VOLUME 13 NUMBER 3 PAGES 181–276 June 2008
Editors
International Advisory Board
Ann Moore PhD, GradDipPhys, FCSP, CertEd, FMACP Clinical Research Centre for Health Professions University of Brighton Aldro Building, 49 Darley Road Eastbourne BN20 7UR, UK
K. Bennell (Victoria, Australia) K. Burton (Hudders¢eld, UK) B. Carstensen (Frederiksberg, Denmark) M. Coppieters (Queensland, Australia) E. Cruz (Setubal Portugal) L. Danneels (Mar|¤ akerke, Belgium) S. Durrell (London, UK) S. Edmondston (Perth, Australia) J. Endresen (Flaktvei, Norway) L. Exelby (Biggleswade, UK) D. Falla (Aalborg, Denmark) T.W. Flynn (Denver, CO, USA) J. Greening (London, UK) C. J. Groen (Utrecht,The Netherlands) A. Gross (Hamilton, Canada) T. Hall (West Leederville, Australia) W. Hing (Auckland, New Zealand) M. Jones (Adelaide, Australia) S. King (Glamorgan, UK) B.W. Koes (Amsterdam,The Netherlands) J. Langendoen (Kempten, Germany) D. Lawrence (Davenport, IA, USA) D. Lee (Delta, Canada) R. Lee (Brighton, UK) C. Liebenson (Los Angeles, CA, USA) L. Ma¡ey-Ward (Calgary, Canada) E. Maheu (Quebec, Canada) C. McCarthy (Coventry, UK) J. McConnell (Northbridge, Australia) S. Mercer (Queensland, Australia) D. Newham (London, UK) J. Ng (Hung Hom, Hong Kong) S. O’Leary (Queensland, Australia) L. Ombregt (Kanegem-Tielt, Belgium) N. Osbourne (Bournemouth, UK) M. Paatelma (Jyvaskyla, Finland) N. Petty (Eastbourne, UK) A. Pool-Goudzwaard (The Netherlands) M. Pope (Aberdeen, UK) G. Rankin (London, UK) D. Reid (Auckland, New Zealand) A. Rushton (Birmingham, UK) C. Shacklady (Manchester, UK) M. Shacklock (Adelaide, Australia) D. Shirley (Lidcombe, Australia) V. Smedmark (Stenhamra, Sweden) W. Smeets (Tongeren, Belgium) C. Snijders (Rotterdam,The Netherlands) R. Soames (Dundee, UK) P. Spencer (Barnstaple, UK) M. Sterling (St Lucia, Australia) P. Tehan (Victoria, Australia) M. Testa (Alassio, Italy) M. Uys (Tygerberg, South Africa) P. van der Wur¡ (Doorn,The Netherlands) P. van Roy (Brussels, Belgium) B.Vicenzino (St Lucia, Australia) H.J.M.Von Piekartz (Wierden,The Netherlands) M.Wallin (Spanga, Sweden) M.Wessely(Paris, France) A.Wright (Perth, Australia) M. Zusman (Mount Lawley, Australia)
Gwendolen Jull PhD, MPhty, Grad Dip ManTher, FACP Department of Physiotherapy University of Queensland Brisbane QLD 4072, Australia Associate Editor’s Darren A. Rivett PhD, MAppSc, (ManipPhty) GradDipManTher, BAppSc (Phty) Discipline of Physiotherapy Faculty of Health The University of Newcastle Callaghan, NSW 2308, Australia Tim McClune D.O. Spinal Research Unit. University of Hudders¢eld 30 Queen Street Hudders¢eld HD12SP, UK Editorial Committee Masterclass Editor Karen Beeton PhD, MPhty, BSc(Hons), MCSP MACP ex o⁄cio member Associate Head of School (Professional Development) School of Health and Emergency Professions University of Hertfordshire College Lane Hat¢eld AL10 9AB, UK Case reports & Professional Issues Editor Je¡rey D. Boyling MSc, BPhty, GradDipAdvManTher, MCSP, MErgS Je¡rey Boyling Associates Broadway Chambers Hammersmith Broadway LondonW6 7AF, UK Book Review Editor Raymond Swinkels MSc, PT, MT Ulenpas 80 5655 JD Eindoven The Netherlands
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Editorial
Specialization in musculoskeletal physiotherapy—the Australian model In many countries around the world, a number of factors over the past decade or more have stimulated changes in the tasks of the health workforce and methods of healthcare delivery. One outcome is that physiotherapists are assuming greater and more diverse roles and responsibilities in provision of healthcare and many are providing specialist expertise to patients in both the private and public sectors. There is a demand for specialists in the sub-disciplines of physiotherapy in this current environment. There is also a need for clear and attainable career pathways for clinicians to provide, and to be recognized, for these specialist services. Around the world, there are different processes and requirements for clinical specialization in musculoskeletal physiotherapy. In this editorial we present an overview of the specialization process in Australia, where the past 5 years in particular have witnessed an impetus in the process and collaborative development of a revised model for clinical