beliefs. These instruments have been described in the previous report on this cohort (Burton et al., 1995). The patients were treated with osteopathic manipulative therapy. Brieﬂy, the treatments comprised a number of sessions (mean=6.6) that variously involved passive soft tissue stretching, passive articulation of the lumbar spine and high-velocity thrust techniques. In addition, patients were given generally positive encouragement, and were advised to remain active and avoid rest so far as possible (in line with primary care guidelines (Royal College of General Practitioners, 1996)); there was no speciﬁc attempt either to assess or treat speciﬁc psychosocial factors. The long-term follow-up was by mailed questionnaire. For logistic reasons patients were re-approached at a ﬁxed point, resulting in data collection at an average four years since presentation (range, 3.5–5 years). This questionnaire was kept deliberately brief to encourage completion. It presented a number of multiple-choice items concerning the history of back trouble since the 1-year follow-up point, and sought to determine the frequency of recurrence along with details of any subsequent health care. Respondents were also asked to rate their present pain intensity and complete the RDQ. Of the original 252 patients, 186 (74%) responded at 1 year, and 151 (60%) responded at an average of 4 years. Patients were categorized, as in our previous paper, as ‘acute’ (symptom duration for presenting episode of 3 weeks or less) and ‘non-acute’ (symptom duration greater than 3 weeks) (Burton et al., 1995). Statistical treatment of the data included t-tests, w2 tests, and General Linear Model analysis. The level of statistical signiﬁcance was set at 5%, whilst 95% conﬁdence intervals (95% CI) were calculated where appropriate.

3. Results The distribution of respondents’ RDQ scores changed substantially between baseline and 1 year, but essentially did not alter thereafter. From the approximately normal distribution at baseline (mean 8.7, SD 4.8), a substantial

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shift towards lower RDQ scores was seen at 1 year (mean 3.4, SD 4.6) and at 4 years (mean 4.2, SD 4.8). For those responding at each follow-up point, the shift between baseline and 1 year (mean difference 5.3, 95% CI 4.5–6.2) was statistically signiﬁcant, but that between 1 and 4 years (mean difference 0.5, 95% CI 1.3–0.3) was not. Respondents with a low RDQ score at the 1year point were not necessarily those with a low score at the 4-year point: whilst 30% experienced an improvement, 42% experienced deterioration during that time. Taking the operational deﬁnition of ‘recovered’ (a score of 0–2 on RDQ) used in the previous paper (Burton et al., 1995), 41% of respondents had not recovered at 1 year and 49% had not recovered at 4 years. A small reduction in pain intensity occurred between 1 and 4 years (mean difference 0.1, 95% CI –0.1–0.3), which was not statistically signiﬁcant. The majority of respondents who were not pain-free at either 1 or 4 years; 73% and 59%, respectively, still reported at least ‘mild’ pain. Viewed overall, at the 4-year point, 118 respondents (78%) reported at least some disability or pain. Of the 151 patients who responded at 4 years, 119 (79%) reported experiencing further LBP after the 1year point. Three categories of recurrence were deﬁned based on recalled frequency of recurrence since 1 year: ‘no recurrence’ (0 spells), ‘recurrent’ (1–5 spells) and ‘persistent’ (more than 5 spells or persisting symptoms). At 4 years 65 patients (43%) reported a recurrent course, whilst 52 (35%) reported persistent trouble (Table 1). The likelihood of persistence of symptoms was related to the duration of symptoms prior to consultation for the index spell. Table 1 shows that of the patients presenting with a history in excess of 3 weeks (the non-acute group), 55% experienced persistent trouble between 1 and 4 years compared with 14% of those presenting within 3 weeks of onset (acute). Stepwise logistic regression was used to explore the capacity of the range of baseline historical, clinical, and psychosocial variables to predict recurrence (dichotomized as 0–1 spell and 2+ spells). The resultant model retained four statistically signiﬁcant variables: longer duration of presenting symptoms, presence of leg pain, Table 1 Frequency of recurrence (number of respondents) tabulated against duration of symptoms prior to presentation (index spell) Acute

Non-acute

Total

No recurrence Recurrent Persistent

21 42 10

12 23 42

33 65 52

Total

73

77

150

Recurrence between 1 and 4 years is categorized as: No recurrence (0 spells), recurrent (1–5 spells), persistent (6+ spells or persistent symptoms). Duration at presentation is categorized as: Acute (p3 weeks), Non-acute (X4 weeks).

Fig. 1. Mean Roland Disability Questionnaire scores from baseline through 1 to 4-year follow-up, for patients whose duration of complaint for the presenting symptoms was either p3 weeks or X4 weeks.

higher fear-avoidance beliefs, and heightened somatic concern. Using general linear modelling and repeated measures analysis of variance, the effect of the duration of presenting symptoms (acute/non-acute) and previous history of LBP (yes/no) on respondents’ changes in mean RDQ over the four years was examined with age and sex as covariates. Fig. 1 shows that the acute patients had a better outcome than the non-acute patients at 1 year (mean difference 2.0, 95% CI 0.7– 3.3), which persisted at 4 years (mean difference 1.51, 95% CI 0.7–3.7). Neither group changed signiﬁcantly between 1 and 4 years (mean difference for acute 0.9, 95% CI –1.9–0.1; mean difference for non-acute 0.2, 95% CI –1.5–1.2). The presence or absence of a previous history of LBP had no statistically signiﬁcant inﬂuence on 4-year outcomes. Table 2 shows the pattern of care seeking between 1 and 4 years by the 50% of respondents who sought treatment for recurrence or continuing symptoms. Some 38% of this sub-cohort consulted their general practitioner, and most were referred for physiotherapy or for a hospital consultant’s opinion. Over 56%, though, returned to an osteopath on at least one occasion (almost always to their original osteopath). When the baseline variables were entered into a stepwise logistic regression model with future care seeking as the dependent variable, only a longer duration of presenting symptoms was retained as a statistically signiﬁcant predictor. The mean RDQ scores at 1 and 4 years were not statistically different among the various care providers seen during the follow-up period. The ﬁnal phase of the analysis used stepwise multiple regression of respondents’ 4-year RDQ scores on the

ARTICLE IN PRESS A.K. Burton et al. / Manual Therapy 9 (2004) 30–35 Table 2 Care seeking between 1 and 4 years by the 76 patients who sought further care (50.3% of the 151 patients responding at 4 years) Number

Percent

General practitioner only Physiotherapy Hospital consultant Osteopathy Other

5 13 11 43 4

6.6 17.1 14.5 56.5 5.3

Total

76

100

Table 3 The multivariable models for prediction of RDQ score at 4 years, based on values for baseline variables. Higher values of these variables predict higher 4-year RDQ score Variable

Percent of variance accounted for

Baseline Modiﬁed Zung Depression Index score Baseline Present Pain Intensity

22 4

Total

26

n ¼ 123; F ¼ 21:82; Po0:001:

range of baseline variables, including demographic characteristics, clinical history, previous health care usage, clinical examination ﬁndings, back function tests, pain intensity, RDQ score, coping strategies, fearavoidance beliefs, depressive symptoms and perception of somatic symptoms. The results are summarized in Table 3. Just two statistically signiﬁcant variables were retained in the model, which together accounted for 26% of the variance in 4-year RDQ score. The single most explanatory variable was the presence of depressive symptoms (measured by the Modiﬁed Zung Depression Index (Main et al., 1992) accounting for 22% of the variance, with higher scores predicting relatively poor outcome; a higher baseline present pain intensity score explained the remaining 4% of the variance.

4. Discussion This study is the ﬁrst attempt to explore the course of low back pain in the manual therapy arena beyond the traditional 1-year follow-up period with a speciﬁc focus on the associations between presenting data and longerterm outcomes. The treatment approach used for the index spell is conducive with most national clinical guidelines (Koes et al., 2001), comprising general advice to stay active with the addition of manipulative treatment. The aim was to describe the resultant

33

longer-term pattern of symptoms, disability, and care seeking, and to determine the predictive capacity of baseline psychosocial variables for longer-term outcomes. The previous report on this cohort, and data from general practice, have shown that a considerable proportion of patients with LBP continue to experience both symptoms and varying degrees of disability at 1 year (Burton et al., 1995; Croft et al., 1998). Based on 1year outcomes in general practice, back pain has been described as ‘a chronic problem with an untidy pattern of grumbling symptoms and periods of relative freedom from pain and disability interspersed with acute episodes, exacerbations and recurrences’ (Croft et al., 1998). The results presented here indicate that picture apparently does not change over the ensuing 3–4 years. Indeed, recurrence and care seeking were common, and there was a trend for the present cohort, on average, to be marginally worse at 4 years in terms of disability. Stated simply, over three-quarters of respondents continued to report measurable pain and/or disability at 4 years, though they were not necessarily seeking care at that point. It is not possible to say whether the patients fared better or worse than they would solely under the care of their general practitioners, but it is clear that manipulative therapy did not lead to a complete resolution of back trouble for the majority of those responding at follow-up. The study had a number of limitations, the foremost of which is the limited response rate (60%) at the 4-year point, which impedes generalizability. It is recognized that testing effects can occur when participants have to repeatedly answer the same questions, which can lead to selective attrition, sensitization, and altered interpretation (Taris and Kompier, 2003). We do not believe this was a likely problem with the present study; participants were followed up at just two well-separated times, and somewhat different questions were used on each occasion. Although the 40% who did not respond at 4 years could not be distinguished from respondents on either baseline or 1-year data, they may have fared quite differently over longer follow-up, and the proportions might differ for the whole study population. Whilst the cohort of patients was drawn from fee-paying patients attending an osteopathic group practice, we have no reason to believe that their response is likely to be different from others offered similar treatment at a similar point in their clinical history. The further care seeking by this cohort corresponds with previous reports of an increase in care seeking by patients receiving manipulative therapy during the 2–3 years after initial presentation (Meade et al., 1995; Carey et al., 1999). That over half of those who did seek care elected to return to the original osteopath variously can be viewed as a failure of manipulative care to solve the problem, or an endorsement of satisfaction with that

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A.K. Burton et al. / Manual Therapy 9 (2004) 30–35

care. It is not unreasonable to assume that patients returned to their osteopath because it helped them cope with their symptoms, despite the fact that it was incapable of altering what might be a natural pattern. Although patient satisfaction was not measured in the present survey, previous studies have suggested that satisfaction with manipulative care is high (Seferlis et al., 1998). Nevertheless, it is possible that the practice of providing manipulative treatment in spite of ongoing symptoms could impart inconsistent messages, thus contributing to the chronicity seen here; this notion deserves further exploration. It should be noted that over one-third of respondents with recurrence did not return for manipulative care, which variously could indicate unmet earlier expectations, a reﬂection of a deteriorating problem, or that they sought alternative care. Factors predictive of longer-term prognosis, particularly factors that might act as obstacles to recovery, were a focus of the present survey. The clear detrimental effect of longer duration of symptoms on disability and recurrence supports similar ﬁndings from primary care outcomes at 1 year (Von Korff et al., 1993; Thomas et al., 1999). It might be tempting to infer that patients should be referred for manipulative therapy at an early stage of symptoms but that notion, whilst interesting, should be the subject of future research. Of more practical interest is the role of psychosocial factors seemingly acting as obstacles to recovery, because there is emerging evidence that they are amenable to intervention (van Tulder et al., 2000; Vlaeyen et al., 2002). The ﬁndings from the present cohort are illuminating in this respect. Standard clinical examination data were unhelpful in the prediction of either recurrence or disability in the longer term, but the role of baseline psychological factors has been extended beyond their accepted role in the shorter-term to cover longer-term outcomes as well. The role of fear-avoidance beliefs and heightened somatic concern as determinants of recurrence in the longer term was a new ﬁnding, and shows their inﬂuence goes beyond the accepted relationship with short-term pain and disability outcomes. Psychological distress (in the form of depressive symptoms) emerged as the strongest single baseline predictor of 4-year outcome, and greatly exceeded the inﬂuence of pain intensity. In contrast to the previous report (Burton et al., 1995), the variables that best predicted 1-year outcomes (coping strategies—catastrophising and praying/hoping) did not have a signiﬁcant inﬂuence in the longer term, suggesting that shorterterm ineffective coping strategies give way to depressive symptoms consistent with a model of learned helplessness (Main and Watson, 1999). In summary, despite the acknowledged limitations of the study, there is a sobering message for the manual therapy professions. A high proportion of back pain

patients attending for manipulative treatment will be unlikely to experience long-term resolution of symptoms and disability, and some will certainly deteriorate. That is not to say that manual therapy for back pain should be considered ineffective, but the results presented here do indicate that (as generally practiced) it is manifestly suboptimal for many patients. There is, however, an additional message lending empirical support to a recommendation that manual therapists need to understand the nature of patients’ pain behaviour and distress, rather than simply the nociceptive component of their pain (Main and Watson, 1999). The corollary is that manual therapists should consider incorporating management strategies focused on biopsychosocial principles (Jones et al., 2002; Main and Williams, 2002). In view of the relatively powerful inﬂuence of psychosocial factors on back pain outcomes, there is now ample justiﬁcation for trials of manual therapy with the inclusion of behavioural approaches to address psychological obstacles to recovery. Furthermore, the ﬁndings from the present survey are evidence that outcomes in back pain trials may best be measured by evaluating changes in the overall impact of the disorder over time, rather than by measures taken at a single time point.

