Manual Therapy Journal - Volume 11, Issue 4, Pages 241-358 (November 2006)

VOLUME 11 NUMBER 4 PAGES 241–358 NOVEMBER 2006 Editors International Advisory Board Ann Moore PhD, GradDipPhys, FCSP,...

Author: Editors: Ann Moore and Gwen Jull

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VOLUME 11 NUMBER 4 PAGES 241–358 NOVEMBER 2006

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) E. Cruz (Setubal Portugal) L. Danneels (Mar|¤ akerke, Belgium) S. Durrell (London, UK) S. Edmondston (Perth, Australia) J. Endresen (Flaktvei, Norway) L. Exelby (Biggleswade, UK) J. Greening (London, UK) C. J. Groen (Utrecht,The Netherlands) A. Gross (Hamilton, Canada) T. Hall (West Leederville, Australia) W. Hing (Auckland, New Zealand) M. Jones (Adelaide, Australia) S. King (Glamorgan, UK) B.W. Koes (Amsterdam,The Netherlands) J. Langendoen (Kempten, Germany) D. Lawrence (Davenport, IA, USA) D. Lee (Delta, Canada) R. Lee (Hung Hom, Hong Kong) C. Liebenson (Los Angeles, CA, USA) L. Ma¡ey-Ward (Calgary, Canada) C. McCarthy (Coventry, UK) J. McConnell (Northbridge, Australia) S. Mercer (Queensland, Australia) E. Maheu (Quebec, Canada) D. Newham (London, UK) J. Ng (Hung Hom, Hong Kong) L. Ombregt (Kanegem-Tielt, Belgium) N. Osbourne (Bournemouth, UK) M. Paatelma (Jyvaskyla, Finland) N. Petty (Eastbourne, UK) A. Pool-Goudzwaard (The Netherlands) M. Pope (Aberdeen, UK) G. Rankin (London, UK) D. Reid (Auckland, New Zealand) M. Rocabado (Santiago, Chile) C. Shacklady (Manchester, UK) M. Shacklock (Adelaide, Australia) D. Shirley (Lidcombe, Australia) V. Smedmark (Stenhamra, Sweden) W. Smeets (Tongeren, Belgium) C. Snijders (Rotterdam,The Netherlands) M. Sterling (St Lucia, Australia) R. Soames (Leeds, UK) P. Spencer (Barnstaple, UK) P. Tehan (Victoria, Australia) M. Testa (Alassio, Italy) M. Uys (Tygerberg, South Africa) P. van Roy (Brussels, Belgium) B.Vicenzino (St Lucia, Australia) H.J.M.Von Piekartz (Wierden,The Netherlands) M.Wallin (Spanga, Sweden) M.Wessely(Paris, France) A.Wright (Perth, Australia) M. Zusman (Mount Lawley, Australia)

Gwendolen Jull PhD, MPhty, Grad Dip ManTher, FACP Department of Physiotherapy University of Queensland Brisbane QLD 4072, Australia Editorial Committee Masterclass Editor Karen Beeton 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 Tim McClune D.O. Spinal Research Unit. University of Hudders¢eld 30 Queen Street Hudders¢eld HD12SP, UK Case reports & Professional Issues Editor Darren A. Rivett PhD, MAppSc, MPhty, GradDip ManTher, BAppSc (Phty) Discipline of Physiotherapy Faculty of Health The University of Newcastle Callaghan, NSW 2308, Australia Book Review Editor Raymond Swinkels MSc, PT, MT Ulenpas 80 5655 JD Eindoven The Netherlands

Visit the journal website at http://www.intl.elsevierhealth.com/journals/math doi:10.1016/S1356-689X(06)00152-4

ARTICLE IN PRESS

Manual Therapy 11 (2006) 241–242 www.elsevier.com/locate/math

Editorial

Adverse events and the vertebral artery: Can they be averted? Cervical spine manipulation continues to be the subject of much debate almost a century after the first manipulative complication was described in 1907. Essentially those who advocate abandoning cervical manipulation contend that despite it remaining a common treatment for neck pain and headache, there are safer and equally effective alternative interventions. However, is this indeed the case? While at this time there is only limited evidence for the efficacy of neck manipulation, there is even less for the most likely alternative intervention, passive joint mobilization (NHMRC, 2003). Similarly, cervical mobilization is not without its risks as recent reports have highlighted (Magarey et al., 2004). Nevertheless, the complications associated with cervical manipulation are more clearly established and in general more serious. Of the various complications attributed to neck manipulation, stroke is arguably the most serious (Rivett, 2004). Despite some recent controversy as to whether the internal carotid artery is also at risk, the vertebral artery is unquestionably the most vulnerable vessel. The intimate relationship of the vertebral artery to the cervical vertebrae as it ascends through the transverse foraminae, the relative fixity of the segment between the atlas and the axis, together with the large excursion of rotation at the atlanto-axial articulation, may lead to ‘kinking’ (or other mechanical stressing) of the contralateral vessel during rotation. Vertebrobasilar insufficiency may result but the individual response largely depends on the calibre and patency of the opposite artery and its ability to maintain hindbrain perfusion. Certainly it is likely that any blood flow changes during neck rotation, whether manifest via symptomatic response or through some form of imaging such as duplex ultrasound, are the consequence of biomechanical stress imparted to the arterial wall (Haynes, 2000). The actual risk of stroke associated with manipulation of the cervical spine is unknown as the event is relatively rare, rendering prospective epidemiological investigations impractical. Best estimates from retrospective studies of the medical (Dvora´k et al., 1993, o1 per 150,450 manipulations), chiropractic (Rothwell 1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.08.001

et al., 2001, 1.3 per 100,000 patients o45 years) and physiotherapy professions (Rivett and Reid, 1998, 1 per 163,371 manipulations) tend to indicate that a practitioner would be unfortunate to encounter such an event even once in their career. Nonetheless, the potential for permanent disability or death from a vertebrobasilar stroke following neck manipulation obliges practitioners to undertake all reasonable precautions to prevent such an incident. So what can be done to prevent such potentially tragic sequelae to the physical treatment of a relatively benign disorder? First, the practitioner should develop a high degree of clinical suspicion when a patient presents with a sudden onset of severe, sharp pain in the posterosuperior neck and occipital region (Haldeman et al., 2002; Krespi et al., 2002; Thiel and Rix, 2005). This presentation is typical of a dissecting vertebral artery and may or may not be associated with a recent history of trauma to the cervical spine or with more recognizable neurological symptoms, such as hemianopia or dysphagia. Of course, there may be simple musculoskeletal causes for such pain, but extreme caution should be exercised in employing any form of manual therapy if there is no prior history of similar pain. It is a sobering thought that pain from a vertebral artery dissection may actually prompt the patient to seek manipulative treatment! Second, do not consider using neck manipulation unless you have been properly trained in the application of the technique. There has been much recent debate about what is the appropriate level of education in spinal manipulation, but with no clear answer emerging (Refshauge et al., 2002; Boissonnault et al., 2004). What is clear however, is that many cases of manipulative complication are the result of poor clinical reasoning and the failure to recognize red flags or atypical clinical findings (Di Fabio, 1999; Rivett, 2004). In addition to technical training in manipulation to reduce hazardous practices such as overly vigorous thrusting forces, the thinking skills needed to appropriately and safely apply neck manipulation also require careful cultivation. To this end, the Australian Physiotherapy Association has produced an ‘at a glance’ colour flowchart to assist the

ARTICLE IN PRESS 242

Editorial / Manual Therapy 11 (2006) 241–242

practitioner in their clinical reasoning when considering cervical spine manipulation for a particular patient (Rivett et al., 2006). Finally, the pre-manipulative use of provocative positional tests still has a role in the prevention of neurovascular manipulative complications (Rivett et al., 2006). Although the validity of tests involving sustained end-range rotation and/or extension of the neck has been seriously challenged of late (Thiel and Rix, 2005), provocative testing may still detect an occasional patient experiencing vertebrobasilar insufficiency related to positional occlusion of a vertebral artery, particularly when the opposite artery provides insufficient collateral flow. However the practitioner needs to be aware that dizziness is not the only possible positive response to provocative testing, but that other less recognized and indistinct symptoms may be elicited, including tinnitus, tremors, anxiety and nausea. The practitioner also needs to be mindful that the tests are limited in their predictive ability with false positive and false negative findings common, and with the number of ultrasonographic studies equally divided as to whether there are flow changes during neck rotation or not (Magarey et al., 2004). Positional testing of the cervical spine in combination with the use of a hand-held Doppler velocimeter shows greater promise and may provide more valid clinical information as to blood flow changes and anomalies (Haynes, 2000). Further research is needed to clearly determine the clinical value of this tool in pre-manipulative screening, and to develop a means to detect patients at risk of vertebral artery dissection. Research is presently being conducted at the University of Newcastle in Australia in both these areas. So can adverse events of the vertebral artery be averted? In many cases yes, if the practitioner is alert to the dissecting vertebral artery, thorough in their routine examination for vertebrobasilar insufficiency, and well trained technically and cognitively in cervical spine manipulation. Despite these precautions, a small number of unfortunate and unpredictable neurovascular complications will continue to occur for some time yet, at least until better screening procedures are developed and proven.