specialization. The Australian College of Physiotherapists is the arm of the Australian Physiotherapy Association responsible for the specialization process and for awards of Fellowship in Specialization in the sub-disciplines of physiotherapy, inclusive of musculoskeletal physiotherapy. Rather than being a mid or end point of a career, the strong vision of the new process is that specialization is the beginning of a career as a specialist in a field of physiotherapy practice, akin to the medical model. It is possible for a physiotherapist in the new model to fulfil all requirements of the process and 5 years after graduation, to begin a specialist career. The specialization process in physiotherapy in Australia is designed and operates for all sub-disciplines of physiotherapy, but musculoskeletal physiotherapy is highlighted in this instance. The revised model of the specialization process considers the new graduate. The initial phase after graduation requires at least 2 years of clinical experience and relevant professional development activities in musculoskeletal physiotherapy. The middle phase of the process requires successful completion of a university postgraduate coursework masters 1356-689X/$ - see front matter r 2008 Published by Elsevier Ltd. doi:10.1016/j.math.2008.03.005
program in musculoskeletal physiotherapy, which has been accredited by Musculoskeletal Physiotherapy Australia (MPA). Alternately, a physiotherapist may successfully complete a more independent program of continuing professional development and sit the MPA challenge examinations in both clinical and theoretical domains. The aim of either route is to attain what is termed ‘titled’ membership status of the MPA and Australian Physiotherapy Association. Following attainment of titled membership, the musculoskeletal physiotherapist can become an associate member of the Australian College of Physiotherapists and, as a candidate for specialization, embark on the final stages of the specialization process. The final stage of the specialization process involves a 2 year training period under the direction of the College as well as final specialist examinations. In the 2 year training period, the candidate works in clinical practice and undertakes a mentored program of professional development, which has a strong emphasis on clinical development. During this training period, the candidate is required to provide evidence of development of quality and specialist-level practice as well as professional leadership through contributions to education of students or peers, a commitment to life-long learning and participation in and support of research activity. Once this period is completed and, on the recommendation of the College mentor, the candidate can present for the final examinations for specialization. These examinations consist of clinical examinations of two patients evaluated and treated over 2 days as well as an oral examination to allow the candidate to demonstrate their clinical expertise and knowledge. An alternate pathway for the training process is successful completion of a postgraduate clinical doctorate in the field of specialization. The College works with the Australian universities offering postgraduate clinical doctorates to ensure the requirements within the clinical doctorate parallel those of the specialization process before the candidate sits for the final examinations in the Fellowship process.
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Editorial / Manual Therapy 13 (2008) 181–182
In the transition to the new model, consideration has been given to existing titled members of the MPA who can provide evidence that they are working at an advanced level in clinical practice and that they have fulfilled the requirements of the specialization training period. In recognition of their expertise, a provision was made for a 3 year period (ending December 2009) for current musculoskeletal physiotherapists to apply immediately for the final examination process. In 2007, the College inducted 26 new Specialist Musculoskeletal Physiotherapists and it is estimated that between 30 and 40 candidates will undertake the final examinations in 2008. In addition, calls will be made this year for applications to join the training program.