References Burton AK, Tillotson KM, Main CJ, Hollis S. Psychosocial predictors of outcome in acute and subchronic low back trouble. Spine 1995;20:722–8. Campbell D, Goss E, Eisenstein SM. The natural history of low back pain. Neuro Orthopaedic 1989;7:32–5. Carey TS, Garrett JM, Jackman A, Hadler N. Recurrence and care seeking after acute back pain: results of a long-term follow up study. North Carolina Back Pain Project. Medical Care 1999;37:157–64. Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E, Silman AJ. Outcome of low back pain in general practice: a prospective study. British Medical Journal 1998;316:1356–9. Deyo RA. Practice variations, treatment fads, rising disability: do we need a new clinical research paradigm? Spine 1993;18:2153–62. Indahl A, Velund L, Reikeraas O. Good prognosis for low back pain when left untampered: a randomized clinical trial. Spine 1995;20:473–7. Jones M, Edwards I, Gifford L. Conceptual models for implementing biopsychosocial theory in clinical practice. Manual Therapy 2002;7:2–9. Koes BW, van Tulder MW, Ostelo R, Burton AK, Waddell G. Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine 2001;26:2504–13. Main CJ, Watson PJ. Psychological aspects of pain. Manual Therapy 1999;4:203–15. Main CJ, Willimas AC. ABC of psychosocial medicine. Musculoskeletal pain. British Medical Journal 2002;325:534–7. Main CJ, Wood PL, Hollis S, Spanswick CC, Waddell G. The distress and risk assessment method: a simple patient classiﬁcation to identify distress and evaluate the risk of poor outcome. Spine 1992;17:42–52.

ARTICLE IN PRESS A.K. Burton et al. / Manual Therapy 9 (2004) 30–35 Malmivaara A, Hakkinen U, Heinrichs M, Koskenniemi L, Kuosma E, Lappi S, Paloheimo R, Servo C, Vaaranen V, Hernberg S. The treatment of acute low back pain—bed rest, exercises, or ordinary activity? New England Journal of Medicine 1995;332:351–5. Meade TW, Dyer S, Browne W, Frank AO. Randomised comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow up. British Medical Journal 1995;311:349–50. Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine 2002;27:E109–20. Roland M, Morris R. A study of the natural history of back pain. Part I: development of a reliable and sensitive measure of disability in low-back pain. Spine 1983;8(2):141–4. Royal College of General Practitioners. Clinical Guidelines for the management of acute low back pain. London: RCGP, 1996. Seferlis T, Nemeth G, Carlsson AM, Gillstrom P. Conservative treatment in patients sick-listed for acute low-back pain: a prospective randomised study with 12 months’ follow-up. European Spine Journal 1998;7:461–70. Taris TW, Kompier M. Challenges in longitudinal designs in occupational health psychology. Scandinavian Journal of Work Environment and Health 2003;28:1–4. Thomas E, Silman AJ, Croft PR, Papageorgiou AC, Jayson MI, Macfarlane GJ. Predicting who develops chronic low back pain in primary care: a prospective study. British Medical Journal 1999;318:1662–7.

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van den Hoogen HMM, Koes BW, Deville W, van Eijk JTM, Bouter LM. The prognosis of low back pain in general practice. Spine 1997;22:1515–21. van Tulder MW, Ostelo R, Vlaeyen JWS, Linton SJ, Morley SJ, Assendelft WJJ. Behavioral treatment for chronic low back pain: a systematic review within the framework of the cochrane back review group. Spine 2000;25:2688–99. Vlaeyen JW, de Jong J, Geilen M, Heuts PH, van Breukelen G. The treatment of fear of movement/(re)injury in chronic low back pain: further evidence on the effectiveness of exposure in vivo. Clinical Journal of Pain 2002;18:251–61. Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 2000;85: 317–32. Von Korff M, Deyo RA, Cherkin D, Barlow W. Back pain in primary care: outcomes at 1-year. Spine 1993;18:855–62. Von Korff M, Saunders K. The course of back pain in primary care. Spine 1996;21:2833–7. Wahlgren DR, Atkinson JH, Epping-Jordan JE, Williams RA, Pruitt SD, Klapow JC, Patterson TL, Grant I, Webster JS, Slater MA. One-year follow-up of ﬁrst onset low back pain. Pain 1997;73: 213–22. Waxman R, Tennant A, Helliwell P. Community survey of factors associated with consultation for low back pain. British Medical Journal 1998;317:1564–7. Weber H, Burton AK. Rational treatment of low back trouble? Clinical Biomechanics 1986;1:160–7.

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www.elsevier.com/locate/math

Professional Issue

Referencing and quotation accuracy in four manual therapy journals Cameron McR Goslinga,*, Melainie Cameronb, Peter F. Gibbonsb a

Centre for Rehabilitation Exercise and Sports Science, Victoria University, Melbourne, Australia b Osteopathic Medicine, School of Health Sciences, Victoria University, Melbourne, Australia Received 24 February 2003; accepted 30 May 2003

Abstract The aim of the study was to investigate the reference and quotation accuracy in four peer-reviewed manual therapy journals. A stratiﬁed random sample of original research ðn ¼ 7Þ was collected from each of the journals spanning the years January 2000 to December 2001. A further random selection of 80 references from each journal paper sampled was then reviewed (Total N=320) for citation and quotation accuracy. Numbers of citations with errors were determined, then classiﬁed as either major or minor and categorized by bibliographic headings (author, title, journal, year, volume, page and irretrievable). Each quotation was individually assessed for accuracy and judged to be either correct or incorrect. A quotation was deemed correct if it accurately substantiated and reported the original authors assertions. One hundred and ﬁfteen citations across all journals contained errors (35.9%). Some citations exhibited multiple major and minor errors. Bibliographically classiﬁed errors for all journals showed 61 author, 51 title, 6 journal, 4 year, 12 volume and 25 page errors. JMPT showed the lowest referencing error rate (20%) while JBWMT recorded the highest (58.8%). The total number of quotation errors across all journals was 69 (12.3%). JMPT showed the lowest quotation error rate of 6 (4.7%), MT had 12 errors (7.3%), JOM produced 21 errors (13.3%), while JBWMT recorded the highest error rate with 32 (27.6%). Poor citation and quotation is a reﬂection on the scholarly work of the authors and the journal. The trend for errors in quotation is more worrying than citation errors as it reﬂects poor diligence on the part of the investigators. r 2003 Elsevier Ltd. All rights reserved. Keywords: Reference; Citation; Quotation; Accuracy

1. Introduction The accuracy of both referencing and quotation in peer-reviewed articles is important for the scholarly progress of any profession. The responsibility for accuracy lies with the authors. Inaccuracies can lead to propagation of errors in the literature (Biebuyck, 1992; Parse, 1996). Many biomedical journals base their instructions to authors on the guidelines created by the International Committee of Medical Journal Editors (1999), which states author(s) must verify references against their original source. Correct and accurate uses of reference lists and quotations reﬂect on the authors’ credibility (Schulmeister, 1998), allow for veriﬁcation of claims (O’Connor, 2002) and provide a resource for readers and researchers (Schulmeister, 1998; O’Connor, *Corresponding author. School of Health Sciences, Victoria University, MCMC, Victoria 8001, Australia. Tel.: 61-3-9248-1290; fax: 61-3-9248-1030. E-mail address: [email protected] (C. Gosling). 1356-689X/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S1356-689X(03)00056-0

2002). Eklund (1995) argues that authors have a professional obligation to correctly cite, and present unbiased informed opinions. Examples of errors in referencing have been identiﬁed back to the late 1800s (Dobell, 1938). Many authors have investigated the error rates in referencing among various biomedical journals (Key and Roland, 1977; De Lacey et al., 1985; Evans et al., 1990; Hansen and McIntire, 1994; Ngan Kee et al., 1997; Roach et al., 1997; Schulmeister, 1998; Siebers, 2000; Siebers and Holt, 2000; O’Connor, 2002), with errors ranging from 4.1% in the New England Journal of Medicine (Siebers and Holt, 2000) to 66.7% in the British Journal of Obstetrics and Gynaecology (Roach et al., 1997). Quotation errors while reported in the literature less often have varied from 0% (Schulmeister, 1998) to 44% (Evans et al., 1990) in biomedical journals. Although many biomedical journals and the most prestigious medical journals have been studied for quotation and referencing accuracy no authors have yet evaluated manual therapy journals for their

ARTICLE IN PRESS C. Gosling et al. / Manual Therapy 9 (2004) 36–40

2. Methodology 2.1. Procedure Four peer-reviewed manual therapy journals JBWMT, JMPT, JOM and MT were selected for investigation. A stratiﬁed random sample of original research papers (four groups of n=7) was collected from each of the journals during the years January 2000 to December 2001. A further random selection of 80 references from each journal paper sampled was then reviewed (total N=320) for referencing and quotation accuracy. Personal communications, letters, books, reports, theses, presentations and monographs were excluded from the selection. Previous investigators have used sample sizes ranging from 50 to 60 for each journal reviewed (De Lacey et al., 1985; Evans et al., 1990; Hansen and McIntire, 1994; Roach et al., 1997; Schulmeister, 1998). A minimum sample size of 22 is required for a signiﬁcance of 0.5, a power of 0.8 and an effect size of 0.5 (Burns and Grove, 1997). The numbers of references with errors was determined and errors then classiﬁed as either major or minor according to criteria previously described by Schulmeister (1998). Major citation errors included incorrect year, incorrect volume number, incorrect page numbers that did not overlap with the correct page numbers, incorrect article title, incorrect spelling of authors’ names and incorrect author order. Minor errors included incorrect author initials and incorrect page numbers that overlapped with the correct page numbers. References could have multiple major and minor errors for the purpose of evaluation. Citation Errors were also classiﬁed by bibliographic headings (author, title, journal, year, volume, page and irretrievable) adapted from the criteria described by O’Connor (2002). Each of the references selected were also individually assessed for quotation accuracy and judged to be either correct or incorrect each time they were used in the body of text. A quotation was deemed correct if it accurately substantiated and reported the original authors assertions. Criteria, based on Schulmeister’s (1998) work, designating an incorrect quotation included: secondary references that did not credit the original author; references that failed to substantiate, were unrelated to or contraindicated the author’s assertion; incorrect spelling or referencing of the author in the text and

citations that appeared in the reference list but not in the text. 2.2. Statistical method All results are reported as raw values and percentages. Statistical analysis of error rate of both citation and quotation errors was calculated using w2 analysis. A gold standard expected error rate of 4.1% for the New England Journal of Medicine (Siebers and Holt, 2000) was used for the citation error rate. A gold standard of 0% error for quotation accuracy has been previously reported by Schulmeister (1998) for Image: Journal of Nursing Scholarship, however we used an expected error of 1% for analysis purposes (w2 cannot be calculated if one category = 0). Signiﬁcance levels were set at Pp0.05.

3. Results 3.1. Citation errors The total number of citations with errors across all journals was 115 (35.9%). The number of references with errors ranged from the lowest error rate of 20% for the JMPT to the highest of 58.8% recorded for the JBWMT (see Fig. 1). Some citations exhibited multiple major and minor errors, which included 121 major errors and 39 minor errors. Major and minor error rates for each journal, which can be seen in Table 1, followed the trend indicated by the overall citation error data. Bibliographically classiﬁed errors for all journals showed 61 author, 50 title, 6 journal, 4 year, 12 volume and 25 page errors (Table 2). These errors in some cases made retrieval of the original articles difﬁcult without doing further data base searches. One citation was irretrievable even after extensive Medline, Cumulative Index to Nursing & Allied Health Literature (CINAHL) and hand library searches. Examples of some of the errors are highlighted here.