References Boissonnault W, Bryan JM, Fox KJ. Joint manipulation curricula in physical therapist professional degree programs. Journal of Orthopaedic & Sports Physical Therapy 2004;34:171–8. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Therapy 1999;79:50–65. Dvora´k J, Loustalot D, Baumgartner H, Antinnes JA. Frequency of complications of manipulation of the spine. A survey among the members of the Swiss Medical Society of Manual Medicine. European Spine Journal 1993;2:136–9. Haldeman S, Kohlbeck FJ, McGregor M. Stroke, cerebral artery dissection, and cervical spine manipulation therapy. Journal of Neurology 2002;249:1098–104. Haynes MJ. Vertebral arteries and neck rotation: Doppler velocimeter and duplex results compared. Ultrasound in Medicine and Biology 2000;26:57–62. Krespi Y, Gurol ME, Coban O, Tuncay R, Bahar S. Vertebral artery dissection presenting with isolated neck pain. Journal of Neuroimaging 2002;12:179–82. Magarey ME, Rebbeck T, Coughlan B, Grimmer K, Rivett DA, Refshauge K. Pre-manipulative testing of the cervical spine. Review, revision and new clinical guidelines. Manual Therapy 2004;9:95–108. National Health and Medical Research Council (NHMRC). Australian Acute Musculoskeletal Pain Guidelines Group. Evidencebased management of acute musculoskeletal pain. Brisbane: Australian Academic Press Pty. Ltd.; 2003 Available at /http:// www.nhmrc.gov.au/publications/_files/cp94.pdfS. Refshauge KM, Parry S, Shirley D, Larsen D, Rivett DA, Boland R. Professional responsibility in relation to cervical spine manipulation. Australian Journal of Physiotherapy 2002;48:171–9. Rivett DA. Adverse effects of cervical manipulative therapy. In: Boyling JD, Jull GA, editors. Grieve’s modern manual therapy of the vertebral column. 3rd ed. Edinburgh: Churchill Livingstone; 2004. p. 533–49. Rivett DA, Reid D. Risk of stroke for cervical spine manipulation in New Zealand. New Zealand Journal of Physiotherapy 1998;26(2):14–7. Rivett DA, Shirley D, Magarey M, Refshauge K. Clinical guidelines for assessing vertebrobasilar insufficiency in the management of cervical spine disorders. Melbourne: Australian Physiotherapy Association; 2006. Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: a population-based case–control study. Stroke 2001;32:1054–60. Thiel H, Rix G. Is it time to stop functional pre-manipulative testing of the cervical spine? Manual Therapy 2005;10:154–8.

Darren A. Rivett Discipline of Physiotherapy, School of Health Sciences, The University of Newcastle, Callaghan, NSW 2308, Australia E-mail address: [email protected].

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Masterclass

Cervical arterial dysfunction assessment and manual therapy Roger Kerrya,, Alan J. Taylorb a

Division of Physiotherapy Education, University of Nottingham, UK b Nottingham Nuffield Hospital, Nottingham, UK

Abstract In this paper, we present a clinical overview of cervical arterial dysfunction (CAD) for manual therapists who treat patients presenting with cervical pain and headache syndromes. An overview of vertebrobasilar arterial insufficiency (VBI) is given, with reference to assessment procedures recommended by commonly used guidelines. We suggest that the evidence supporting contemporary practice is limited and present a more holistic, evidence-based approach to considering CAD. This approach considers typical pain patterns and clinical progressions of both vertebrobasilar, and internal carotid arterial pathologies. Attention to the risk factors and pathomechanics of arterial dysfunction is also given. We suggest that consideration of the information provided in this Masterclass will enhance the manual therapist’s clinical reasoning with regard to differential diagnosis of cervical pain syndromes, and prediction of serious adverse reactions to treatment. r 2006 Elsevier Ltd. All rights reserved. Keywords: Vertebrobasilar insufficiency; Internal carotid artery; Arterial dissection; Haemodynamics; Clinical reasoning

1. Introduction Guidelines for screening patients for the risk of neurovascular complication post-manual therapy have been available for clinical use for a number of years (APA, 1988, 2000, 2006; Barker et al., 2001). However, several authors have recently questioned the utility of such guidelines (AJP, 2001; Kerry, 2002; Childs et al., 2005; Rivett et al., 2005; Thiel and Rix, 2005). These authors suggest that current practice based on available guidelines and information may be limited by a number of factors including: validity and reliability of the guidelines (AJP, 2001); validity and reliability of physical tests used for pre-treatment screening (Rivett et al., 2005; Thiel and Rix, 2005); uncertainty associated with clinical decision making (Childs et al., 2005); uncertainty of risks of treatment, an unsubstantiated knowledge base, a questionable evidence-base to guidelines, and discomfort among the profession regarding medico-legal issues (AJP, 2001; Kerry, 2002). Corresponding author. Tel.: +44 0115 8231790.

E-mail address: [email protected] (R. Kerry). 1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.09.006

The main aim of this paper is to facilitate and encourage manual therapists to broaden their clinical approach to the understanding and assessment of CAD. A more holistic approach can be achieved by considering recent advances in the evidence base, together with a change in thinking with regard to movement, and the resulting haemodynamics of the cervical spine. The paper is divided into two distinct clinical sections; (1) vertebrobasilar arterial system (posterior system); (2) internal carotid arteries (anterior system). Risk factors and mechanisms of CAD are then presented, followed by an indication of possible directions for future approaches to clinical assessment.

2. Vertebrobasilar arterial system Both traditional and contemporary thinking in manual therapy has been concerned with blood flow


R. Kerry, A.J. Taylor / Manual Therapy 11 (2006) 243–253

problems related to the vertebrobasilar arterial (VBA) system. The term ‘vertebrobasilar insufficiency’ (VBI) is a familiar term with all therapists and attempts have been made throughout the years to find the best way to identify patients with VBI (e.g., Magarey et al., 2004; APA, 2006). A brief review of the posterior vascular anatomy will help appreciate what is meant by the term VBI. 2.1. The vertebrobasilar arterial system and vertebrobasilar insufficiency The VBA system provides blood flow to the hind brain (i.e. brain-stem, Medulla Oblongata, Pons, Cerebellum, and Vestibular apparatus). The left and right vertebral arteries arise from the subclavian arteries and pass through the transverse foramina of cervical vertebral levels 6 to 1—see Fig. 1. When they exit the atlas, the vessels make a sharp posteromedial turn to pass along the posterior mass of the atlas. They then enter the skull through the foramen magnum of the occiput. The vessels are ‘tethered’ at various points along this route: namely C2 transverse foramina, C1 transverse foramina, and at the atlanto-occiptal membrane. It is this tethering, combined with the convoluted route of the vessels around C2/C1 and the occiput, that have been a cause of concern for therapists. Considering this anatomy of the upper cervical spine it is easy to appreciate how, during rotation, the contralateral vessel may be stretched therefore potentially affecting flow (Fig. 2). This is the basis for the ‘VBI Tests’ that have commonly been advocated for VBI screening. Once inside the skull, the two vertebral arteries join each other to form the basilar artery, which in turn feeds

Fig. 1. Course of the vertebral and internal carotid arteries through the cervical spine. (adapted with permission from Elsevier Ltd, Drake et al., Gray’s Anatomy for Students, www.studentconsult.com)

Fig. 2. Vertebral and Internal Carotid arteries during upper cervical rotation (Reprinted with the permission of NCMIC Group, Inc. No further reproduction is allowed without the express permission of NCMIC.)

into the Circle of Willis. When there is a reduction of blood supply to specific parts of the hind-brain, certain signs and symptoms are displayed. This is what can be referred to as VBI. 2.1.1. Vertebrobasilar insufficiency—signs and symptoms Classically, the signs and symptoms related to hindbrain ischemia are considered as the ‘‘5 Ds and 3 Ns’’ of Coman (Coman, 1986). These signs and symptoms are presented in Table 1 (together with a ninth ‘classic’ sign—ataxia), along with the associated neuro-anatomical site of insult. Unreasoned adherence to these cardinal ‘classic’ signs and symptoms can, however, be misleading and result in an incomplete understanding of patient presentations. A closer look at contemporary evidence from the medical, opthalmic and neurological literature shows that the typical presentation of vertebrobasilar dysfunction is not always in line with this classical picture. The haemodynamic presentations of VBI can be better understood if the symptomology is divided into nonischemic (i.e. local, somatic causes) and ischemic (i.e. symptoms of hind brain ischemia) manifestations (see Table 2). VBI is often a result of arterial dissection. This is a tearing of the intimal wall which may lead to severe stenotic lesions or embolization. The non-ischemic presentation of vertebral dissection is typically ipsilateral posterior neck pain and /or occipital headache alone—Fig. 3 (e.g. Arnold and Bousser, 2005; Asavasopon et al., 2005; Childs et al., 2005; Savitz and Caplan, 2005; Thanvi et al., 2005). Very rarely cervical root impairment (usually C5/6) can be present as a result of