There is a need for physiotherapists to have high-level expertise to provide leadership in the delivery of specialist assessment and care of patients with musculoskeletal disorders. Specialization provides the avenue for training and importantly the recognition of the specialist skills of physiotherapists and has been enthusiastically embraced in the Australian context.
Editors Gwendolen Jull & Ann Moore (Gwendolen Jull is President, Australian College of Physiotherapists)
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Original article
Standing balance: A comparison between idiopathic and whiplash-induced neck pain Sandra Field, Julia Treleaven, Gwendolen Jull Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, 4072 Queensland, Australia Received 24 April 2006; received in revised form 7 August 2006; accepted 1 December 2006
Abstract Disturbances of balance have been found both in patients with whiplash-associated disorders and idiopathic neck pain. This study directly compared balance between these groups to determine if neck pain precipitated by trauma resulted in greater or different balance impairments. The study was a comparative, observational design. Thirty subjects with whiplash, 30 with idiopathic neck pain and 30 healthy controls, took part in the study. Subjects performed balance tests in comfortable, narrow and tandem stances. Balance disturbances (sway energy and/or root mean squared (RMS) amplitude) were evident in several tests between subjects with neck pain and controls. Direct comparison between the neck pain groups revealed that the whiplash group had significantly greater sway energy and RMS amplitude than the idiopathic group in comfortable stance tests on a soft surface (F44.4, po0.04). Further, the whiplash group had greater RMS, but significantly less sway energy than the idiopathic group in most narrow stance tests in the anterior posterior direction F45.8, po0.02). Both neck pain groups were also significantly less able to complete the eyes closed, tandem test compared to control subjects. In conclusion, the study has found that balance deficits exist in both subjects with whiplash-associated disorders and idiopathic neck pain compared to controls; however, differences in balance strategies may exist between the neck pain groups. Overall, subjects who have experienced trauma appear to have greater balance disturbances. r 2007 Elsevier Ltd. All rights reserved. Keywords: Balance; Whiplash; Neck pain; Proprioception; Wavelet analysis; RMS
1. Introduction Recently, neck pain has been broadly classified as idiopathic or trauma-induced neck pain (e.g. neck pain from a whiplash injury)1 as is not possible to make a definitive pathoanatomical diagnosis in most cases. Such a classification recognizes a difference in mechanism of onset, which implies that with the involvement of trauma, there might be differences in the nature or magnitude of pathophysiological features between the two neck pain types. Recent research is supporting this Corresponding author. Tel./fax: +61 7 3365 1622.