Error Percentage

accuracy. The aim of this study was to investigate the reference and quotation accuracy in four peerreviewed manual therapy journals: Journal of Bodywork and Movement Therapies (JBWMT), Journal of Manipulative and Physiological Therapeutics (JMPT), Journal of Osteopathic Medicine (JOM) and Manual Therapy (MT).

37

100 90 80 70 60 50 40 30 20 10 0

Citation Error Percentage

58.8

31.3

33.8

JOM

MT

35.9

20 4.1 NEJM

JMPT

JBWMT

Combined

Journal

Fig. 1. Total numbers of citations with errors for each journal as expressed as a percentage of total citations reviewed. New England Journal of Medicine (NEJM) error rate from Siebers and Holt (2000).

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Example 1 with errors highlighted in bold exhibits three major errors (missing authors, incorrect title and incorrect journal title) and two minor ones (incorrect author initial and incorrect page numbers— overlapping). Referenced: Di Fabio RD. Extended out patient rehabilitation for persons with progressive Multiple Sclerosis. Archives Physiological Medicine 1998; 79: 114–146. Actual: Di Fabio RP, Soderberg J, Choi T, Hansen CR, Schapiro RT. Extended out patient rehabilitation: Its inﬂuence on symptom frequency, fatigue, and functional status for persons with progressive Multiple Sclerosis. Archives of Physical Medicine and Rehabilitation 1998; 79:141–146. Example 2 with errors highlighted in bold exhibits two major errors (incorrect title and incorrect year) and one minor one (incorrect author initial). Referenced: Rogers G. The effects of spinal manipulation on cervical kinesthesia with chronic neck pain: A pilot study. Journal of Manipulative and Physiological Therapeutics. 1995;20:80–5. Actual: Rogers R. The effects of spinal manipulation on cervical kinesthesia in patients with chronic neck pain: A pilot study. Journal of Manipulative and Physiological Therapeutics. 1997;20:80–5.

error across all journals can be seen in Table 3 with errors ranging from 6 (4.7%) observed in the JMPT to the highest rate of 32 (27.6%) seen in the JBWMT. Failure to substantiate, secondary source and unrelated to quotation are the most common types of errors (Table 4) at 31.4%, 22.9% and 18.5%, respectively. An example of a typical failure to substantiate error is highlighted following: Quoted: ‘‘yHaynes (1996) tested in supine...’’ Actual: ‘‘The vertebral arteries were examined with the patients sitting uprighty.’’ Haynes (1996). An example of an unrelated error is: Quoted: ‘‘Patients with hypertension showyyy..and marked cardiovascular reactions to situational stressors’’ (Ditto and France, 1990). Actual: Study used ‘‘Forty healthy young adult males...’’ and ‘‘y21 healthy male college students with at least one hypertensive parent and 25 college males without a parental history of hypertensiony.’’ (Ditto and France, 1990). 3.3. Statistical analysis

3.2. Quotation errors The total number of errors across all journals was 70 (12.4%) of 565 direct quotations. The rate of quotation

The referencing and quotation error percentages were compared to expected rates of 4.1% and 1%,

Table 3 Quotation error rate for all journals evaluated Table 1 Major and minor error rates for all journal citations Journal JBWMT JMPT JOM MT Total

Major errors

Minor errors

Journal

Total errors

Total quotations

Error percentage (%)

JBWMT JMPT JOM MT

32 6 21 11

116 127 158 164

27.6 4.7 13.3 6.7

Total

70

565

12.4

Total errors

62 15 24 20

12 5 10 12

74 20 34 32

121

39

160

Table 2 Bibliographical classiﬁcation errors for all journal citations Bibliographical classiﬁcation

JBWMT

Author Title Journal Year Volume Page Irretrievable

36 18 6 1 3 9 1

Total

74

JMPT

JOM

MT

Total errors

8 7 0 1 3 1 0

7 14 0 2 5 6 0

10 11 0 0 2 9 0

61 50 6 4 13 25 1

20

34

32

160

Percentage (%) 38.1 31.3 3.8 2.5 8.1 15.6 0.6 100

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Table 4 Quotation Errors by type of error Quotation error

JBWMT

JMPT

JOM

MT

Total errors

Secondary Source Unrelated Contradicted Spelling Not in text Failure to Substantiate

3 10 6 2 5 6

3 0 1 0 0 2

7 2 1 0 1 10

3 1 1 2 0 4

16 13 9 4 6 22

Total

32

6

21

11

70

Error percentage (%) 22.9 18.5 12.9 5.7 8.6 31.4 100

Table 5 w2 analysis of citation and quotation errors. Expected error is 1% for purposes of quotation error analysis only Citation errors

Quotation errors 2

Journal

Observed

Expected

w

P value

Observed

Expected

w2

P value

JBWMT JMPT JOM MT

58.8 20 31.3 33.8

4.1 4.1 4.1 4.1

729.8 61.7 180.5 215.1

o0.01 o0.01 o0.01 o0.01

27.6 4.7 13.3 6.7

1 1 1 1

707.6 13.7 151.3 32.5

o0.01 o0.01 o0.01 o0.01

respectively, using w2 analysis. All reported w2 values were signiﬁcant (Po0.01) when compared to the expected gold standard (Table 5).

4. Discussion There have been many articles investigating the errors in referencing and quotation in biomedical journals but this paper is the ﬁrst to review the error rates in manual therapy journals. The results of this investigation have highlighted a common but very alarming problem within the scientiﬁc literature. We have reported that the error rate for the journals reviewed was between 20% and 58.8%. The combined referencing error rate for all four journals studied (35.9%) is about the midrange for the error rates reported for other journals in previous research (Key and Roland, 1977; De Lacey et al., 1985; Evan et al., 1990; Ngan Kee et al., 1997; Roach et al., 1997; Schulmeister, 1998; Siebers, 2000; Siebers and Holt, 2000; O’Connor, 2002) however all four journals showed a signiﬁcant difference (Po0.01) when compared to the best rate of 4.1% reported for the New England Journal of Medicine (Siebers and Holt, 2000). Most errors we observed for bibliographical classiﬁcations occurred in the author or title sections of the citations. Similar observations have been reported by Seibers and Holt (2000), Roach et al. (1997) and Siebers (2000) however O’Connor (2002) identiﬁed the title and page referencing as being areas with the highest rate of error for Emergency Medicine. These two areas of error,

which in the most part were minor spelling or order errors, did not hamper retrieval of the articles but did reﬂect poorly upon the authors. The errors we observed in more critical areas such as journal title, year or journal volume number were fewer but they made the search for the original document more difﬁcult and time consuming. One example was a reference cited as coming from Cancer when the original article was from Cancer Nursing. One reference was incorrect in so many elements that it was unable to be retrieved. A limited number of articles have investigated the quotation accuracy within biomedical journals (DeLacey et al., 1985; Evan et al., 1990 Schulmeister, 1998). Reported rates of quotation error have ranged from 0% for Image: Journal of Nursing Scholarship (Schulmeister, 1998) to 44.4% for The American Journal of Surgery (Evans et al., 1990). The rates of error we observed were within these previously reported values with two journals, JMPT (4.7%) and MT (6.7%), below the error rate reported by De Lacey et al. (1985) for the New England Journal of Medicine (12%). However all of our reported error rates were signiﬁcantly different from an expected gold standard (Po0.01). We have reported the highest error rates occurring in the categories of failure to substantiate claims (31.4%), the use of secondary sources (22.9%) and the use of unrelated references (18.5%). Quotation errors, especially those that contradict or fail to substantiate the authors’ statements, may raise doubt as to whether the original reference was read by the author(s) or if it was obtained from other sources such as other articles, textbooks or data bases (Evans et al., 1990). The authors

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of articles have a responsibility to the journal they are publishing in and to the audience that reads their work. The responsibility for accuracy and veriﬁcation lies ultimately with the author(s) (Parse, 1996; International Committee of Medical Journal Editors, 1999). Further inaccuracy may be propagated by the readers’ use of the material (Parse, 1996). The lack of diligence by some authors’ work is highlighted by a total of six references credited in reference sections across all journals but not used in the text. The task of ﬁnding appropriate remedies for these errors is not an easy one. Poor citation accuracy reﬂects poorly on scholarly work and may have ramiﬁcations for the prestige of the author(s) and the journal. The International Committee of Medical Journal Editors, 1999 state ‘‘The references must be veriﬁed by the author(s) against the original documents.’’ The authors of articles and the editors of journals must take ownership of these issues if we are to overcome them. Authors must be more vigilant and precise in their referencing practices and in the ﬁnal review and reading of galley proofs. Editors may take steps such as random auditing of journal submissions, editorial checking of citations as is the gold standard (New England Journal of Medicine & Annuals of Internal Medicine) described by Siebers and Holt (2000), or using criteria described for the Clinical Journal of Oncology Nursing (Schulmeister, 1998), which includes submission of various primary references. More recently computer technology, the use of referencing software (such as End-note) and downloadable E-Journals should decrease the level of error, especially those of referencing. In an editorial by Lock (1985) he hails the advantages of using computers but warns of the risks of inaccuracy, duplication and triviality that may be tempered with the long established tradition of rigorous peer review to safe guard and insure against substandard quality. The manual therapy professions are not immune to errors of referencing and quotation in the peer-reviewed literature. The error rates observed in the journals we reviewed are about the mid range when compared to the errors for all the journals previously reviewed by other authors. The high rate of quotation and referencing error by the JBWMT is a concern. Place (1916) best sums up the approach we must take to address referencing and quotation errors: ‘‘Take no reference for granted. Verify the reference that your best friend gives you. Verify the reference that your revered chief gives you. Verify, most of all, the

reference that you yourself found and jotted down. To err is human, to verify is necessary.’’

References Biebuyck JF. Concerning the ethics and accuracy of scientiﬁc citations. Anesthesiology 1992;77(1):1–2. Burns N, Grove SK. The practice of nursing research: conduct, critique, and utilization, 3rd ed. Philadelphia: W.B. Saunders; 1997. p. 293–318. De Lacey G, Record C, Wade J. How accurate are quotations and references in medical journals? British Medical Journal 1985; 291(6499):884–6. Ditto B, France C. Carotid baroreﬂex sensitivity at rest and during psychological stress in offspring of hypertensives and non-twin sibling pairs. Psychosomatic Medicine 1990;52(6):610–20. Dobell C. Dr. O. Uplavici (1887–1938). Parasitology 1938;30:239–41. Eklund J. Proper and accurate use of references. Acta Anaesthesiologica Scandinavica 1995;39(5):575–6. Evans JT, Nadjari HI, Burchell SA. Quotational and reference accuracy in surgical journals. A continuing peer review problem. Journal of the American Medical Association 1990;263(10): 1353–4. Hansen ME, McIntire DD. Reference Citations in radiology: accuracy and appropriateness of use in two major journals. American Journal of Roentgenology 1994;163(3):719–23. Haynes MJ. Doppler studies comparing the effects of cervical rotation and lateral ﬂexion on vertebral artery blood ﬂow. Journal of Manipulative and Physiological Therapeutics 1996;19(6):378–84. International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. Medical Education 1999;33(1): 66–78. Key JD, Roland CG. Reference accuracy in articles accepted for publication in the archives of physical medicine and rehabilitation. Archives of Physical Medicine and Rehabilitation 1977;58(3): 136–7. Lock S. Two cheers for the computer? British Medical Journal 1985;290(6482):1609–10. Ngan Kee WD, Roach VJ, Lau TK. How Accurate are References in the Australian and New Zealand Journal of Surgery. Australian and New Zealand Journal of Surgery 1997;67(7):417–9. O’Connor AE. A Review of the Accuracy of References in the Journal Emergency Medicine. Emergency Medicine 2002;14(2):139–41. Parse RR. Hear ye, hear ye, novice and seasoned authors!. Nursing Science Quarterly 1996;9(1):1. Place Jr. F. Verify your references: a word to medical writers. New York Medical Journal 1916;104:697–9. Roach VJ, Lau TK, Ngan Kee WD. The quality of citations in major international obstetrics and gynecology journals. American Journal of Obstetrics and Gynecology 1997;177(4):973–5. Schulmeister L. Quotation and referencing accuracy of three nursing journals. Image: Journal of Nursing Scholarship 1998;30(2):143–6. Siebers R. The accuracy of references of three allergy journals. Journal of Allergy and Clinical Immunology 2000;105(4):837–8. Siebers R, Holt S. Accuracy of references in ﬁve leading medical journals. The Lancet 2000;356(9239):1445.