ARTICLE IN PRESS R. Kerry, A.J. Taylor / Manual Therapy 11 (2006) 243–253

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Table 1 Classic signs and symptoms of vertebrobasilar insufficiency (VBI) with associated neuroanatomy Sign or Symptom

Associated Neuroanatomy

Dizziness (vertigo, giddiness, lightheadedness) Drop attacks (loss of consciousness)

Lower vestibular nuclei (vestibular ganglion ¼ nuclei of CN VIII vestibular branch)

Diplopia (amaurosis fugax; corneal reflux) Dysarthria (speech difficulties) Dysphagia (+ hoarseness/hiccups) Ataxia Nausea Numbness (unilateral) Nystagmus

Reticular formation of midbrain Rostral Pons Descending spinal tract, descending sympathetic tracts (Horner’s syndrome); CN V nucleus (trigeminal ganglion) CN XII nucleus (Medulla, trigeminal gangion) Nucleus ambiguous of CN IX and X, Medulla Inferior cerebellar peduncle Lower vestibular nuclei Ipsilateral face: descending spinal tract and CN V Contralateral body: ascending spinothalamic tract Lower vestibular nuclei+various other sites depending on type of nystagmus (at least 20 types)

See text for the limitations of only considering these features for potential VBI.

Table 2 Presentations of vertebral artery dissection Non-ischaemic (local) signs and symptoms

Ischaemic signs/symptoms

Ipsilateral posterior neck pain/Occipital headache Hind-brain TIA (dizziness, diplopia, dysarthria, dysphagia, drop attacks, nausea, nystagmus, facial numbness, ataxia, vomiting,hoarseness, loss of short-term memory, C5/6 cervical root impairment (rare)

vagueness, hypotonia/limb weakness (arm or leg), anhidrosis (lack of facial sweating), hearing disturbances, malaise, perioral dysthesia, photophobia, papillary changes, clumsiness and agitation) Hind-brain stroke (e.g. Wallenberg’s syndrome, Locked-In syndrome) Cranial nerve palsies

Non-ischaemic symptoms can precede ischaemic events by a few days to several weeks.

local neural ischemia (Crum et al., 2000). These clinical features may then be followed by the ischemic events associated with vertebrobasilar dysfunction. These may also include some of the classic 5Ds and 3Ns as stated above, but may also include many other symptoms (see Table 2) (Arnold and Bousser, 2005; Rivett et al., 2005; Savitz and Caplan, 2005). It is rare for posterior dysfunction to manifest in only one sign or symptom, and isolated dizziness or transient loss of consciousness are often misattributed to posterior circulation ischemia (Savitz and Caplan, 2005). Dizziness is often reported as being one of the most common symptoms of VBI (Cote et al., 1996). However, there have been cases reported when dizziness has not been present. The nature of dizziness can be a differentiating factor in establishing a vascular versus non-vascular cause. Typically, posterior circulation dizziness does not present as frank vertigo, although some authors have suggested this could occur (e.g Savitz and Caplan, 2005). Vascular dizziness occurs as an effect of neck rotation, and does not improve with continued movement. This pattern differs from non-vascular vestibular dizziness (see below) which often has a short latency to it, and can improve with repeated movement.

2.2. VBI testing 2.2.1. Functional positioning tests Functional positional tests of the cervical spine are commonly used to identify the presence of VBI (Grant, 1994; APA, 2006). The purpose of establishing whether a patient has VBI is of obvious great importance to health professionals to whom a patient has sought help for their cervical pain. The reason for undertaking these tests is based on the principle that some treatment interventions commonly used to help patients with neck pain hold inherent risks if applied in the presence of VBI. It would seem, therefore, to be necessary to identify whether or not VBI was present. The primary risk associated with VBI (i.e. the longer-term sequelae of these transient events) is one of neurovascular accident (i.e. stroke) as a result of further insult to an already compromised (insufficient) blood supply to the brain. Functional positioning tests are based on the principle of compromising flow in the vertebral arteries by passively sustaining the cervical spine in a particular position. Positions can include extension, combined extension and rotation, a pre-manipulation position, or most commonly, rotation alone. The APA



Fig. 4. Functional positional testing of the vertebral artery (rotation). The patient’s head is passively rotated and held for 10 s. Reproduction of symptoms associated with vertebrobasilar insufficiency result in a positive test.

symptoms associated with VBI during the sustained hold. Reproduction of symptoms during the test is classed as a positive test result and contraindicates certain treatment interventions (APA, 2006). The underlying mechanical principle of these tests has been the subject of a number of research reports focusing on the clinical question of ‘does rotation of the neck affect blood flow?’. Many blood flow studies have demonstrated a reduction in blood flow in the contra-lateral vertebral artery during rotation (e.g. Refshauge, 1994; Rossitti and Volkmann, 1995; Licht et al., 1998; Li et al., 1999; Rivett et al., 1998, 1999; Mitchell, 2003; Arnold et al., 2004; Mitchell et al., 2004). Most of this work has been undertaken on asymptomatic subjects. Some authors have used these studies to support the validity of screening tests; in other words these studies demonstrate that rotation changes blood flow, therefore the test is valid. The tests may be valid in that they may alter blood flow, but there is little consistent evidence relating these changes to alterations in symptoms. e.g. a patient could have significant reduction in blood flow, but no ‘‘VBI’’ symptoms and vice versa. This makes the specificity and sensitivity of these tests poor and variable, and this has been mathematically demonstrated in diagnostic utility calculations (Kerry and Rushton, 2003; Gross et al., 2005; Ritcher and Reinking, 2005). Fig. 3. Typical pain distribution relating to extra-cranial vertebral artery dissection—ipsilateral posterior upper cervical pain and occipital headache.

pre-manipulative guidelines suggest a 10 s sustained hold of rotation as a minimum requirement to establish whether or not VBI is present (APA, 2006)—Fig. 4. The purpose of these tests is to monitor for reproduction of

2.2.2. Limitations of VBI and differentiation testing On the basis of the inconsistency of the evidence, there have been recent propositions regarding cessation of the use of functional pre-screening tests (Thiel and Rix, 2005; Rivett et al., 2005). Despite some of the above-mentioned tests being advocated in published guidelines for the assessment of VBI, and other tests


being oft quoted in textbooks (e.g. Hautant’s test, etc., in Magee, 2005), it is essential that the clinician is aware of the limitations of using information gained from these tests in their diagnostic, clinical decision making. As stated above, the functional positional tests have poor diagnostic utility i.e. a positive test response does not necessarily mean that the condition (VBI) exists, and a negative test response does not necessarily mean the condition does not exist. This phenomenon has been highlighted in a number of case reports and studies which have documented either patients having adverse neurovascular effects in the absence of a positive test (i.e. false-negative: Rivett et al., 1998; Westaway et al., 2003), or no identifiable vascular dysfunction despite a positive test result (i.e. false-positive: Licht et al., 2000). With these limitations in mind, it is necessary to explore other possible approaches to the assessment of cervical arterial dysfunction. Below is a brief overview of the anterior cervical arterial system (the internal carotid artery) which appears to be a neglected source of diagnostic information within manual therapy literature and education.