E-mail address:
[email protected] (J. Treleaven). Australian Acute Musculoskeletal Pain Guidelines. Evidence Based Management of Acute Musculoskeletal Pained. Brisbane: Australian Academic Press, 2003 /http://www.nhmrc.gov.auS. 1
1356-689X/$ - see front matter r 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.12.005
assumption. For example, Scott et al. (2005) found greater and more widespread mechanical and thermal hyperalgesia in a chronic whiplash group compared to an idiopathic neck pain group. There is also some preliminary evidence to suggest that measured impairments reflective of the sensorimotor control system (eye movement control and cervical joint position error) are of greater magnitude when trauma has precipitated the neck pain (Kristjansson et al., 2003; Michaelson et al., 2003; Tjell et al., 2003). Our interest in this study is in balance disturbances. Patients with neck pain of both idiopathic and whiplash origin have been found to have deficits in standing balance (Karlberg et al., 1995, 1996a, b; Koskimies et al., 1997; McPartland et al., 1997; El-Kahky et al., 2000; Michaelson et al., 2003; Schieppati et al., 2003; Sjostrom et al., 2003; Treleaven
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et al., 2005a). In the absence of vestibular pathology, this has been attributed to altered cervical somotosensory input (Karlberg et al., 1996a). A link between neck pain and impairment in balance is suggested in several studies, which have demonstrated improvements in standing balance following treatment localized to the cervical spine (Alund et al., 1993; Fattori et al., 1996; Karlberg et al., 1996b; Persson et al., 1996). The co-occurrence of neck pain and balance disturbances is not surprising as the abundant cervical receptors in the muscles and joints of the cervical spine as well as their central and reflex connections to the vestibular, visual and postural control systems suggest that they have an important role in providing information for general postural control (Karlberg et al., 1995; Lekhel et al., 1998; Bove et al., 2002; Peterson, 2004). The association between disturbances to cervical afferentation and disturbances to standing balance has been demonstrated in several ways. At the extreme, sectioning of the cervical dorsal root ganglions or anaesthetization of deep neck structures causes severe ataxia (Ishikawa et al., 1998) and disequilibrium (DeJong and DeJong, 1977). Less extremely, neck muscle vibration, which primarily stimulates the muscle spindle afferents, increases body sway (Kavounoudias et al., 1999) and influences velocity and direction of gait and running (Bove et al., 2002; Courtine et al., 2003). Vibration of neck muscles has a greater influence on postural sway when compared to most other muscles in the body (Pyykko et al., 1989). Studies have also demonstrated the direct deleterious effects of neck extensor muscle fatigue on standing balance (Schieppati et al., 2003; Gosselin et al., 2004), and McPartland et al. (1997) determined a significant correlation between poor balance control and fatty infiltration of the rectus capitis posterior minor muscle. There are several mechanisms via which neck pain might cause altered cervical somotosensory input and integration to the postural control system. These include: direct trauma to the cervical receptors or the functional impairment of cervical muscle and joint receptors that may result from the trauma (Heikkila and Astrom, 1996); inflammatory mediators may activate chemosensitive nerve endings in joints and muscles leading to altered muscle spindle activity (Wenngren et al., 1998; Thunberg et al., 2001); the effects of pain on nociceptor and mechanoreceptor activity locally at the spinal cord and within the central nervous system may influence the central modulation of afferent input and in consequence, neuromuscular and postural control (Le Pera et al., 2001; Ageborg, 2002). We questioned whether balance disturbances were greater when neck pain was associated with trauma (whiplash in this instance) when compared to an idiopathic or non-trauma origin. In trauma, a larger number of structures and thus sources of afferent input
could be damaged and a greater number of mechanisms may be involved. As a consequence, there may be differences in either the nature or magnitude of pathophysiological features between the two neck pain types, which may have implications for clinical assessment and management. This study was conducted to provide a direct comparison of balance responses between these groups to inform practice. We hypothesized that there would be differences between the groups and balance deficits would be more pronounced in the whiplash group.