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Technical and Measurement Report

Measurement of abdominal muscle thickness using M-mode ultrasound imaging during functional activities Steve M. Bunce*, Alan D. Hough, Ann P. Moore Clinical Research Centre for Health Professions, University of Brighton, Aldro Building 49 Darley Road, Eastbourne BN20 7UR, UK Received 23 July 2002; received in revised form 10 March 2003; accepted 20 June 2003

Abstract Ultrasound imaging has been previously utilized in the measurement of muscle thickness and cross-sectional area in research studies, and advocated as a clinical biofeedback tool in the rehabilitation of transversus abdominis function following episodes of low back pain. This paper describes how the thickness of the abdominal muscles can be quantiﬁed with a new measurement technique using M-mode ultrasound. The technique uses a custom-made transducer holder that facilitates measurement of muscle thickness changes during functional activity. Limitations of the technique and potential future applications are discussed. The M-mode ultrasound technique may provide an effective method for the non-invasive measurement of abdominal muscle thickness during functional activities. r 2003 Elsevier Ltd. All rights reserved.

1. Introduction The transversus abdominis (TrA) muscle is reported to be part of a deep muscle cylinder that contributes to the stability of the lumbar spine during function (Richardson et al., 1999). People with low back pain (LBP) may present with different patterns of abdominal muscle activation than those who do not experience LBP (Hodges and Richardson, 1996; Hodges, 1999; O’Sullivan, 2000). If these altered patterns of trunk muscle activity are present and relevant in LBP patients, it is appropriate that such activity can be measured and monitored in the clinical environment. The activity of the Rectus Abdominis, External and Internal Oblique abdominal muscles may be measured by surface electromyography in the clinic. However, the accurate measurement of TrA activity normally requires an invasive EMG technique, which may be impractical in the clinical situation. Ultrasound imaging (US) provides a potential solution for quantifying abdominal muscle activity. The muscle layers of the abdominal wall can be clearly identiﬁed using real-time B-mode US to facilitate the accurate placement of ﬁne-wire electromyography (EMG) electrodes into the TrA (De Troyer et al., *Corresponding author. Tel.: +44-1273-643945; fax: +44-1273643944. E-mail address: [email protected] (S.M. Bunce). 1356-689X/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S1356-689X(03)00069-9

1990; Abe et al., 1996; Hodges and Richardson, 1996). Critchley and Coutts (2002) used US to measure differences in abdominal muscle thickness changes during abdominal hollowing manoeuvres in subjects with low back pain. Ultrasound imaging is also advocated as a biofeedback tool in the facilitation strategy for the rehabilitation of TrA activity in clinical practice (Richardson et al., 1999). With this clinical application, the real-time ultrasound image provides a visual cue for the patient, as they are able to observe the actual thickening of the muscle when it contracts. Changes to the thickness of TrA and the other abdominal muscles during speciﬁc exercises have been measured (Critchley and Coutts, 2002). However, no studies to date have reported TrA thickness change during a continual period of function, such as walking. This technical and measurement note describes how thickness changes in the abdominal muscles can be measured during functional activities using motion (M)mode ultrasound.

2. M-mode ultrasound Motion (M)-mode ultrasound was primarily developed for use in cardiology for diagnostic examinations of the myocardium and heart valves (Picard, 1995; Anderson

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Fig. 1. An M-mode image simultaneously displayed with a B-mode image.

and McDicken, 1999). M-mode has also been used for non-cardiovascular applications, such as quantiﬁcation of diaphragmatic motion during respiration (Blaney et al., 1999) and change of diaphragm thickness in relation to contractile activity (Wait et al., 1989). A real-time B-mode image depicts a cross-section of anatomical structures. In contrast, M-mode is a stationary, narrow beam that produces a one-dimensional view of the anatomical structures over time. Mmode can be used simultaneously with B-mode to enable the operator to accurately adjust the position of the Mmode beam, which is indicated by a dotted line on the Bmode display (Fig. 1). Information from sound waves reﬂected back to the transducer from anatomical structures in the US beam is used to produce a depth versus time chart of these structures in the M-mode display. The movement of structures in M-mode is onedimensional and provides information on structural movement towards or away from the transducer. Orientating the plane of the US beam to capture the movement of anatomical structures of interest enables information to be obtained, over time, in a single image.

examinations. In order to achieve accurate and repeatable measurements, the transducer position needs to be consistent. With appropriate experience, a strict protocol and a stationary subject, a consistent position may be achieved with the operator holding the transducer. However, if a subject is moving, it may be more difﬁcult to control the transducer position for a sustained period. Feasibility studies using M-mode imaging of the abdominal muscles, during simple functional tasks such as sit to stand indicated that transducer positioning could be satisfactorily maintained by the operators’ hand. However, with more complex functional tasks, such as walking, it proved more difﬁcult for the operator to control the transducer position. Consideration was given to the development of a hands-free method of attaching the transducer to the subject during walking. The authors’ designed a transducer holder and belt to facilitate transducer positioning during walking. A block of high-density foam was used as a holder. The centre was cut away sufﬁciently to accommodate the transducer. The holder was taped to a belt, made from seat-belt-type material, and incorporated a plastic clasp locking mechanism (Fig. 2).

3. Transducer holder Ultrasound imaging is usually performed with the operator holding the transducer to control position. This enables experienced operators to easily adjust the orientation of the US plane when conducting diagnostic

4. M-mode US measurement technique of the abdominal muscles during functional activities The US system used for all work carried out to date is the Sonoace 6000C (Medison Co. Ltd, Seoul, Korea)

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43

Fig. 2. The application of the ultrasound transducer using high-density foam reinforced belt.

using a wide-band linear array transducer (frequency= 6–10 MHz) set to 10 MHz. Non-back pain and low back pain volunteers have participated in work that had received ethical approval from the University of Brighton Ethics Committee and the East Sussex Local Research Ethics Committee. With the subject in a supine position, the US transducer was located in an area between the 12th rib and the iliac crest, and a vertical line from the anterior superior iliac spine and the frontal plane. This is consistent with transducer positions described in other studies (Critchley and Coutts, 2002). The belt was then fastened to provide a ﬁrm support for the transducer. The US mode was set to simultaneous B/M mode. The display was set to depict a 60 mm depth of view and the M-mode chart set to10 s of continuous information. The power and gain were adjusted to provide the optimum clarity of the fascial planes between the abdominal layers. The image was then frozen and saved to the instruments hard disc. From the supine position, the subject was assisted to a comfortable standing position where an image was recorded in the same way as the supine position. Following the standing position, the subject was assisted onto a treadmill, and walked with arms unsupported at 4 kph speed. The time taken to complete 3 strides was timed using a hand-held stopwatch and a mean time for one stride calculated. The image recording was activated at heel-strike on the side of the trunk being scanned. The point of heel-strike activation was located on the saved

image and the subsequent heel-strikes were measured by the time previously calculated for each stride. Most US imaging systems include on-screen measurement software. Muscle thickness can be measured immediately the image is complete using on-screen callipers and would provide a simple and quick measurement method in the clinic environment. For research purposes, saved bitmap images from the US unit hard drive were transferred, via ﬂoppy or zip disks, to a desktop commuter. The NIH Image measurement software (http://rsb.info.nih.gov/nih-image/) was used to measure the thickness of the abdominal muscles for each image. The advantage of measuring images off-line with this type of software include the facility to enlarge images which provides for more accurate placement of the callipers. The data collection process is also accelerated, as no time is required to measure each image whilst the subject is present and the images can be randomized at a later date, enabling a blinding process for the protocol. Mean thickness calculations were produced for a series of ten measurements taken from the stance and swing phase of walking, and at 1-s intervals for the supine and standing images.

5. Discussion The use of the custom-made belt helps to maintain consistent transducer placement whilst scanning subjects during a functional activity. While no direct evidence is

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available to substantiate this claim, preliminary experimentation has indicated the beneﬁt of hands-free positioning. Potential beneﬁts include the subjects’ ability to move relatively unhindered by the close proximity of the researcher and the freedom for the researcher to concentrate on preparing the image without having to constantly observe and control the transducer position. Further investigations would quantify the beneﬁts of a belt support for the transducer compared to a hand-held process. Preliminary studies on the imaging of abdominal muscles using the transducer holder yielded sharper and more consistent M-mode displays than those with the operator-held method. This indicated a higher degree of consistency in maintaining the transducer position using the holder. Further studies will quantify any differences in the reliability of US measurement of the abdominal muscles between a hand-held transducer and the use of the holder. The optimal tension required to hold the belt in position in order to minimize changes to the scan plane is unknown at this time and requires further investigation. Abdominal muscle thickness changes have been reported with the use of B-mode ultrasound (Critchley and Coutts, 2002), however, the use of M-mode (B/M mode) ultrasound to measure changes in abdominal muscle thickness has not been reported. B-mode US quantiﬁcation of muscle and fat tissue thickness under changing conditions may require a sequence of individual images. With a split-screen option one image can be saved on-screen, while a second, representing the change of subject position or task, would be saved alongside the ﬁrst image. This ‘before and after’ format enables a comparison for thickness changes between two images. However, this only provides data for two moments in time. M-mode US is an option with the capacity to provide information, continuously over a period of time in one measurable image. The measurement technique described in this paper has been reported to be reliable (Bunce et al., 2002). Intraclass correlation coefﬁcients of 0.94 (supine lying), 0.88 (standing) and 0.88 (walking) were calculated for 22 subjects repeated on three separate occasions. Standard error of measurement analysis was calculated as 0.35 mm (supine), 0.66 mm (standing) and 0.56 mm (walking). With muscle thickness changes often exceeding 1 mm during function the potential exists to observe for changes beyond the range of error. The use of a hands-free application for the transducer and the time dimension provided by M-mode US has shown potential for the evaluation of abdominal muscle activity in functional tasks. If patterns of abdominal muscle thickness change are shown to differ in subjects reporting low back pain during functional activity then the effects of speciﬁc rehabilitation

programmes may be re-measured in functional conditions. Thickness change is also observable in the internal and external oblique abdominal muscles using this technique, although ﬁbre alignment differences may need to be investigated regarding the thickness change for the different muscles in the same image. The ability to visualize the activation of TrA as both a clinical measure and rehabilitation tool may prove valuable within a clinical setting. This process provides potential for use in clinical setting in addition to the biofeedback approach already advocated (Richardson et al., 1999) and offers opportunities for further use in the clinic for musculoskeletal diagnosis. Results from studies using M-mode US to measure abdominal muscle thickness change in subjects with and without low back pain are currently being prepared for publication. Measurable differences in thickness between subjects with and without low back pain may conﬁrm and demonstrate the potential for the use of M-mode US as a clinical tool.

References Abe T, Kusuhara N, Yoshimura N, Tomita T, Easton PA. Differential respiratory activity of four abdominal muscles in humans. Journal of Applied Physiology 1996;80(4):1379–89. Anderson T, McDicken WN. Measurement of tissue motion. Proceedings of the Institute of Mechanical Engineers. Part H. Journal of Engineering in Medicine 1999;213(3):181–91. Blaney F, English CS, Sawyer T. Sonographic measurement of diaphragmatic displacement during tidal breathing manoeuvres— a reliability study. Australian Journal of Physiotherapy 1999;45: 41–3. Bunce SM, Moore APM, Hough A. M-Mode ultrasound: a reliable measure of transversus abdominis thickness? Clinical Biomechanics 2002;17(4):235–324. Critchley DJ, Coutts FJ. Abdominal muscle function in chronic low back pain patients. Measurement with real-time ultrasound scanning. Physiotherapy 2002;88(6):322–32. De Troyer A, Estenne M, Ninane V, Gansbeke DV, Gorini M. Transversus abdominis muscle function in humans. Journal of Applied Physiology 1990;68(3):1010–6. Hodges PW. Is there a role for transversus abdominis in lumbo-pelvic stability? Manual Therapy 1999;4(2):74–86. Hodges PW, Richardson CA. Inefﬁcient muscular stabilisation of the lumbar spine associated with low back pain. Spine 1996;21(22): 2640–50. O’Sullivan. Lumbar segmental ‘instability’: clinical presentation and speciﬁc stabilizing exercise management. Manual Therapy 2000; 5(1):2–12. Picard MH. M-mode echocardiography: principles and examination techniques. In: Feigenbaum H, editor. Endocardiology. 5th ed. Philadelphia: Lea and Febiger; 1995. p. 282–301. Richardson CA, Jull GA, Hodges P, Hides J. Treatment of motor control problems. In: Therapeutic exercise for spinal segmental stabilisation in low back pain—scientiﬁc basis and clinical approach. Churchill Livingstone, Edinburgh; 1999. p. 125–43. Wait JL, Nahormek PA, Yost WT, Rochester DP. Diaphragmatic thickness-lung volume relationship in vivo. Journal of Applied Physiology 1989;62:180–6.