3. The internal carotid arteries Due to its perceived anatomical vulnerability, the posterior cervical arterial system has traditionally been the focus of attention for manual therapists. In order to enhance clinical reasoning and facilitate diagnostic decisions and judgments, it is necessary to consider an approach which incorporates the anterior cervical arterial system; i.e the internal carotid arteries (ICA). Knowledge of the ICA is important for manual therapists because: (1) The ICA’s provide the most significant proportion of blood to the brain (Gabella, 1995; Schoning and Hartig, 1998). (2) Pathological changes of the ICA are very common (ACST, 2004). (3) Blood flow in the ICA is known to be influenced by movement of the neck (Schoning et al., 1994; Rivett et al., 1999; Scheel et al., 2000). 3.1. The internal carotid arteries and related pathologies The ICAs carry the majority of blood flow to the brain—around 80%—compared to 20% through the posterior system. It is primarily increased flow through the ICA which helps maintain brain perfusion in the presence of reduced flow through the vertebral arteries. The ICA arise from around the C3 level of the cervical spine where they bifurcate (with the External Carotid Artery) from the Common Carotid Artery (see Figs. 1 and 2). The course of the ICA takes them through a

247

number of contractile structures such as the sternocleidomastoid, longus capitis, stylohyoid, omohyoid, and diagastric muscles. In the upper cervical spine, they pass by the anterior body of C1, to which they are tethered. The ICA enters the skull through the carotid canal in the pertous temporal bone, where it continues intracranially to join the Circle of Willis. Extra-cranially, the flow through the ICA is influenced by movement of the cervical spine—primarily extension, and less so, rotation (Rivett et al., 1999; Scheel et al., 2000). 3.1.1. Internal carotid artery (anterior) dissection The ICA supplies the brain and the retina. The natural onset and progress of ICA dissection begins with local arterial trauma (the dissection event itself). This dissection event can manifest in a number of signs and symptoms which, like early vertebral artery dissection, are non-ischaemic (i.e. somatic pain related to local injury). These local signs and symptoms can precede cerebral ischemia (Transient ischaemic attack (TIA) or stroke) or retinal ischemia by anything from less than a week, to beyond 30 days (Biousse et al., 1994, Zetterling et al., 2000). There is, therefore, a period of time when a patient with ICA dissection may present to the manual therapist with signs and symptoms which may mimic a neuromuscluloskeletal presentation (Taylor and Kerry, 2005a). Table 3 shows the classic ICA non-ischaemic and ischaemic manifestations of ICA dissection. It is important to appreciate that most commonly, particularly in the early stages of the pathology, headache and/or cervical pain can be the sole presentations of internal carotid artery dysfunction (Pezzini et al., 2005; Rogalewski and Evers, 2005; Taylor and Kerry, 2005a). Fig. 5 shows a typical pain distribution associated with dissection of the ICA. The frontotemporal headaches are often described as cluster-like, thunder-clap, migraine without aura, hemicrania continua, or simply ‘‘different from previous headaches’’ (Silbert et al., 1995; Caplan and Biousse, 2004; Arnold and Bousser, 2005; Rogalewski and Evers, 2005; Taylor and Kerry, 2005a). The upper cervical or antero-lateral neck pain, facial pain and/or facial sensitivity are described in medical literature as ‘‘carotidynia’’. The local pain mechanisms involved with the internal carotid artery are likely to be related to either deformation of nerve-endings in the tunica-adventita, or direct compression on local somatic structures (Nichols et al., 1993). Specifically, the terminal nerve endings in the carotid wall are supplied by the trigeminal nerve, which accounts for instances of facial pain and carotidynia. Stimulation of the trigeminovascular system may account for this carotid induced pain (Leira et al., 2001). Cranial nerve palsies and Horner’s syndrome are phenomena which are often indicative of ICA pathology, especially if the onset is acute. The hypoglossal


248 Table 3 Clinical features of ICA dissection Non-ischaemic (local) signs/symptoms

Head/Neck pain Horner’s syndrome, Pulsatile tinnitus Cranial nerve palsies (most commonly CN IX to XII)

Ischaemic (cerebral or retinal) signs/symptoms

Transient Ischaemic Attack (TIA) Ischaemic stroke (usually Middle Cerebral Artery territory) Retinal infarction Amaurosis fugax

Less common local signs and symptoms include: Ipsilateral carotid bruit, Scalp tenderness, Neck swelling, CN VI palsy, Orbital pain, and Anhidrosis (facial dryness)

Non-ischaemic signs and symptoms may precede cerebral/retinal ischaemia by anything from a few days to over a month.

(Zetterling et al., 2000). If the dissection extends into the cavernous sinus, the occulomotor, trochlear, or abducens can be affected (Lemesle et al., 1998; Zetterling et al., 2000). The two most likely mechanisms for these cranial nerve palsies are: (1) Ischemia to the nerve via the vasa nervorum (comparable to peripheral neurodynamic theory). (2) Direct compression of the nerve axon by the enlarged vessel (Lemesle et al., 1998; Zetterling et al., 2000; Arnold and Bousser, 2005).

Fig. 5. Typical pain distribution relating to dissection of Internal Carotid Artery—ipsilateral front-temporal headache, and upper/mid cervical pain.

nerve is the most commonly affected followed by the glossopharyngeal, vagus, or accessory (Zetterling et al., 2000; Arnold and Bousser, 2005). However, all cranial nerves (except the olfactory nerve) can be affected

Identification of the early stages of ICA dissection may be facilitated by testing the cranial nerves and observing the eyes. Cranial nerve and eye examination should therefore be an integral and important component of manual therapists’ assessment procedures. Previous authors have also highlighted the importance of neurological examination with regard to CAD (Powell et al., 1993; Childs et al., 2005). Horner’s syndrome has been found to be present in up to 82% of patients with known internal carotid dissection (Chan et al., 2001). Most commonly, this syndrome occurs with head, neck, or facial pain. Carotid induced Horner’s syndrome manifests as a drooping eyelid (ptosis), sunken eye (enophthalmia), a small, constricted pupil (miosis), and facial dryness (anhidrosis). The syndrome is the result of interruption to the sympathetic nerve fibres supplying the eye. In the case of carotid Horner’s syndrome, the pathology is classed as post-ganglionic. The superior cervical sympathetic ganglion lies in the posterior wall of the carotid sheath, and the postganlionic fibres follow the course of the carotid artery before making their way deep towards the eye through the cavernous sinus. Compression or ischemia as a result of internal carotid dysfunction will occur at the ganglion or distal to it.


In addition to the above early signs, it is important for the manual therapist to be aware of signs and symptoms related to cerebral, and retinal ischemia. It is unlikely that a patient with full stage cerebral ischemic stroke will present to the manual therapist, but the more subtle presentation of retinal ischemia might, which makes simple eye examination a key part of assessment. The internal carotid artery supplies (via the ophthalmic artery) the retina, and emboli from the ICA can result in retinal ischemic dysfunction. Symptoms include a painless episodic loss of vision, or blackout (amauris fugax), and localized/patchy blurring of vision (scintillating scotomas). Orbital ischemia syndrome, as a result of ophthalmic artery occlusion, presents as weakness of the ocular muscles (ophthalmoparesis); protrusion of the eye due to weakness of extrinsic eye muscles (proptosis); swelling of the eye or conjunctiva (chemosis) (Zetterling et al., 2000; Dziewas et al., 2003; Arnold and Bousser, 2005).

4. Aetiology of cervico-cranial arterial dysfunction Whilst the exact mechanism of arterial dissection remains unexplained, vertebral and internal carotid artery disease and dysfunction are intrinsically associated to two inter-related principles: (1) Underlying pathology (including atherosclerosis) which may predispose a vessel to dissection. (2) Mechanical forces generated as a result of movement or biomechanics, which results in altered haemodynamics. Both of the above may be linked to trauma to the blood vessels. Atherosclerosis is an inflammatory process associated with a number of factors including (Ross, 1999, Mitchell, 2002; Kaperonis et al., 2006);

hypertension hypercholesterolemia hyperlidemia hyperhomocysteinemia diabetes mellitus genetic clotting disorders infections smoking free radicals direct vessel trauma iatrogenic causes (surgery, medical interventions)

It is important for the clinician to appreciate that hypertension (indicated by measurement of blood pressure) is positively related to disease and dysfunction of the carotid arteries (Polak et al., 1996; Ebrahim et al.,

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1999; Mannami et al., 2000; Sun et al., 2002; Kawamoto et al., 2006). Consequently, this may indicate that recognition of hypertension by the clinician could be important when assessing the likelihood of potential cervico-cranial neurovascular dysfunction. 4.1. Mechanisms of cervico-cranial dysfunction Important mechanisms in the pathogenesis of localized vascular pathology for clinicians to consider are: (I) Spontaneous arterial dissection is known to occur in certain individuals and is often related to innocuous day to day movements such as turning to reverse the car or visiting the hairdresser (Caplan and Biousse, 2004). The pathogenesis of such events remains unknown but is considered by some to be due to inherent vessel wall weakness linked to connective tissue abnormalities (Pelkonen et al., 2003; Benninger et al., 2004) (II) Intimal trauma (intimal dissection/injury) is known to occur as a result of blood flow changes and/or vessel wall pathology due to frank trauma, i.e. extreme neck movement, sustained neck movement, or repeated neck movement (e.g. whiplash injury, domestic violence, sport, medical interventions, intubation, manual therapies, etc. (Arnold and Bousser, 2005)). (III) Localised endothelial inflammatory events (i.e. atherosclerosis) (Ross, 1999; Kaperonis et al., 2006) linked to abnormal flow in vessels due to biomechanical factors such as kinking/looping or localized obstructions (e.g. 1st rib and subclavian artery) (IV) Endothelial inflammatory disease—e.g Temporal arteritis. Giant cell arteritis of the Temporal Artery (extra-cranial branch of the External Carotid Artery) can present as unilateral headache and/or temple soreness, sore neck, and jaw soreness. The medium-term sequelae of this disease is potential blindness as a result of ischaemia to the optic nerve, thus making early recognition critical (Smeeth et al., 2006). Temporal arteritis has also been associated with ICA and VBA disease (Pfadenhauer et al., 2005). (V) Upper cervical instability has been associated with localized atherosclerotic changes in the cervical vessels (Garg et al., 2004; Yamazaki et al., 2004). The mechanism of injury is possibly associated with repetitive micro-trauma to the VA and ICA secondary to increased upper cervical vertebral movement and/or the presence of connective tissue inflammatory disease. Consideration should be given to patients with known rheumatoid arthritis and acute whiplash injury.