2. Methods 2.1. Participants Thirty subjects with idiopathic neck pain, 30 subjects with persistent whiplash associated disorders and 30 healthy control subjects participated in the study. Idiopathic neck pain and healthy subjects were recruited from advertisements within the community. Whiplash subjects were recruited from eligible consecutive patients attending a Whiplash Research Unit and were included if categorized as WAD II according to the Quebec Task Force classification (Spitzer et al., 1995). The age range of subjects was restricted to 18–45 years inclusively, to exclude the variable of aging on balance measures (Speers et al., 1998). To be included in either neck pain group, pain was to be of greater than 3 months duration with a score of at least 10 out of 100 on the Neck Disability Index (NDI) (Vernon, 1996). In our previous research on subjects with whiplashassociated disorders, we have determined that those reporting dizziness and unsteadiness have greater deficits in balance than those not complaining of these symptoms (Treleaven et al., 2005a). To better standardize the three groups, no volunteer was considered if they reported dizziness or unsteadiness. To control for other variables, which could influence balance responses, no subject was considered if they had current or past lower limb problems, known vestibular pathology, significant visual or hearing deficits, neurological deficits, Type II diabetes, abnormal blood pressure, or diagnosed psychiatric disorders. Whiplash subjects were also excluded if there was a loss of consciousness at the time of injury and volunteers for the idiopathic neck pain and control groups were not considered if they had a past history of whiplash. All volunteers accepted into the study were asked to refrain from taking medication such as antipsychotic and narcotic medication that may influence balance and from consuming alcohol for 24 h prior to testing (Alund et al., 1991). Ethical clearance for the study was obtained from the institutional Medical Ethics Committee and all procedures
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were conducted according to the Declaration of Helsinki. All the subjects gave their written informed consent to undertake the study. 2.2. Measurements Questionnaires were administered to collect demographic data, levels of current resting pain (VAS, Huskisson, 1983), and self-reported neck disability (NDI, Vernon, 1996). Neck pain subjects also completed the State Trait Anxiety Inventory—short form (Marteau and Bekker, 1992), which included measures of both ‘state’ (how they felt at the time of the investigation) and ‘trait’ (how they generally felt) anxiety levels. Scores were prorated to the full score. Both features were scored from 20 (little anxiety) to 80 (maximum anxiety). 2.3. Computerized posturography Postural sway was measured on a 40 60 cm stable computerized force platform. Centre of pressure force changes in the medio-lateral (ML) and antero-posterior (AP) directions were measured, over time, by ground reaction forces registering on four, corner strain gauges mounted within the floor. The force changes were converted to electrical signals by the force transducers and charge amplifiers. An analogue low pass filter was used to restrict the frequency content on the signals to within 0–5 Hz. The force signals were then AD converted at a sampling rate of 15 Hz and recorded using a Labview (2000 National Instruments) programme. The raw signal was produced both numerically and graphically. A modified Clinical Test of Sensory Integration and Balance (CTSIB) was used to assess standing balance (Shumway-Cook and Horak, 1986). Ten tests were performed in total (Shumway-Cook and Horak, 1986). The tests consisted of four tests in comfortable stance—standing on a firm surface and on a soft surface (a piece of high density 10-cm-thick foam rubber placed on the force platform) with eyes open and eyes closed. These four tests were then repeated in narrow stance. Each subject also performed two tests in tandem stance—firm surface with eyes open and closed. Only pass/failure rates were recorded for tandem tests, as it was known from previous research that limited numbers of subjects from the neck pain groups would be able to complete these tests (Treleaven et al., 2005a). 2.4. Procedure Inclusion/exclusion criteria were determined via telephone interview and questionnaires were completed at the time of testing. For the tests of balance, the subjects stood on the force platform. They were instructed to stare at a dot clearly marked on the wall at a distance of 1.5 m and asked to stand as steadily as possible with
185
their arms by their sides. Consistent clear instruction was given for each test. Each subject performed ten tests. Foot position for comfortable stance was repositioned exactly using a paper trace as described by McIlroy and Maki (1997). For narrow stance, the subjects were asked to place the middle of their right foot to the right of the marked centre point of the force plate, their left foot was placed parallel and as close as possible to their right foot. For tandem stance, the dominant foot, defined as that which would be most likely used to kick a ball, was placed directly behind the non-dominant foot (McPartland et al., 1997; Riemann and Guskiewicz, 2000). One 30-s trial was performed for each balance condition. For all tests, an inability to stand without losing balance for a 30 s time period was recorded as failure to complete the particular test. 2.5. Statistical analysis Failure rates and percentages were calculated for tandem stance conditions. Fischer’s exact test was used to determine any significant differences between groups. Wavelet analysis using Daubechies filter 6 was chosen for the analysis of postural sway, as our previous studies of balance in comfortable stance had determined that this analysis was better able to distinguish between whiplash and asymptomatic subjects than the measure of total sway distance (Treleaven et al., 2005b). Analysis was conducted for both the AP and ML traces in comfortable and narrow stance tests and both directions were considered separately. Normality of the data set was assessed using Q–Q plots to verify parametric test use and data were logged. Differences between the chronic neck pain groups for age, VAS, anxiety (state and trait) and NDI scores were assessed initially using a series of one-way ANOVA’s. Group differences due to signal energies were examined using a generalized linear model, MANOVA. Current and general anxiety levels, the NDI, current pain level (VAS) and age were included as separate factors in the MANOVA for both neck pain groups. Where these had a significant influence on within subjects’ balance measures, they were included into the final between groups analysis as co-variates.