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Letter to the Editor

Statistics and pain-related fear measures in acute low back pain Swinkels-Meewisse et al. (2003) examined some of the psychometric properties of both the Dutch Tampa Scale for Kinesiophobia (TSK-DV) and the Fear-Avoidance Beliefs Questionnaire (FABQ) in acute low back pain patients. We congratulate the authors for their work; early identiﬁcation of acute (low back) pain patients at risk of becoming chronic may be of prime importance to reduce both economic costs and patients’ disability. In this view, the usage of a reliable and valid measure to assess pain-related fear (of movement) should be encouraged. However, we are concerned about the statistical analysis. Since the items on both the TSK-DV and the FABQ are scored on a Likert scale, they generate ordinal data (even the total scores are ordinal data). A Pearson correlation analysis is therefore inappropriate for both the analysis of the test–retest data and the examination of the concurrent validity of both measures. The Pearson product-moment correlation coefﬁcient is the most commonly reported measure of correlation, but its area of application is restricted to the interval and ratio scales (Portney and Watkins, 2000a). The Spearman rank correlation coefﬁcient should be used with ordinal data (Portney and Watkins, 2000a), and would therefore have been appropriate to analyse the concurrent validity of both measures. Second, the descriptive data of the total scores obtained with the TSK-DV and the FABQ were not reported adequately: the median and the interquartile range are the appropriate descriptive statistics for ordinal data, but Swinkels-Meewisse et al. (2003) reported only the means, medians and standard deviations of the total scores of both the TSK-DV and the FABQ (on p. 32 and 33). The authors were not the ﬁrst to do so, previous research using the TSK(-DV) consistently reported mean and standard deviations for the total scores on the TSK(-DV) (Vlaeyen et al., 1995; Goubert et al., 2000; Silver et al., 2002). Furthermore, neither a Spearman correlation, nor a Pearson correlation analysis, would have been appropriate for the analysis of the test–retest data. Correlation tells us how the scores vary together, but it cannot tell us the extent of agreement between the two sets of measurement (Portney and Watkins, 2000b). If a test is reliable, then the performance of the test on different occasions should yield (nearly) identical results (Fritz and 1356-689X/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S1356-689X(03)00096-1

Wainner, 2001), and not just results that vary together. Two sets of measurement can show perfect correlation, while at the same time have poor reliability. Assuming that Swinkels-Meewisse et al. (2003) aimed at examining the agreement between the two sets of measurement (as is most often the essence of reliability in clinical and research settings), the reported Pearson correlation coefﬁcients may have generated irrelevant data (that is, irrelevant to the aims of their study). Rehabilitation medicine has its own measurement ‘bible’ (Dijkers et al., 2002), which clearly indicates that for the analysis of test– retest data of ordinal data, the kappa statistic (k) and the intraclass correlation coefﬁcient are the appropriate statistics (Johnston et al 1992). Moreover, these measurement standards indicate that if a Pearson correlation is used to describe reliability, then central tendency differences also need to be examined (Johnston et al 1992). No such examination of central tendency differences is reported in the manuscript. The intraclass correlation coefﬁcient, reﬂecting both correlation and agreement (Portney and Watkins 2000b), should have been used to examine the test–retest reliability. Fourth, one can question the internal consistency of the items of both the TSK-DV (0.70 and 0.76) and the fear-avoidance beliefs about physical activities subscale of the FABQ (0.70 and 0.72). An internal consistency below the often-recommended cut-off of Cronbach’s alpha of 0.80 is considered to be indicative of poor reliability (Dijkers et al., 2002). The fact that these Cronbach’s Alpha values are similar to those reported by Vlaeyen et al. (1995), as indicated by the authors, does not change anything and is somewhat misleading. Stating that short questionnaires are less reliable would have provided the reader with more objective information. Fifth, the 95% limits of agreement between the two data sets (test and retest) (as reported in the Silver et al., 2002 trial) would have been of interest to the manual therapist who is trying to reduce pain-related fear in acute low back pain patients. The authors themselves indicate that the manual therapist, in acute low back pain patients exhibiting high pain-related fear, should try to focus the intervention on the fear rather than on impairments of anatomical structures. In this view, exposure in vivo to a set of individually tailored and fear eliciting physical movements has shown promising

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Letter to the Editor / Manual Therapy 9 (2004) 45–46

preliminary results in patients with chronic low back pain (Vlaeyen et al., 2002; de Jong et al., 2002). In order the track possible changes in the scores obtained with the TSK-DV or the FABQ and relate these changes to the intervention, the 95% conﬁdence intervals may assist the practitioner in assessing the efﬁcacy of the intervention. Assuming that we have obtained both a baseline (initial visit) and post treatment score for the TSK-DV, we subtract the post treatment from the pretreatment score to obtain a change in score. The observed change in TSK-DV score should exceed the 95% conﬁdence intervals to be considered clinically signiﬁcant (for more details: Selfe et al., 2001). References de Jong JR, Vlaeyen JWS, Geilen MJ. Graduele exposure in vivo bij pijngerelateerde vrees. Nederlands Tijdschrift voor Fysiotherapie 2002;112:50–7. Dijkers MPJM, Kropp GC, Esper RM, Yavuzer G, Cullen N, Bakdalieh Y. Reporting on reliability and validity of outcome measures in medical rehabilitation research. Disability and Rehabilitation 2002;24:819–27. Fritz JM, Wainner RS. Examining diagnostic tests: an evidence-based perspective. Physical Therapy 2001;81:1546–64. Goubert L, Crombez G, Vlaeyen J, Van Damme S, Van den Broeck A, Van Houdenhove B. De Tampa schaal voor Kinesiofobie: psychometrische karakteristieken en normering. Gedrag en Gezondheid 2000;28:54–62. Johnston MV, Keith RA, Hinderer SR. Measurement standards for interdisciplinary medical rehabilitation. Archives of Physical Medicine and Rehabilitation 1992;73:S3–23. Portney LG, Watkins MP Correlation. Chapter 23 in: Portney LG, Watkins MP, editors. Foundations of clinical research — application to practice, 2nd ed. New Jersey: Prentice-Hall Health 2000a; p. 491–508. [Chapter 23]. Portney LG, Watkins MP. Reliability. In: Portney LG, Watkins MP, editors. Foundations of clinical research — application to practice,

2nd ed. New Jersey: Prentice-Hall Health 2000b; p. 61–77. [Chapter 5]. Selfe J, Harper L, Pedersen I, Breen-Turner J, Waring J. Four outcome measures for patellofemoral joint problems. Part 2: reliability and clinical sensitivity. Physiotherapy 2001;87: 516–22. Silver A, Haeney M, Vijayadurai P, Wilks D, Pattrick M, Main CJ. The role of fear of physical movement and activity in chronic fatigue syndrome. Journal of Psychosomatic Research 2002;52: 485–93. Swinkels-Meewisse EJCM, Swinkels RAHM, Verbeek ALM, Vlaeyen JWS, Oostendorp RAB. Psychomatric properties of the Tampa scale for kinesiophobia and the fear-avoidance beliefs questionnaire in acute low back pain. Manual Therapy 2003;8:29–36. Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eek H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain 1995;62:363–72. Vlaeyen JW, de Jong J, Geilen M, Heuts PH, van Breukelen G. The treatment of fear of movement/(re)injury in chronic low back pain: further evidence on the effectiveness of exposure in vivo. Clinical Journal of Pain 2002;18:251–61.

Jo Nijs Department of Human Physiology, Faculty of Physical Education and Physical Therapy Vrije Universiteit Brussel (V.U.B.), Brussel 1090, Belgium Department of Health Sciences, Division of Occupational and Physical Therapy, Hogeschool Antwerpen, Belgium E-mail address: [email protected] Steven Truyen Department of Health Sciences, Division of Occupational and Physical Therapy, Hogeschool Antwerpen, Belgium

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Author’s Reply

Statistics and pain-related fear measures in acute low back pain We would like to thank Dr. Nijs and Dr. Truyen for their interest in and careful reading of our paper entitled ‘‘Psychometric properties of the Tampa Scale for Kinesiophobia and the Fear-Avoidance Beliefs Questionnaire’’ (Swinkels-Meewisse et al., 2003). Dr. Nijs and Dr. Truyen expressed concerns about the statistical analyses that have been used in the study. In this response, we would like to comment on these concerns in a point-by-point reply. The ﬁrst concern is that items of the TSK-DV and FABQ are scored on a Likert scale and individual items as well as total scores should be considered ordinal data. Consequently, the Spearman rank correlation coefﬁcient should have been used to analyze concurrent validity of both measures, rather than the Pearson product– moment correlation, of which the application is only restricted to interval and ratio scales. We agree that individual items of the TSK-DV and the FABQ should be considered ordinal data. Measurement on an ordinal scale involves rank-ordered categories. An interval scale also has this rank-order characteristic but also assumes equal distances or intervals between units of measurement (Portney and Watkins, 2000). For an individual item, it would perhaps be difﬁcult to assume that a difference between 1 and 2 is the same as the difference between 3 and 4. However, none of the analyses have relied on scores on individual items, but all have been conducted on total scores (TSK) or total scores of subscales (FABQ) of these measures. It is not possible to statistically test whether total scores could be considered as interval data, but we can only assume that each item is equally important in the composition of the total score and subsequently assume that we may treat total scores of the TSK-DV and FABQ as continuous variables measured at an interval level. This is a common assumption in examining self-report measures in the behavioral and social sciences. In our opinion, the Pearson product–moment correlation is an appropriate measure for analyzing concurrent validity of both measures. The second concern relates to the ﬁrst one: descriptive statistics should comprise the median and the interquartile range as is appropriate for ordinal data. Again, we assume the total scores of the measures are continuous and measured on an interval scale. Thus, we consider the mean as a measure of central tendency 1356-689X/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S1356-689X(03)00097-3

and the corresponding standard deviation as appropriate descriptive statistics of the measures. Also, direct comparisons with other studies that have reported means and standard deviations of these measures are possible. The third concern relates to the analysis of the test– retest reliability. An intra-class correlation coefﬁcient (ICC) or a kappa statistic (k) should have been used to examine test–retest reliability. We fully agree that an ICC is the most preferred index for examining test– retest reliability as it not only accounts for the degree of correspondence (i.e., correlation) but also the degree of agreement. If all individuals that complete a self-report measure would score exactly 10 points higher on this measure at the second test occasion as compared to the ﬁrst occasion, then a perfect correlation coefﬁcient (Pearson r ¼ 1:0) would be obtained but agreement is poor. An ICC accounts for both these issues. However, it should be noted that computations of ICC involves the estimation of variance estimates obtained through analysis of variance, which assumes equal intervals between the measurement units of the total scores (Portney and Watkins, 2000). This is only the case when total scores of the TSK-DV and total scores on the subscales of the FABQ are assumed to be at the interval level. In reanalyzing our data, we obtained an ICC for the TSK-DV of 0.78 (95% conﬁdence interval: 0.71– 0.83). For two total scores on the FABQ/w and FABQ/ pa subscales we found an ICC of 0.80 (95% conﬁdence interval: 0.74–0.85) and 0.64 (95% conﬁdence interval: 0.55–0.72), respectively. The ICC estimates are almost identical to the Pearson product moment correlation coefﬁcient reported in our study. The fourth concern relates to the internal consistency of the TSK-DV and the FABQ. We agree that measurement instruments with a Cronbach’s alpha below 0.80 are considered less reliable. As correctly pointed out by Dr. Nijs and Dr. Truyen, Cronbach’s alpha is affected by the number of items in a scale. Future studies could extend these measures with appropriate items. In the ﬁnal concern, Dr. Nijs and Dr. Truyen stress the importance of reporting the 95% conﬁdence intervals of TSK-DV and FABQ scores for evaluating interventions as they may be useful for determining whether a change in the scores on these measures can be

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Correspondence / Manual Therapy 9 (2004) 47–48

considered clinically relevant. We agree with their notion but a greater time interval between both test occasions than used in our study, should be applied to address this concern. Future studies may focus on the responsiveness of the TSK-DV and the subscales of the FABQ. Responsiveness refers to the ability of an instrument to detect change over time, which is important in both clinical practice and research (Sim and Waterﬁeld, 1997). To assess the responsiveness of an instrument an external criterion is necessary to determine whether real change has occurred or not (De Vet et al., 2001). Responsiveness can be quantiﬁed by either comparing change scores with the corresponding smallest real difference (SRD) or by receiver operating characteristics curves (ROC curves) (see De Vet et al., 2001 for more details). We hope that this response sufﬁciently clears up the concerns raised by Dr. Nijs and Dr. Truyen.