5. Directions for the future It is becoming progressively clear that the current manual therapy knowledge base does not equip therapists with the information required to make valid risk assessment prior to treatment. The alert clinician requires not only the vast neuromusculoskeletal knowledge base but also integration of the basic functional anatomy of the arterial system. Knowledge of haemodynamic principles, pathophysiology, risk factors of arterial dysfunction, and above all an awareness of classical vascular clinical presentations is paramount. The integration of such knowledge will allow the manual therapist to make the best informed decisions when assessing and treating patients presenting with head and neck symptoms. It is important for the clinician to understand that headache/neck pain may be the early presentation of an underlying vascular pathology. The task for the therapist is to differentiate the symptoms by: (1) having a high index of suspicion; (2) testing the vascular hypothesis. This should take place at an early point in the assessment process—i.e. soon into the history taking. The symptomology and history of patients suffering vascular pathology is what may reveal the alert clinician to an underlying problem. Reliance solely on objective clinical tests, i.e. so called ‘‘vertebral artery tests’’ which have poor validity and reliability (Taylor and Kerry, 2005b; Thiel and Rix, 2005), should be avoided. As movement of the neck, particularly rotation and extension movements, can be a potential risk factor for vascular events in itself, identification of patients with other pre-existing vascular risk factors (especially hypertension) should also be of great importance to the therapist before manual therapy interventions are undertaken. Careful monitoring of patients’ signs and symptoms after treatment is also necessary, especially acute post-treatment onset of localized upper cervical pain, or headache, which is worsening. Furthermore, where post-treatment pain or ‘‘treatment soreness’’ is encountered (i.e. an apparent response to joint or soft tissue techniques), the therapist should consider carefully whether there has been a vascular or haemodynamic response to treatment. Numerous reports suggest that such presentations may be the manifestation of a traumatically (treatment) induced arterial trauma or dissection (eg Smith et al., 2003). A high index of suspicion of cervical vascular involvement is required in cases of acute onset neck/ head pain described as ‘‘unlike any other’’. Observation and conservative treatment may well be advised in such

cases in the early stages of treatment, unless frank arterial injury is suspected (especially in the presence of posterior circulation ischemia). In this case, the appropriate action is triage to an emergency or suitable diagnostic centre as a matter of urgency, particularly in the case of a deteriorating patient. Vascular testing such as Duplex ultrasound, magnetic resonance arteriography and computerized tomographic angiography are increasingly sophisticated methods of vascular diagnosis with increasing reliability. The key maxim for the clinician is as always DO NO HARM. Medical evidence suggests that the diagnosis of carotid and vertebral arterial dissections is on the increase, as both awareness develops and diagnostic imaging becomes more reliable and less expensive. The causes of arterial dissection remain largely unknown, but are thought to involve a combination of genetic predisposition and environmental factors such as trauma. Early diagnosis is essential to prevent the potential sequelae of stroke. Manual therapists may be exposed to patients presenting with the early signs of stroke (i.e. neck pain/headache) and as such need both knowledge and awareness of the mechanisms involved. A basic understanding of vascular anatomy, haemodynamics, and the pathogenesis of arterial dysfunction may help the clinician differentiate vascular head and neck pain from a musculoskeletal cause. It is apparent, however, that dissemination of knowledge and further work is necessary in establishing the best way to identify patients who may present as, or be at risk of neurovascular accident as a result of treatment. One valuable focus of ongoing clinical research is the use of simple hand-held ultrasound Doppler units to objectively assist in identifying flow dysfunction (Haynes et al., 2005; Rivett et al., 2005). It is beyond the scope of this article to discuss the logistics and implications of Doppler ultrasound in manual therapy. However, whilst the clinical utility of this diagnostic tool remains without known sensitivity and specificity, it may in future, provide an adjunct to the objective examination, therefore supporting the clinician’s ability to provide a thorough assessment of arterial function. Table 4 gives a summary of the objective examination procedures referred to so far.

6. Summary Attempts have recently been made to provide guidelines for the effective screening of patients who may be at risk of neurovascular accident post-manual therapy. However, current evidence questions the validity and utility of such guidelines. It is therefore necessary to reconsider the clinical approach towards assessment of potential CAD. Based on the existing evidence base, the


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Table 4 Summary of key objective examination procedures for differentiating vasculogenic head and neck pain Test

Purpose

Evidence status

Limitations and advantages

Functional positional test— Cervical rotation

Affects flow in contralateral vertebral artery. Limited effect on internal carotid artery.

Poor sensitivity, variable specificity.

Only assesses posterior circulation.

Blood flow studies support effect on VA flow.

Results should be interpreted with caution. Recommended by existing protocols. Cannot predict propensity for injury.

Functional positional test— Cervical extension

Affects flow in internal carotid arteries. Limited effect on vertebral arteries.

No specific diagnostic utility evidence available. Blood flow studies support effect on ICA flow.

Only assesses anterior circulation.

Blood pressure examination

Measure of cardiovascular health.

Correlates to ICA atherosclerotic pathology.

Reliability dependent on equipment, environment, and experience.

Cranial nerve examination

Identifies specific cranial nerve dysfunction resulting from ischemia or vessel compression.

No specific diagnostic utility evidence available.

Reliability dependent on experience.

Eye examination

Assists in diagnosis of possible neural deficit related to ICA dysfunction

No specific diagnostic utility evidence available.

Eye symptoms may be early warning of serious underlying pathology

Hand held Doppler ultrasound

Direct assessment of blood flow velocity

Limited manual therapy specific evidence. Existing studies suggest good to excellent reliability. Validity requires further study.

Reliability dependent on equipment, environment, and experience.

authors suggest manual therapists consider the following recommendations: (1) Develop a high index of suspicion for cervical vascular pathology, particularly in cases of trauma. (2) Develop increased awareness that neck pain and headache may be precursors to potential posterior circulation ischaemia. (3) Expand manual therapy theory to encompass the whole cervical vascular system, including the carotid arteries. (4) Expand manual therapy theory and practice to include haemodynamic principles and their relationship to movement anatomy and biomechanics. (5) Develop an awareness of the limitations of current objective tests and enhance the knowledge that reliance on objective testing alone represents incomplete clinical reasoning. (6) Enhance subjective/objective examination by including vascular risk factors such as hypertension, and procedures such as cranial nerve and simple eye examination. (7) Consider new advances in the objective assessment of cervical arteries.

(8) In cases of acute onset headache ‘‘unlike any other’’, conservative or gentle treatment techniques are recommended in the early stages. (9) Where frank arterial injury is suspected prior to, or following, treatment, immediate triage to an appropriate emergency centre is recommended, together with a report on any treatment methods undertaken. The summarized points above are not intended as definitive guidance—rather an advancement of practice and clinical reasoning based on the emerging evidence base.