3. Results Group characteristics for age, gender, VAS, NDI, anxiety (state and trait) scores are presented in Table 1. There were no significant between group differences for age (p ¼ 0.20) and anxiety scores (state, p ¼ 0.47; trait p ¼ 0.12). The whiplash group had significantly greater resting pain (VAS p ¼ 0.05) and NDI scores (p ¼ 0.00) and these were included as co-variates in analyses of the neck pain groups.
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3.1. Comfortable stance
comparison between the whiplash and idiopathic groups demonstrated that the whiplash subjects had significantly greater sway energy in tests of both eyes open (F ¼ 4.4, p ¼ 0.04) and closed (F ¼ 5.7, p ¼ 0.02) on the soft surface in the ML direction.
The means, standard errors and the significance between group differences for the logged energy values are presented for each test condition in the anterior posterior and medial lateral directions of the tests in comfortable stance (Fig. 1a and b) for the whiplash, idiopathic neck pain and control groups. As a general observation, there was a trend for more impaired balance (greater mean total energy of sway) for both the whiplash and idiopathic neck pain groups compared to the control group. Differences between the whiplash and control subjects were significant only in the tests of eyes open, firm surface and eyes closed, soft surface in the AP direction and eyes open and closed on the soft surface in the ML direction (Fig. 1a and b). Direct
3.2. Narrow stance The means, standard errors and the significant between group differences for the logged energy values are presented for each test condition in the AP and ML directions for the tests in narrow stance (Fig. 2a and b) for the whiplash, idiopathic neck pain and control groups. In narrow stance, subjects with idiopathic neck pain had greater sway energy in most narrow stance tests in the AP direction when compared to both subjects with whiplash and control subjects. Specifically differences between the subjects with whiplash and subjects with idiopathic neck pain revealed greater energy of sway in the idiopathic neck pain subjects for all tests in the AP direction in narrow stance apart from the eyes open on the firm surface condition (F45.8, po0.02). Conversely, in the narrow stance test of eyes open on a firm surface in the ML direction, subjects with whiplash had significantly greater energy than the idiopathic neck pain subjects (F ¼ 5.0, p ¼ 0.03). There were no other significant differences between the whiplash subjects and the control subjects in energy of sway in narrow stance. These results in narrow stance for the whiplash subjects were unexpected and against the general trend observed in comfortable stance. In order to determine if this was a true finding or a factor of the type of analysis
Table 1 Subject demographics for the control, idiopathic neck pain and whiplash groups
Age (years) Gender (% female) Resting pain (VAS) NDI (%) Anxiety State (/80) Trait (/80)
Control (n ¼ 30) Mean (SE)
Idiopathic (n ¼ 30) Mean (SE)
Whiplash (n ¼ 30) Mean (SE)
26.8 (1.3) 77 — — — — —
27.9 (1.3) 77 2.2 (0.2) 21.5 (1.4)
30.3 (1.3) 80 3.2 (0.4)* 36.9 (2.8)*
34 (2) 41(2)
32 (2) 45 (2)
*po0.05.
a
b 2
*
*
* Controls IDP WAD
1.8 1.6
*
*
2 1.8 1.6 Logged Energy
1.4 Logged Energy
*
1.2 1 0.8 0.6
1.4 1.2 1 0.8 0.6
0.4
0.4
0.2
0.2 0
0 EOF
ECF
EOS
ECS
EOF
ECF
EOS
ECS
Test Test *=p