Portney LG, Watkins MP. Foundations of clinical research. Application to practice. New Jersey: Prentice-Hall Health; 2000. Sim J, Waterﬁeld J. Validity, reliability and responsiveness in the assessment of pain. Physiotherapy Theory and Practice 1997;13: 23–37. De Vet HC, Bouter LM, Bezemer PD, Beurskens AJ. Reproducibility and responsiveness of evaluative outcome measures. Theoretical considerations illustrated by an empirical example. International Journal of Technology Assessment and Health Care 2001;17: 479–87.

E.J.C.M. Swinkels-Meewisse Ulenpas 80 5655 JD Eindhoven, The Netherlands E-mail address: [email protected] J. Roelofs R.A.H.M Swinkels

References Swinkels-Meewisse EJ, Swinkels RA, Verbeek AL, Vlaeyen JW, Oostendorp RA. Psychometric properties of the tampa scale for kinesiophobia and the fear-avoidance beliefs questionnaire in acute low back pain. Manual Therapy 2003;8:29–36.

A.L.M. Verbeek J.W.S. Vlaeyen R.A.B. Oostendorp

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Book reviews Joint motion; clinical measurement & evaluation Roger Soames; Churchill Livingstone, Edinburgh, 2003, p. 203, price d15.99, ISBN 0443058083 Roger Soames has attempted to demonstrate, both pictorially and in text, clinical methods of joint measurement and evaluation. He has ably succeeded in producing what is described as a quick reference guide to the subject. The opening section simply outlines joint structure and function, followed by a discussion on ﬂexibility and mobility. Principles of measurement and clinical application then are covered brieﬂy. The text uses the same sequence for each joint: a review of the relevant anatomy using clear line drawings, a description of the possible ranges of movement, and then methods of evaluation of this range, illustrated by black and white photographs. These would enable an under-

graduate physiotherapist to easily perform the movements described. Tables give the required ranges of joint movement during common activities. More attention and space is given to the peripheral joints than the vertebral, where mostly gross active movements are described. The temporo-mandibular joint is also covered brieﬂy. The beneﬁt of having speciﬁc joint range of motion measurements for each area, and the accuracy of such measurements, can be debated, but overall this is an excellent text book and a useful addition, particularly for students training in the evaluation of patients with musculo-skeletal lesions. Stephanie Saunders 20 Aisla Road, Twickenham TWI 1QW, UK E-mail address: [email protected]

doi:10.1016/S1356-689X(03)00088-2

Assessment of the lower limb, 2nd edition Linda Merriman and Warren Turner (Eds.); Churchill Livingstone, Edinburgh, 2002, p. 504, price d39.99, ISBN 0443071128 This is the second edition of a textbook written mostly by podiatrists. It is a comprehensive text covering all aspects of lower limb assessment and includes some general but related issues such as clinical measurement. Physical examination is approached from a systems perspective (vascular, neurological, orthopaedic, skin and footwear) across separate chapters. This section is followed by the next, which explores the adaptation of general principles of assessment to different client groups, such as children and the ‘sports patient’. The book generally appears to be mostly written from a podiatry perspective although this is not entirely consistent as an attempt has been made to make the book useful to a wider audience. Unsurprisingly, the chapter on gait analysis is a particular strength of the book. Although brief, it is sufﬁciently detailed to include calcaneal and navicular movement during the gait cycle. The chapter on orthopaedic assessment covers an orthopaedic overview of the lower limb, doi:10.1016/S1356-689X(03)00089-4

which is insufﬁciently detailed in regard to assessment of joint movements and muscle tissue for students or practitioners of manual therapy. Neurological assessment, however, is written from the view of diagnosing which part of the nervous system is functioning abnormally, rather than from a screening purpose. Some theoretical concepts are missing, for example, where the skin and wound healing is discussed, information on the patho-physiology of healing, atrophy, tissue biomechanics is omitted. The vascular assessment chapter, by contrast, includes broad explanatory physiological detail. The book is clearly written and is in hardcover, with colour photographs at the beginning and halftones throughout. The text is accurate and provides a useful overview and would beneﬁt from some further development through linkage to clinical decision making and intervention. It would be a useful addition to the library of any manual therapist, to dip into, and would be a valuable textbook to the podiatry student. Liz Holey School of Health and Social Care, University of Teesside Tees Valley, Middlesbrough TS1 3BA, UK E-mail address: [email protected]

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The clinical neurobiology of ﬁbromyalgia and myofascial pain R.M. Bennett; The Haworth Medical Press, New York, 2002, pp. 278, price d34.95, ISBN 0789017431 This book is one of a series built around the MYOPAIN congresses, in this case MYOPAIN 2001. There are 19 chapters, each individually referenced and with a standardized initial summary. There is an extensive overall index for the whole book. The book is divided in three main sections. The ﬁrst has six chapters on the neurobiology of central sensitization, with four reviews covering neurobiology, pharmacology, brain mechanisms and the role of the cerebral cortex, respectively. The other two chapters consider aspects of central sensitization relevant to ﬁbromyalgia. The second section has the title: regional pain syndromes. This is, however, a little misleading as only one chapter deals with a regional problem (masticatory myofascial pain). The other chapters cover visceral pain, visceral–myofascial interactions, inﬂammatory muscle pain, deep tissue hyperalgesia, and physical therapy approaches to ﬁbromyalgia. The chapter on doi:10.1016/S1356-689X(03)00090-0

visceral–myofascial interactions includes a broad survey of the way visceral pathology can produce a well-deﬁned myofascial pain state, and stresses the importance of considering the possibility of visceral disease when diagnosing a patient presenting with myofascial pain. The last section of the book covers chronic widespread pain with three chapters on ﬁbromyalgia and others on pain from torture, pain following traumatic injuries, and widespread pain epidemiology. This latter chapter presents an excellent concise summary of recent epidemiological ﬁndings showing that widespread pain conditions have a prevalence of 5–13%, emphasizing the importance of work in this ﬁeld. In summary this is an interesting book providing an update on many important aspects of myofascial pain and ﬁbromyalgia.

Dr. Bruce Lynn Department of Physiology, University College London Gower Street, London WC1E 6BT, UK E-mail address: [email protected]

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Diary of events

Information and Call for Papers: www.worldcongresslbp.com http://www.worldcongresslbp.com Deadline submitting papers: December 15, 2003 For all further information: info@world congresslbp.com mailto: info@worldcongresslbp. com

21–26 March 2004 8th IFOMT Congress (International Federation of Manipulative Therapy), International Convention Centre, Cape Town, South Africa. This promises to be one of the most exciting events in the history of physiotherapy in South Africa and you are encouraged to start your planning now. The theme for the conference is ‘‘Balancing the Outcome of Manual Therapy.’’ The programme will range from research based to clinical outcomes papers. Several speakers of international standing have indicated their willingness to participate. The programme will include sessions on Pain, Outcome Based Research, Community and Industrial Considerations, Musculo-Skeletal Spinal and Peripheral Dysfunctions. Website: Our website will be continually updated as further information becomes available – please keep watching: www.uct.ac.za/depgc/pgc/ Enquiries: If you would like further information, please send an expression of interest to: Sally Elliott, Conference Management Centre, UCT Medical School, Anzio Road, Observatory 7925, Cape Town, South Africa Tel: +27 21 406-6381; Fax: +27 21 448-6263; E-mail: [email protected]

21–26 August 2005, Sydney, Australia 11th World Congress on Pain, Workshop and Plenary Proposals. Please send proposals to the Chair of the Scientiﬁc Program Committee: Herta Flor, PhD, Central Institute of Mental Health, Dept of Clinical and Cognitive Neuroscience, PF 12 21 20, 68072 Mannheim, Germany. Tel: 49-621-170-3922; Fax: 49-621-170-3932; E-mail: ﬂ[email protected] Workshop and plenary suggestions should be submitted by 15 March 2003 at the latest so that they can be considered by the Scientiﬁc Program Committee. Note that announcements, deadlines, and other information relating to the 2005 Congress will be routinely updated on the IASP Web page: www.iasp-pain.org Janet G. Travell, MD Seminar Series, Bethesda, USA

16, 17 & 18 September 2004, Provinciehuis Antwerp (Belgium)

For information, contact: Myopain Seminars, 7830 Old Georgetown Road, Suite C-15, Bethesda, MD 20814-2432, USA. Tel.: +1 301 656 0220; Fax: +1 301 654 0333; website: www.painpoints.com/seminars.htm; e-mail: [email protected]

Movement Impairments and Stability Disorders in the Lower Quadrant. ‘‘European Course Tour 2004’’ with Dr. Serge Gracovetsky, Prof. Shirley Sahrmann, Sarah Mottram and Sean Gibbons. Organisation: Belgian Scientiﬁc Manual Therapy Association (BWMT). Contact ECT 2004 Bureau: Avignonlaan 57, B-8310 Brugge Tel: 0032 (0) 50 370528; Fax: 0032 (0) 26112968 & 0032 (0) 9 3699382; E-mail: mailto: [email protected] Website: http://www.belgianmedcare.com/bwmt

Evidence-based manual therapy congress Further information: www.medicongress.com Intensive courses in Manual Therapy Further information: http://allserv.rug.ac.be/bvthillo If you wish to advertise a course/conference, please contact: Karen Beeton, Department of Physiotherapy, University of Hertfordshire, College Lane, Hatﬁeld, Herts AL10 9AB, UK. There is no charge for this service.

10–13 November, 2004, Melbourne, Australia 5th Interdisciplinary World Congress on Low Back & Pelvic Pain Eﬀective Diagnosis and Treatment of Lumbopelvic Pain.