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ARTICLE IN PRESS


Review

The lumbar multifidus: Does the evidence support clinical beliefs? David A. MacDonalda, G. Lorimer Moseleyb, Paul W. Hodgesa, a

Division of Physiotherapy, The University of Queensland, Brisbane QLD 4072, Australia b School of Physiotherapy, The University of Sydney, Sydney, Australia

Received 14 June 2005; received in revised form 18 January 2006; accepted 3 February 2006

Abstract The contribution of the trunk muscles to spinal stability is well established. There is convincing evidence for the role of multifidus in spinal stability. Recently, emphasis has shifted to the deep fibres of this muscle (DM) and five key clinical beliefs have arisen: (i) that DM stabilizes the lumbar spine whereas the superficial fibres of lumbar multifidus (SM) and the erector spinae (ES) extend and/ or rotate the lumbar spine, (ii) that DM has a greater percentage of type I (slow twitch) muscle fibres than SM and ES, (iii) that DM is tonically active during movements of the trunk and gait, whereas SM and ES are phasically active, (iv) that DM and the transversus abdominis (TrA) co-contract during function, and (v) that changes in the lumbar paraspinal muscles associated with LBP affect DM more than SM or ES. This paper reviews the biomechanical, electromyographic, histochemical and morphological data that underpin these beliefs. Although there is support for the importance of the lumbar multifidus and the specific contribution of this muscle to intervertebral control, several of the clinical beliefs have little or no support and require further evaluation. These findings have implications for clinical practice. r 2006 Elsevier Ltd. All rights reserved. Keywords: Exercise therapy; Low back pain; Review; Rehabilitation; Lumbar multifidus

1. Introduction Exercise programmes that aim to improve the ‘‘stability’’ of the lumbar spine are widely utilized in the management of patients with low back pain (LBP) (Grieve, 1982; Saal and Saal, 1989; Porterfield and DeRosa, 1991a, b; Norris, 1995a, b; Richardson and Jull, 1995, 2000; O’Sullivan et al., 1997; Pool-Goudzwaard et al., 1998; Porterfield and DeRosa, 1998a, b; Richardson et al., 1999a; Taylor and O’Sullivan, 2000; McGill, 2001; Richardson et al., 2004). These programmes target a variety of trunk muscles and aim to optimize the control of segmental motion, spinal stability, spinal stiffness, spinal orientation, or a combination of these characteristics.

Corresponding author. Tel.: +61 7 3365 2008; fax: +61 7 3365 2775. E-mail address: [email protected] (P.W. Hodges).

1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.02.004

Two fundamental principles that underpin these exercise programmes are that trunk muscle activity is necessary to control and stabilize the lumbar spine (Panjabi, 1992a, b) and that this activity must be restored, optimized, or enhanced in LBP (Richardson et al., 1999e; McGill, 2001; Hides, 2004a, b). In vitro studies have demonstrated that the osseoligamentous lumbar spine is inherently unstable (Lucas and Bresler, 1961; Panjabi, et al., 1989) and is dependent on the integrated function of the active, passive and neural subsystems to control stability and movement (Panjabi, 1992a, b). Therefore, exercise programmes which train trunk muscles to control spinal motion in patients with LBP seem logical (Norris, 1995a, b; O’Sullivan et al., 1997; Richardson et al., 1999a; Hides et al., 2004), and have been argued to reduce stress on injured osseoligamentous structures, which in turn leads to pain reduction and enhanced function. (Saal and Saal, 1989; Panjabi, 1992a, b; Norris, 1995a, b; O’Sullivan et al., 1997; Hides et al., 2001).

ARTICLE IN PRESS D.A. MacDonald et al. / Manual Therapy 11 (2006) 254–263

Although it is agreed that exercise should be part of the management of LBP, there is significant variation in the type of exercise and the proposed mechanisms of effect of each type. Some authors advocate exercises which activate the entire paraspinal muscle group in order to control spinal motion (Grieve, 1982; Porterfield and DeRosa, 1991a, b, 1998a, b; McGill, 2001). These authors propose that the effectiveness of these exercises is due to increased power of the trunk muscles both segmentally and regionally (Grieve, 1982), increased tension in the thoracolumbar fascia through multifidus hypertrophy (Porterfield and DeRosa, 1998a, b), increased segmental compression (Porterfield and DeRosa, 1998a, b), and facilitation of co-contraction of the trunk flexors and extensors to optimize control of buckling (Euler stability) (McGill, 2001). Other authors suggest that rather than increasing the strength or hypertrophy of the trunk muscles, the aim of therapeutic exercise in LBP should be to enhance the function of trunk muscles which are thought to be preferentially suited to stabilizing the lumbar spine (Richardson and Jull, 1995). In contrast to the general approach, this strategy aims to activate the lumbar multifidus independent of the other paraspinal muscles in the initial stages of rehabilitation, and to then integrate appropriate multifidus activation into functional activities (Richardson and Jull, 1995; O’Sullivan et al., 1997; Richardson et al., 1999a, c). Specific exercises have been designed to activate the lumbar multifidus in an isometric, low load, tonic manner, while maintaining a neutral lumbar spine, to restore the proposed function of the lumbar multifidus and its contribution to spinal control (Saal and Saal, 1989; Richardson and Jull, 1995; O’Sullivan et al., 1997; Richardson et al., 1999e; Hides, 2004a, b). Recently, this selective activation of the lumbar multifidus from the other paraspinal muscles has been further refined. The clinical literature has focussed on the deep segmental fibres of the lumbar multifidus (DM) as the target of exercise interventions (Richardson et al., 1999e; Richardson and Jull, 2000; Taylor and O’Sullivan, 2000; Hides, 2004a, b). This specific type of exercise approach has been demonstrated to reduce recurrence following acute LBP (Hides et al., 2001), and to reduce pain and disability in patients with chronic LBP (O’Sullivan et al., 1997). The recent focus on DM in therapeutic exercise, rather than the superficial fibres of the lumbar multifidus (SM) or the erector spinae (ES), appears to be based on five common beliefs: (i) DM stabilizes the lumbar spine whereas SM, like ES, function as extensors/rotators of the lumbar spine (Richardson and Jull, 1995; Richardson et al., 1999f); (ii) DM has a greater percentage of type I (slow twitch) muscle fibres than SM and the ES (Porterfield and DeRosa, 1991a, b; Richardson et al., 1999f); (iii) DM is tonically active

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during movements of the trunk and gait while SM and the ES are phasically active (O’Sullivan et al., 1997; Richardson et al., 1999f; Taylor and O’Sullivan, 2000; Hides, 2004a, b); (iv) DM and transversus abdominis (TrA) co-contract during function (Richardson and Jull, 1995; O’Sullivan et al., 1997; Pool-Goudzwaard et al., 1998; Richardson et al., 1999b; Richardson et al., 2000; Taylor and O’Sullivan, 2000; Arokoski et al., 2001; Hides et al., 2004); and (v) changes in the lumbar paraspinal muscles associated with LBP affect DM more than SM or ES (Norris, 1995a, b; Pool-Goudzwaard et al., 1998; Richardson et al., 1999d; Arokoski et al., 2001; Hides 2004a, b). The purpose of this review is to critically evaluate the literature to determine whether neurophysiological, biomechanical and histological data support these clinical beliefs. A further aim is to consider the implications of this evidence for clinical practice.

2. Differential contribution of DM, SM and ES to mechanical control of the spine It has been argued that therapeutic exercise for the paraspinal muscles should focus on DM because these fibres are anatomically and biomechanically suited to the control of segmental motion, whereas SM and ES are not (Richardson and Jull, 1995; Arokoski et al., 2001). Do the anatomical and biomechanical data support this argument? The lumbar multifidus consists of multiple fascicles that originate from the caudal tip and inferolateral aspect of the spinous process and lamina at one vertebral level and insert between two and five spinal levels caudal onto the zygapophyseal joint capsule (Lewin et al., 1962), mamillary process, lamina, medial posterior superior iliac spine and dorsal sacrum (Macintosh et al., 1986). The fibres of multifidus that cross just two spinal levels and insert onto the lamina, mamillary process (Macintosh et al., 1986) and zygapophyseal joint capsule (Lewin et al., 1962; Jemmett et al., 2004) are referred to as DM. The lumbar ES consist of two separate muscles: longissimus thoracis pars lumborum and iliocostalis lumborum pars lumborum. The longissimus thoracis pars lumborum originate from the lumbar transverse and accessory processes, and insert onto the ventral surface of the posterior superior iliac spine. The iliocostalis lumborum pars lumborum originate from the tips of the lumbar transverse processes and adjacent middle layer of the thoracolumbar fascia and insert onto the ventral edge of the iliac crest (Macintosh and Bogduk, 1987). Biomechanical models, based on those anatomical data, suggest that SM and ES produce sufficient torque to create a posterior sagittal rotation (extension) of the lumbar spine, in addition to intervertebral compression


D.A. MacDonald et al. / Manual Therapy 11 (2006) 254–263

(Macintosh and Bogduk, 1986; Bogduk et al., 1992). DM, due to its proximity to the predicted instantaneous axis of rotation of the lumbar segments, primarily generates compressive forces, with minimal associated torque (Bogduk et al., 1992). Further, the length of DM remains unchanged during three planes of spinal motion suggesting that DM does not rotate the lumbar vertebra (McGill, 1991). There is strong evidence that the lumbar multifidus controls spinal motion. Of the muscles examined, multifidus contributes 2/3 to the stiffness at L4/5 (Wilke et al., 1995), and in vitro studies (Panjabi et al., 1989; Kaigle et al., 1995) demonstrate contraction increases intervertebral stiffness at an injured lumbar segment. Thus, multifidus has the capacity to control motion of an uninjured lumbar motion segment and restore control of segmental motion following injury. However, it is important to consider that all lumbar muscles contribute to stability of the lumbar spine (Crisco and Panjabi, 1991; McGill, 1991; Wilke et al., 1995; Cholewicki et al., 1997; Granata and Marras, 2000; Cholewicki and VanVliet, 2002; McGill et al., 2003). Notably, co-contraction of the superficial flexors and extensors is required to control spinal buckling (Euler stability), and can also impart control of intervertebral motion via compression. However, the resulting increase in spinal load, if sustained, has been argued to have detrimental effects on the spine (Nachemson and Morris, 1964). The anatomical and biomechanical evidence supports the clinical belief that DM stabilizes the lumbar spine and that SM and ES extends/rotates the lumbar spine. However, in addition to their extensor function, when co-contracted with the trunk flexors, SM and ES increase Euler stability and control of intervertebral motion. However, selective training of DM has theoretical justification in that data suggest that this muscle can control a single segment without generating associated torque which, if present, would require cocontraction of the abdominal flexors. Consequently, activation of this muscle has the potential to provide a strategy to control intervertebral motion without restricting movement of the spine.