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Subject Index for Volume 8 A Achilles tendinopathy, comments on (letter), 189, 190 Altered motor control, around the shoulder complex, dynamic evaluation and early management of (masterclass), 195 Ankle injury, anatomical and possible clinical relationships between calcaneoﬁbular ligament and peroneus brevis, 170 Ataralgesia, effect of manual therapy after pulmonary resection, 42 Athletes osteitis pubis: treatment via pelvic muscles (case report), 257 static innominate asymmetry and leg length discrepancy in asymptomatic collegiate athletes, 207 stretching for prevention of exercise-related injury: systematic literature review of efﬁcacy, 141

B Back pain adherence to rehabilitaiton in patients with low back, 110 health care provider’s attitudes and beliefs towards chronic low pack pain: development of a questionnaire, 214 neuromuscular control of walking with chronic low-back pain, 21 psychometric properties of generic health measure in Chinese patients with low back pain in Hong Kong, 151 psychometric properties of Tampa Scale for Kinesiophobia and fear-avoidance beliefs questionnaire in acute low-back pain, 29 side-to-side weight-bearing asymmetry in subjects with low back pain, 166 spinal manipulation for low-back pain: a treatment package agreed by the UK chiropractic, osteopathy and physiotherapy professional associations, 46 stabilizing training compared with manual treatment in sub-acute and chronic low-back pain, 233 Blood ﬂow in contralateral vertebral artery, effect of cervical rotation on, 103 in patient with atretic and hypoplastic vertebral artery, falsenegative extension/rotation pre-manipulative screening test (case report), 120 Body position, lumbar multiﬁdus muscle size does not differ whether ultrasound imaging is performed in prone or side lying, 161 Book reviews Chronic Fatigue Syndrome, Christianity and Culture, 263 Clinical Application of Neuromuscular Techniques, Volume 2: The Lower Body, 187 Clinical Reﬂexology: A Guide for Health Professionals, 56 50 Challenging Spinal Pain Syndrome Cases, 262 How to Appraise research: A Guide for Chiropractic Students and Practitioners, 264 Journal of Whiplash & Related Disorders, 188 The Malalignment Syndrome: Biomechanical and Clinical Implications for Medicine and Sports, 187 A Manual Therapist’s Guide to Surface Anatomy & Palpation Skills, 187 Massage Therapy—the Evidence for Practice, 56 Outcome Based Massage, 56 doi:10.1016/S1356-689X(03)00129-2

Positional Release Techniques, 57 Stroke Rehabilitation: Guidelines for Exercise and Training to Optimize Motor Skill, 261

C Calcaneoﬁbular ligament, anatomical and possible clinical relationships between peroneus brevis and, 170 Cervical spine, see also Mechanical neck disorders cervical rotation, effect of on blood ﬂow in contralateral vertebral artery, 103 control subjects in whiplash studies (letter), 52, 54 false-negative extension/rotation pre-manipulative screening test on patient with atretic and hypoplastic vertebral artery (case report), 120 manipulation of (masterclass), 2 measuring range of active cervical rotation in a position of full head ﬂexion using 3D Fastrak measurement system: an intra-tester reliability study, 176 Chinese health proﬁle, psychometric properties of generic health measure in Chinese patients with low back pain in Hong Kong, 151 Chronic pain health care provider’s attitudes and beliefs towards chronic low pack pain: development of a questionnaire, 214 neuromuscular control of walking with chronic low-back pain, 21 pain neuromatrix approach to patients with chronic pain (masterclass), 130 stabilizing training compared with manual treatment in chronic lowback pain, 233 Clinical guidelines, development of (editorial), 193 Clinical practice altered motor control around the shoulder complex, dynamic evaluation and early management of (masterclass), 195 clinical guideline developments (editorial), 193 lateral epicondylalgia: a musculoskeletal physiotherapy perspective letter, 265, 266, 267 masterclass, 66 manipulation of cervical spine (masterclass), 2 Masterclasses reconsidered and revisited (editorial), 129 pain neuromatrix approach to patients with chronic pain (masterclass), 130 postoperative ataralgesia by manual therapy after pulmonary resection, 42 speciﬁc evaluation of the function of force couples relevant for stabilization of the glenohumeral joint, 247 validating clinical reasoning, 117 Clinical reasoning, validity theory and, 117 Contralateral vertebral artery, effect of cervical rotation on, 103 Cranio-cervical ﬂexion test, relationship between cranio-cervical ﬂexion range of motion and pressure change during, 92 Current Perceived Health 42 (CPH42) Proﬁle, psychometric properties of in Chinese patients with low back pain in Hong Kong, 151

ARTICLE IN PRESS Subject index / Manual Therapy 9 (2004) 52–55 D Dynamic Relocation Test (DRT), speciﬁc evaluation of the function of for stabilization of the glenohumeral joint, 247 Dynamic Rotary Stability Test (DRST), speciﬁc evaluation of the function of for stabilization of the glenohumeral joint, 247 E Exercise efﬁcacy of stretching for prevention of exercise-related injury: systematic literature review, 141 static innominate asymmetry and leg length discrepancy in asymptomatic collegiate athletes, 207 Exercise therapy, in mechanical neck disorders (review), 10 Extended/rotated screening, false-negative screening test on patient with atretic and hypoplastic vertebral artery (case report), 120 F Fastrak measurement system, measuring range of active cervical rotation in a position of full head ﬂexion using 3D Fastrak measurement system: an intra-tester reliability study, 176 Fear-avoidance beliefs, in acute low-back pain, psychometric properties of Tampa Scale for Kinesiophobia and, 29 Force couples, speciﬁc evaluation of the function of for stabilization of the glenohumeral joint, 247 G Glenohumeral joint quantitive analysis of traction in: in vivo radiographic measurements, 97 speciﬁc evaluation of the function of force couples relevant for stabilization of, 247 Goniometer, telemedicine: Internet use as medium to evaluate knee angle, 242 H Health care providers, attitudes and beliefs towards chronic low pack pain: development of a questionnaire, 214 Hip extensors, neuromuscular control of walking and chronic lowback pain, 21 I Imaging lumbar multiﬁdus muscle size does not differ whether ultrasound imaging is performed in prone or side lying, 161 traction in glenohumeral joint, quantitive analysis of with in vivo radiographic measurements, 97 Injury prevention, efﬁcacy of stretching for prevention of exerciserelated injury: systematic literature review, 141 Innominate asymmetry, static innominate asymmetry and leg length discrepancy in asymptomatic collegiate athletes, 207 K Knee angle, telemedicine: Internet use as medium to evaluate knee angle, 242 L Lateral ankle injury, anatomical and possible clinical relationships between calcaneoﬁbular ligament and peroneus brevis, 170

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Lateral epicondylalgia (LE) musculoskeletal physiotherapy perspective letter, 265, 266 masterclass, 66 Leg length discrepancy, static innominate asymmetry and leg length discrepancy in asymptomatic collegiate athletes, 207 Long-term patients, on-going physiotherapy management of (professional issue), 254 Low-back pain acute, psychometric properties of Tampa Scale for Kinesiophobia and fear-avoidance beliefs questionnaire in, 29 adherence to rehabilitation in patients with, 110 chronic health care provider’s attitudes and beliefs towards: development of a questionnaire, 214 neuromuscular control of walking with, 21 stabilizing training compared with manual treatment in, 233 psychometric properties of generic health measure in Chinese patients with low back pain in Hong Kong, 151 side-to-side weight-bearing asymmetry in subjects with, 166 spinal manipulation for: a treatment package agreed by the UK chiropractic, osteopathy and physiotherapy professional associations, 46 spondylolysis and spondylolisthesis, systematic review of physiotherapy for (review), 80 sub-acute, stabilizing training compared with manual treatment in, 233 Lumbar multiﬁdus muscle, muscle size does not differ whether ultrasound imaging is performed in prone or side lying, 161 Lumbar spine altered motor control around the shoulder complex, dynamic evaluation and early management of (masterclass), 195 neuromuscular control of walking and chronic low-back pain, 21 Lung resection, effect of postoperative ataralgesia by manual therapy following, 42

M Manipulation Abstracts—Manipulation Association of Chartered Physiotherapists (UK) Research Awards 2002, 185 of cervical spine (masterclass), 2 spinal manipulation for low-back pain: a treatment package agreed by the UK chiropractic, osteopathy and physiotherapy professional associations, 46 Measurement range of active cervical rotation in a position of full head ﬂexion using 3D Fastrak measurement system: an intra-tester reliability study, 176 relationship between cranio-cervical ﬂexion range of motion and pressure change during cranio-cervical ﬂexion test, 92 telemedicine: Internet use as medium to evaluate knee angle, 242 Mechanical neck disorders, see also Cervical spine evidence for exercise therapy in (review), 10 Multiﬁdus muscle, lumbar multiﬁdus muscle size does not differ whether ultrasound imaging is performed in prone or side lying, 161 Muscle strain injury, efﬁcacy of stretching for prevention of exerciserelated injury: systematic literature review, 141 Muscle therapy, effect of postoperative ataralgesia by manual therapy following pulmonary resection, 42

N Neck, see also Cervical spine; Mechanical neck disorders cranio-cervical ﬂexion test, relationship between cranio-cervical ﬂexion range of motion and pressure change during, 92

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Subject index / Manual Therapy 9 (2004) 52–55

Neuralgia, post-herpetic neuralgia: pain relief with manual therapy (case report), 180 New Zealand, manipulation of the cervical spine (masterclass), 2 O Osteitis pubis, treatment via pelvic muscles (case report), 257 P Pain pain neuromatrix approach to patients with chronic pain (masterclass), 130 post-herpetic neuralgia: pain relief with manual therapy (case report), 180 postoperative ataralgesia, effect of manual therapy after pulmonary resection, 42 Pain-related fear, psychometric properties of Tampa Scale for Kinesiophobia and fear-avoidance beliefs questionnaire in acute low back pain, 29 Palpation, reproducibility and repeatability: errors of three groups of physiotherapists in locating spinal levels by palpation, 223 Patient compliance, adherence to rehabilitaiton in patients with low back pain, 110 Pelvic asymmetry, static innominate asymmetry and leg length discrepancy in asymptomatic collegiate athletes, 207 Pelvic muscles, treatment of osteitis pubis via (case report), 257 Peroneus brevis, anatomical and possible clinical relationships between calcaneoﬁbular ligament and, 170 Posterolateral thoracotomy, effect of postoperative ataralgesia by manual therapy following, 42 Post-herpetic neuralgia, pain relief with manual therapy (case report), 180 Postoperative ataralgesia, effect of manual therapy after pulmonary resection, 42 Professional issues, on-going physiotherapy management of long-term patients, 254 Psychometric properties of generic health measure in Chinese patients with low back pain in Hong Kong, 151 of Tampa Scale for Kinesiophobia and fear-avoidance beliefs questionnaire in acute low-back pain, 29 Pulmonary resection, effect of postoperative ataralgesia by manual therapy following, 42

Reliability reproducibility and repeatability: errors of three groups of physiotherapists in locating spinal levels by palpation, 223 telemedicine: Internet use as medium to evaluate knee angle, 242 Retromalleolar pain, anatomical and possible clinical relationships between calcaneoﬁbular ligament and peroneus brevis, 170 Rotator cuff, altered motor control around the shoulder complex, dynamic evaluation and early management of (masterclass), 195 Rural and remote areas, telemedicine: Internet use as medium to evaluate knee angle, 242 S Scholarly debate, encouraging (editorial), 1 Screening, false-negative extension/rotation pre-manipulative screening test on patient with atretic and hypoplastic vertebral artery (case report), 120 "Shingles," post-herpetic neuralgia: pain relief with manual therapy (case report), 180 Shoulder dysfunction altered motor control around the shoulder complex, dynamic evaluation and early management of (masterclass), 195 trapezius muscle, does tape facilitate or inhibit lower ﬁbres of, 37 Side-to-side weight-bearing asymmetry, in subjects with low back pain, 166 Spinal manipulation, for low-back pain: a treatment package agreed by the UK chiropractic, osteopathy and physiotherapy professional associations, 46 Spine back pain, see Back pain cervical, see Cervical spine; Mechanical neck disorders lumbar, see Lumbar spine reproducibility and repeatability: errors of three groups of physiotherapists in locating spinal levels by palpation, 223 Spondylolisthesis, systematic review of physiotherapy for (review), 80 Spondylolysis, systematic review of physiotherapy for (review), 80 Sports-related injury, efﬁcacy of stretching for prevention of exerciserelated injury: systematic literature review, 141 Stabilizing training, compared with manual treatment in sub-acute and chronic low-back pain, 233 Stretching, efﬁcacy for prevention of exercise-related injury: systematic literature review, 141 Supination ankle sprain, anatomical and possible clinical relationships between calcaneoﬁbular ligament and peroneus brevis, 170 T

Q Questionnaires fear-avoidance beliefs questionnaire in acute low back pain, 29 for health care provider’s attitudes and beliefs towards chronic low pack pain, 214 R Radiography, traction in glenohumeral joint, quantitive analysis of with in vivo radiographic measurements, 97 Range of motion cranio-cervical ﬂexion test, relationship between cranio-cervical ﬂexion range of motion and pressure change during, 92 measuring range of active cervical rotation in a position of full head ﬂexion using 3D Fastrak measurement system: an intra-tester reliability study, 176 telemedicine: Internet use as medium to evaluate knee angle, 242 traction in glenohumeral joint, quantitive analysis of with in vivo radiographic measurements, 97

Tampa Scale, psychometric properties of Tampa Scale for Kinesiophobia and fear-avoidance beliefs questionnaire in acute low back pain, 29 Taping, lower ﬁbres of trapezius and, facilitated or inhibited by tape, 37 Telemedicine, Internet use as medium to evaluate knee angle, 242 Tennis elbow lateral epicondylalgia: a musculoskeletal physiotherapy perspective letter, 265, 266 masterclass, 66 Traction, in glenohumeral joint, quantitive analysis of with in vivo radiographic measurements, 97 Trapezius muscle, does tape facilitate or inhibit lower ﬁbres of, 37 Traumatic brain injuries (TBI), bridging the gap across ﬁelds of practice (editorial), 63 U Ultrasound, lumbar multiﬁdus muscle size does not differ whether imaging is performed in prone or side lying, 161