3. Fibre type percentage in DM, SM, and ES A fundamental belief underpinning the rehabilitation of lumbar multifidus is that DM has a greater percentage of type I muscle fibres than SM or ES (Porterfield and DeRosa, 1991a, b). Type I (slow twitch) muscle fibres, while being fatigue resistant and ideally suited to low load tonic activity, have been argued to be more susceptible to the adverse effects of pain and immobilization than type II (fast twitch) muscle fibres (Appell, 1990). The proposed fibre type composition has

formed, in conjunction with the proposed tonic activation of DM, the justification for low load, tonic exercise in LBP rehabilitation (Richardson et al., 1999e; Arokoski et al., 2001) as well as providing a possible explanation for changes in multifidus in LBP (Hides, 2004b). A number of studies evaluated the fibre type composition of DM, SM and ES (Fidler et al., 1975; Jowett et al., 1975; Ford et al., 1983; Bagnall et al., 1984; Sirca and Kostevc, 1985; Mattila et al., 1986; Thorstensson and Carlson, 1987; Jorgensen et al., 1993; Rantanen et al., 1993; Mannion et al., 1997a, b). It is important to note that all DM samples have been harvested from cadavers or people undergoing spinal surgery. Therefore, these results may not represent healthy tissue (Johnson et al., 1973; Fidler et al., 1975; Jowett et al., 1975; Ford et al., 1983; Bagnall et al., 1984; Sirca and Kostevc, 1985; Mattila et al., 1986; Rantanen et al., 1993). Samples from individuals without LBP have been restricted to SM and ES (Thorstensson and Carlson, 1987; Jorgensen et al., 1993; Mannion et al., 1997a, b), which limits discussion of DM fibre type composition in pain-free individuals. The pooled results (Table 1) from these studies indicate that DM, SM and ES each have a greater percentage of type I than type II muscle fibres. There is only limited evidence to support the presence of a greater percentage of type I fibres in the deep, compared to the superficial, paraspinal muscles (Sirca and Kostevc, 1985). Further, the evidence does not appear to support the argument that fibre type composition is responsible for the specific changes seen in multifidus in LBP. However, the predominance of type I muscle fibres in the lumbar multifidus supports the use of low load exercise, at least initially. Direct, within-subject comparisons of DM, SM and ES histology in normals is required to clarify the issue of relative proportions of fibre types.

4. Activation of DM, SM and ES during functional movements The argument that multifidus has a tonic postural role is based on reports of continuous activity reported during standing, and tonic activation during gait (Richardson et al., 1999f; Hides, 2004a). It has also been argued that absence of electrical silence in multifidus at the end of trunk flexion constitutes evidence that this muscle has a stabilization role (Richardson et al., 1999f; Hides, 2004a). The proposed tonic activation of multifidus and the fibre composition of this muscle, form the basis for training tonic holding of this muscle in the rehabilitation of LBP patients. As tonic retraining of multifidus has been directed to the segmental portions of this muscle (Hides, 2004a), the clinical belief has

6 male cadavers (aged 17–30)

17 subjects (aged 34–80) undergoing surgery for lumbar derangement

Johnson et al. (1973)

Fidler et al. (1975)

Cadavers: 63% (deep muscle) Surgical patients: 63% (deep muscle)

Multifidus and longissimus at the L2 spinal level *samples divided into deep and superficial muscle

21 male cadavers (aged 22–46)

12 male and 5 female patients undergoing lumbar IVD surgery (aged 28–50)

Males: R 48% L 60% Females: R 54% L 65%

Sirca and Kostevc (1985)

Multifidus sampled 1 cm from the inferior border of the L5 lamina and 1 cm lateral to the L5 spinous process just below the TLF bilaterally

Males: R 53% L 41% Females: R 58% L 58%

19 patients undergoing lumbar IVD surgery (aged 26–73)

Affected side: 59% Non—affected side: 53%

Affected side: 53% Non—affected side:49%

Bagnall et al. (1984)

1 cm lateral to the tip of the L5 spinous process and 1 cm from the inferior border of the L5 lamina bilaterally

18 patients undergoing lumbar IVD surgery (aged 28–73)

Ford et al. (1983)

Patients with idiopathic scoliosis: varied between 36% and 97%. With a greater percentage being present on the apex of the convex side of the curve

5 male and 12 female patients with spinal derangements (aged 15–58), 2 male cadavers and 1 female cadaver (aged 19–51), and 4 male and 6 female patients with idiopathic scoliosis (aged 12–17) Patients with idiopathic scoliosis: apex of concave and convex curves and in 2 subjects the top and bottom of the concave and convex curves. No other information provided

Patients with spinal derangements and cadaver results combined: 60–66%

% Type I fibres SM

Cadavers: between 43% and 69% Patients with spinal derangements: between 36% and 93%. With an average of 72% at the L5 level samples

% Type I fibres DM

Cadavers: lumbar only. No other information provided. Patients with spinal derangements: between L3 and L 5. No other information provided

Patients with spinal derangements: lumbar multifidus samples taken at the time of surgery. Superficial procedure described Cadavers: L5 spinal level

1 cm3 blocks were taken from the deep and superficial ES. No other information provided

Sample site

Jowett et al. (1975)

2 male and 1 female cadaver (aged 19–51)

Population sampled

Authors

Table 1 Percentage of type I muscle fibres in DM, SM and ES

Surgical patients: 56% (superficial muscle)

Cadavers: 57% (superficial muscle)

Superficial ES ranged from 100–26.7% Deep ES ranged from 88.6–34.0%

% Type I fibres ES

* More type I fibres in deep than superficial muscle

*At any one level of the vertebral column, large differences in muscle fibre characteristics can exist

*Wide variation in muscle characteristics between sides, not related to side of dysfunction

The results suggest that multifidus adopts an increasingly postural role with advancing age and with disabling lesions of the lumbar spine

Comments by authors

ARTICLE IN PRESS

D.A. MacDonald et al. / Manual Therapy 11 (2006) 254–263 257

9 males and 7 females with no history of LBP (aged 20–30)

6 male cadavers with no known history of LBP (aged 17–29)

14 male and 7 female cadavers with no known history of LBP (aged 23–65)

22 males and 19 females undergoing lumbar IVD surgery at L4/5 or L5/S1 under the age of 55 9 male and 3 female cadavers with no known history of LBP (aged 21–58)

17 male and 14 female subjects with no history of LBP (mean age for men 2374.3 years and for females 29710.6 years)

12 male and 9 female subjects with no history of low back pain 12 male and 9 female subjects about to undergo lumbar spinal surgery

Thorstensson and Carlson (1987)

Jorgensen et al. (1993)

Rantanen et al., (1993)

Mattila et al. (1996)

Mannion et al. (1997a)

Mannion et al. (1997b))

Control group: Left ES at the level of the 3rd lumbar vertebrae Surgical patients: superficial multifidus from the level of L3 or L4 taken during surgery

Left erector spinae approximately 3–4 cm from the midline at the 10th thoracic and 3rd lumbar spinal levels

Multifidus at the transversospinal corner at L4/5 and L5/S1

DM at the right side of the L4/ 5 spinal level in all cadavers and the right L3/4 and right L5/S1 spinal levels in the last 12 cadavers SM, deep and superficial illiocostalis lumborum at the right L4/5 spinal level in last 12 cadavers

Superficial and central portions of multifidus, longissimus, and iliocostalis at the upper level of L3 spinal level bilaterally

Superficial longissimus and multifidus at the left side of the L3 spinal level

Sample site

Surgical patients: 57.7% (male) 61.5% (female)

Cadavers: 60.8% (male) 62.5% (female)

69.6% at L3/4 61.7% at L5/S1

62.6% at L4/5

% Type I fibres DM

Controls: 66.177.7% (male) 66.5712.0% (female)

67.8% (female)

63.6% (female) Surgical Patients: 51.0712.9% (male) 50.177.7% (female)

62.0% (male)

65.0% (male)

66.55% superficial illiocostalis lumborum

66.6% deep

70.5% longissimus (superficial and central samples pooled) 55.0% iliocostalis (superficial and central samples pooled)

54.0% multifidus (superficial and central samples pooled)

57.4% at L4/5

57% (average across all subjects)

% Type I fibres ES

62% (average across all subjects)

% Type I fibres SM

*A slight predominance of type 1 fibers

*Longissimus significantly greater percentage of type I fibers than multifidus and iliocostalis (Po0.001)

*No significant differences in the relative number of different fiber types between multifidus and longissimus

Comments by authors

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Note: DM, deep fibres of lumbar multifidus; SM, superficial fibres of lumbar multifidus; ES, erector spinae; IVD, intervertebral disc.