ARTICLE IN PRESS Subject index / Manual Therapy 9 (2004) 52–55 V Validity, integration of concept with clinical reasoning, 117 Varicella zoster virus infection, post-herpetic neuralgia: pain relief with manual therapy (case report), 180 Vertebral artery testing effect of cervical rotation on blood ﬂow in contralateral vertebral artery, 103 false-negative extension/rotation pre-manipulative screening test on patient with an atretic and hypoplastic vertebral artery (case report), 120 VISA-A questionnaire, Achilles tendinopathy and (letter), 189, 190

55

W Walking, neuromuscular control of, with chronic low-back pain, 21 Weight-bearing asymmetry, side-to-side weight-bearing asymmetry in subjects with low back pain, 166 Whiplash associated disorders (WAD) bridging the gap across ﬁelds of practice (editorial), 63 control subjects in whiplash studies (letter), 52, 54

ARTICLE IN PRESS

Manual Therapy 9 (2004) 56–58

www.elsevier.com/locate/math

List of Reviewers 2003 Allison, Gary T.; The Centre for Musculoskeletal Studies, The University Department of Surgery, The University of Western Australia, Level 2 Medical Research Foundation Building, Rear 50 Murray Street, Perth 6000, Australia; Tel.: 618-9224-0219; fax: 618-9224-0204; [email protected] Beeton, Karen; Senior Lecturer, Department of Physiotherapy, University of Hertfordshire, College Lane, Hatﬁeld, Herts AL10 9AB, UK; Tel.: 01707284-114; fax: 01701-284-977; [email protected] Burge, Julie; Physiotherapy Department, Maidstone Hospital, Hermitage Lane, Barming, Kent ME16 9QQ, UK; Tel.: 01622-224300; [email protected] Bullock-Saxton, Joanne; [email protected] Burton, Kim; Spinal Research Unit, University of Huddersﬁeld, Ramsden Building, Queensgate, Huddersﬁeld, UK; Tel.: +44-01-484-535200; fax: +44-01-484435744; [email protected] Cairns, Mindy C.; Senior Lecturer, Department of Physiotherapy, Faculty of Health and Human Sciences, University of Hertfordshire, College Lane, Hatﬁeld, Herts AL10 9AB, UK; Tel.: (0)1707-284-127; fax: (0)1707-284-977; [email protected] Cools, Ann; University Hospital, Department of Rehabilitation Sciences and Physiotherapy and Postgraduate Education in Manual Therapy, De Pintelaan 185, 1B3, B9000 Gent, Belgium; Tel.: +32-9-240-26-32; fax: +32-9-240-38-11; [email protected] Cowell, Ian M.; Chigwell Physiotherapy Clinic, 8A Brook Parade, Chigwell, Essex IG7 6PB, UK; 020-85011449; fax: 020-8501-4126; [email protected] Danneels, Lieven; Department of Rehabilitation Science and Physical Therapy, University Hospital Gent, De Pinterlaan 185 6K3, 900 Gent, Belgium; Tel.: 32-9-240-26-35; [email protected] Edmondston, Steven J.; School of Physiotherapy, Curtin University of Technology, GPO Box U 1987, doi:10.1016/S1356-689X(03)00125-5

Perth, WA 6845, Australia; Tel.: +61-8-9266-3665; fax: +61-8-9266-3699; [email protected] Exelby, Linda; 165 Church Street, Langford, Beds, SG18 9NX, UK; Tel.: 01462-422822; fax: 01462-421968; [email protected] Falla, Deborah L.; Department of Physiotherapy, The University of Queensland, Brisbane, QLD 4072, Australia; Tel.: 61-7-33-65-46-91; fax: 61-7-33-65-2775; [email protected] Grant, Ruth; Division of Health Sciences, University of South Australia, GPO Box 2471, Adelaide SA 5001, Australia; Tel.: 61-8-8302-2030; fax: 61-8-8302-2028; [email protected] Gross, Anita; Hamilton Health Sciences, Chedoke Campus, Out-Patient Physiotherapy, Wilcox Building 1st Floor, 565 Sanatorium Road, Hamilton, Ont., CA L8N 3Z5, Canada; Tel.: 1-905-521-7945; fax: 1-905-5212606; [email protected] Hall, Toby; 81 Northwood Street, West Leederville, Western Australia 6007, Australia; Tel.: 61-8-9381-1863; [email protected] Hammond, John; Physiotherapy Department, St. Georges Hospital, Blackshaw Road, Tooting, London SW17 OQT, UK; Tel.: 0208-725-0320; [email protected] Hing, Wayne; Principal Lecturer, School of Physiotherapy, Auckland University of Technology, Private Bag 92006, Auckland 1020, New Zealand; Tel.: 64-9917-9999 ext-7800; fax: 64-9-9179796; [email protected] Hodges, Paul; Health and Rehab Sciences, School of Physiotherapy, University of Queensland, Australia; [email protected] Hough, Alan; Research Fellow/Clinical Research Centre for Healthcare Professionals, Aldro Building, University of Brighton, 49 Darley Road, Eastbourne BN20 7UR, UK; Tel.: 01273-643766; fax: 01273-643944; [email protected] Jull, Gwendolen; Department of Physiotherapy, University of Queensland, Brisbane, Queensland 4072, Australia; Tel.: 61-7-3365-2008/2019; fax: 61-7-3365-2775 [email protected]

ARTICLE IN PRESS List of Reviewers / Manual Therapy 9 (2004) 56–58

Kirk, Robin; London School of Osteopathy, 56-60 Nelson Street, London E12, UK; Tel.: 0207-2659333; [email protected] Koes, Bart; Head of Research Department, Erasmus University Rotterdam, Department of General Practice, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands; Tel.: 31-20-444-8180; fax: 31-10-4089491; [email protected] Lee, Raymond; Department of Rehabilitation Sciences, Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, Peoples’ Republic of China; Tel.: +852766-4889; fax: +852-2330-8656; [email protected] Lew, Paul; Moonee Pond Physiotherapy Centre, 25 Moore SE, Melbourne, Australia; lew@paciﬁc.net.au Lewis, Jeremy; Physiotherapy Department, Chelsea and Westminster NHS Trust, 369 Fulham Road, London SW12 9NH, UK; Tel.: +44-020-8746-8406; fax: +44-020-8746-8880; [email protected] Maheu, Elaine; 3511 Bernadette, Laval, Quebec, H7P 5J3, Canada; el.: 1-514-748-0004; fax: 1-514-748-5834; [email protected] McCarthy, Chris; The Centre for Rehabilitation Science, University of Manchester, Manchester Royal Inﬁrmary, Oxford Road, Manchester M13 9WL, UK; Tel.: 0161-276-6672; fax: 0161-276-6672; [email protected] McClune, Tim; Spinal Research Unit, University of Huddersﬁeld, 30 Queen Street, Huddersﬁeld, HD1 2SP, UK; [email protected] McMeeken, Joan; Head, School of Physiotherapy, The University of Melbourne, Victoria 3010, Australia; Tel.: 61-3-8344-4427; fax: 61-3-8344-4188; [email protected] Mercer, Susan; Senior Lecturer, Department of Anatomy and Structural Biology, Lindo Ferguson Building, University of Otago, P.O. Box 913, Otago, New Zealand; Tel.: 00-64-3-479-7353; fax: 00-64-3-479-7254; [email protected] Moore, Ann; Director of Clinical Research Centre for Healthcare Professionals, Aldro Building, University of Brighton, 49 Darley Road, Eastbourne BN20 7UR, UK; Tel. 01273-643766 fax: 01273-643944; [email protected] Mottram, Sarah; Bury Croft, Luston, Leominster HR6 0AP, UK; Tel.: 08451-300808; fax: +44-01568614993; [email protected] Newham, Diana; Head of Physiotherapy, Physiotherapy Group, King’s College London, Kensington Campus, Campden Hill Road, London W8 7AH, UK; Tel.: 0207-333-4032/4099; fax: 0207-333-4032; [email protected]

57

Ng, Joseph; Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong; Tel.: 0852-2766-6765; fax: +852-2766-23308656; [email protected] Niere, Ken; School of Physiotherapy, Faculty of Health Sciences, LaTrobe University, Locked Bag 12, Carlton South Victoria 3053, Australia; [email protected] O’Sullivan, Peter; School of Physiotherapy, Curtin University of Technology, Selby Street, Sheldon Park WA 6008, Australia; Tel.: 61-8-9266-3629; fax: 61-89266-3699; [email protected] Phillips, Dean; School of Health Professions and Rehabilitation Sciences, University of Southampton. Building 45, Highﬁeld, Southampton SO17 7BJ, UK; [email protected] Pope, Malcolm; Department of Bio-Medical Physics and Bioeningeering, University of Aberdeen, Foresthill, Aberdeen, AB25 22D, UK; Tel.: 01224-663-123 ext51155; fax: 01224-685-645; [email protected] Pool-Goudzwaard, Annelies; Medical Centre Impact, Meeuwenveld 1, 2727 AK Foefermeer, The Netherlands; Tel.: 31-79-3313-065; fax: +31-793425-765 Proctor-Smith, Nicola; Manipulative Therapy Programme, Coventry, UK; Tel.: 024-7688-7688x8719; fax: 024-7688-8020; [email protected] Rankin, Gabrielle; Research Department, Royal Hospital for Neuro-Disability, West Hill, Putney, London SW15 3SW, UK; Tel.: 020-8780-4500 ext5142; fax: 020-870-8154; [email protected] Richardson, Carolyn; Department of Phyiotherapy, The University of Queensland, Brisbane, Queensland 4072, Australia; Tel.: 317-3365-2209; fax: 317-3-365-2275; [email protected] Rivett, Darren; Head, Physiotherapy, Faculty of Medicine and Health Sciences, The University of Newcastle, University Drive, Callaghan, Newcastle NSW 2308, Australia; Tel.: 00-61-2-4921-7821; fax: 0061-2-4921-7479; [email protected] Rushton, Alison; School of Health Sciences (Physiotherapy), University of Birmingham—Morris House, Edgbaston, Birmingham B15 2TT, UK; Tel.: +44-0121627-2832; fax: +44-0121-627-2021; [email protected] Schonstein, Eva; Lecturer, School of Physiotherapy, The University of Sydney, Cumberland Campus, East Street, Lidcombe NSW 2141, Australia; Tel.: 61-2-93519550; fax: 61-2-9351-9278; [email protected]

ARTICLE IN PRESS 58

List of Reviewers / Manual Therapy 9 (2004) 56–58

Shacklock, Michael; 6th Floor, 118 King William Street, Adelaide, SA 5000, Australia; Tel.: 00-61-8-82124886; fax: +61-(0)8-8212-8028; [email protected] Shirley, Deborah; School of Physiotherapy, Faculty of Health Sciences, University of Sydney, P.O. Box 170, Lidcombe, NSW 1825, Australia; Tel.: 0061-2-93519177; fax: 0061-2-9351-9601; [email protected] Sims, Kevin; [email protected] Singer, Kevin; Director, Centre for Musculoskeletal Studies, Department of Surgery, Royal Perth Hospital, The University of Western Australia, 58 Murrary Street, Perth, WA 6000, Australia; Tel.: 61-8-9224-0200; [email protected] Sterling, Michele; Department of Physiotherapy, The University of Queensland, St. Lucia 4072, Australia; Tel.: 61-7-3365-2275; fax: 61-7-3365-2775; [email protected]

Stokes, Maria; Director of Research and Development, Royal Hospital for Neurodissability, West Hill, Putney, London SW15 3SW, UK; Tel.: 0208-7804531; fax: 0208-7804507; [email protected] Vicenzino, Bill; Department of Physiotherapy, The University of Queensland, Brisbane, Queensland 4072, Australia; Tel.: 61-7-33652781; fax: 61-7-33652775; [email protected] Vlaeyen, Johan; Department of Medical, Clinical and Experimental Psychology, Maastricht University, P.O. Box 616, 6200 MD Maatsricht, The Netherlands; [email protected] Wright, Tony; The Head of School of Physiotherapy, Curtin University of Technology, GPO Box U1978, Perth WA 6845, Australia; Tel.: 61-8-9266-3618; fax: 618-9266-3699; [email protected]