Population sampled

Authors

Table 1 (continued )

ARTICLE IN PRESS



arisen that DM is active tonically whereas SM and ES are active phasically. Is this argument supported? Electromyographic activity (EMG) of multifidus has been evaluated during a variety of tasks and postural perturbations with surface and intramuscular electrodes inserted with and without visual guidance (Floyd and Silver, 1951; Joseph and McColl, 1961; Morris et al., 1962; Joseph, 1963; Pauly, 1966; Jonsson, 1970; Donisch and Basmajian, 1972; Waters and Morris, 1972; Dofferhof and Vink, 1985; Valencia and Munro, 1985; Lindgren et al., 1993; Leinonen et al., 2001; Andersson et al., 2002; Moseley et al., 2002, 2003; White and McNair, 2002; Saunders et al., 2004). Unfortunately, recordings made with surface electrodes over multifidus correlate better with activity of lumbar longissimus than that of multifidus (Stokes et al., 2003). Furthermore, intramuscular EMG recordings indicate that activity of the deep back muscles can be different to that of the superficial components, and this difference is unlikely to be detected with surface electrodes (Wolf et al., 1989). Therefore, it is difficult to interpret the results of studies of multifidus in which surface electrodes have been used (Joseph and McColl, 1961; Joseph, 1963; Dofferhof and Vink, 1985; Arokoski et al., 2001; Leinonen et al., 2001). In most studies using intramuscular electrodes, suggestions of tonic activation during trunk movements have been based on qualitative judgments in a few subjects (Morris et al., 1962; Pauly, 1966; Jonsson, 1970; Donisch and Basmajian, 1972; Valencia and Munro, 1985). For instance, in a trunk rotation task, Donisch and Basmajian (1972) reported that 7 out of their 25 subjects had activity in the lumbar multifidus that was not related to the direction of movement. However, this activity was described by the authors as ‘‘burst like’’ or phasic in nature. During trunk flexion, Valencia and Munro (1985) reported that 10–15 subjects did not decrease multifidus activity at the end of range of trunk flexion (Valencia and Munro, 1985). However, 9 of those subjects were reported to be apprehensive to move and did not achieve full flexion with intramuscular electrodes. In 5 subjects who were not apprehensive and reached full flexion, electrical silence was demonstrated. It was concluded that the ‘‘flexion–relaxation phenomenon’’ was not as characteristic a feature of multifidus as that of ES. However, an alternative explanation is that activity of multifidus was altered by apprehension to move, rather than reflecting a normal feature of multifidus activity. Multifidus EMG has been shown to vary in static postures. Valencia and Munro (1985) reported slight intermittent activity of multifidus whilst standing in 14 subjects and no activity in three subjects. Donisch and Basmajian (1972) demonstrated either slight or no multifidus activity in quiet standing. Jonsson (1970) reported slight multifidus activity in more than half of their recordings, and activity was varied in intensity

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more often than not. This activity has been shown to be affected by posture, slight changes in standing position (Floyd and Silver, 1955; Morris et al., 1962; Joseph, 1963; Waters and Morris, 1972), and to vary between spinal levels (Joseph and McColl, 1961). In general, ES and the lumbar multifidus have been shown to be active in any posture that requires lumbar extension. In addition, ipsilateral ES is active during lateral flexion and rotation, and contralateral ES is active when carrying a load in a hand (Jonsson, 1970). Multifidus and ES are phasically active during gait (Pauly, 1966; Waters and Morris, 1972; Dofferhof and Vink, 1985; White and McNair, 2002). A recent study by Saunders et al. (2004) was the first to simultaneously record activity from DM and SM with intramuscular electrodes during gait. Phasic bursts of DM and SM activity occurred with ipsilateral and contralateral heel strike. Recent quantitative EMG studies have investigated the possibility that, although not tonically active, DM and SM may be differentially active. Moseley et al. (2002) reported that, unlike SM and ES, DM is active in a non-direction-specific feedforward manner in association with rapid arm movements. Differential activity of DM and SM has also been demonstrated during expected, but not in unexpected, trunk loading (Moseley et al., 2003). This suggests that DM and SM are differentially active in loading tasks, and that differential activity is dependent on input from higher centres. Such differentiation may serve to fine tune spinal control. In summary, these data suggest that the nervous system does not simply maintain tonic multifidus activity. Rather, it matches the spatial and temporal features of multifidus activity to the demands of spinal control, which vary with constantly changing internal and external forces. As such, the clinical belief regarding tonic activation of DM and phasic activation of SM and ES is not supported. However, it is apparent that DM, SM and ES are differentially active in functional tasks, which should be considered in the design of therapeutic exercise interventions.

5. Co-contraction of DM and TrA It has been proposed that DM and TrA may cocontract during an abdominal hollowing manoeuvre (Richardson et al., 2000). Furthermore, it has been proposed that co-contraction of DM and TrA is required for lumbar stability and must be retrained in patients with LBP (Richardson et al., 1990, 1992, 2000; O’Sullivan, 2000; Taylor and O’Sullivan, 2000). Is there evidence to support those proposals? Several studies have demonstrated activity of the abdominal and paraspinal muscles during an abdominal



hollowing manoeuvre (Richardson et al., 1990, 1992; Vezina and Hubley-Kozey, 2000; Arokoski et al., 2001) but none have recorded TrA or DM EMG. Furthermore, whether abdominal hollowing preferentially activates DM compared to SM or ES has not been tested. During function it is unlikely that co-contraction of DM and TrA is obligatory. Although there is evidence that TrA is continuously active (with amplitude modulation) during gait (Saunders et al., 2004) and in static postures (Cresswell et al., 1992), DM is active with phasic bursts as outlined above. Thus, while periods of co-contraction will occur it is not necessary for stability. However, there is evidence that suggests similarities in activity of TrA and DM. For instance, DM (Moseley et al., 2002) and TrA (Hodges and Richardson, 1997) are both active in a non-direction-specific feedforward manner in preparation for the perturbation to the spine from arm movement. Although contraction of these muscles is not simultaneous, it is possible that the mechanical effects occur more or less simultaneously because the electromechanical delay of TrA is likely to be longer than that for DM due to its long elastic anterior fascias. Earlier activity of TrA may compensate for this delay. Although there is no evidence that DM and TrA cocontract during abdominal hollowing, there is no evidence that they do not. Although DM and TrA do not co-contract tonically in function, further investigation of whether such co-contraction needs to be trained in patients with LBP is required.

6. Dysfunction of DM in LBP Changes in the lumbar paraspinal muscles associated with LBP have been suggested to affect DM more than SM or ES (Norris, 1995a, b; Pool-Goudzwaard et al., 1998; Richardson et al., 1999d; Arokoski et al., 2001; Hides, 2004b). Changes in activation patterns and cross sectional area (CSA) of the segmental portion of the lumbar multifidus (Hides, 2004b) have been suggested, and therapeutic exercise programmes that target multifidus have been tailored to address these issues. Several studies have demonstrated morphological changes in the lumbar multifidus in LBP. The CSA of multifidus has been shown to decrease on the painful side, and at the clinically determined level of symptom provocation (Hides et al., 1994). In chronic LBP the CSA of multifidus measured with CT (but not psoas) is reduced (Danneels et al., 2000). Furthermore, intramuscular fat in multifidus has been shown to be increased in chronic LBP (Parkkola et al., 1993; Kader et al., 2000) and following spinal surgery (Laasonen, 1984). Increased intramuscular fat has been argued to be greatest in DM (Kader et al., 2000).

Histochemical changes in multifidus have also been identified in LBP. Degeneration of type I muscle fibres (Jowett et al., 1975; Bagnall et al., 1984; Mattila et al., 1986; Rantanen et al., 1993) and atrophy of type II fibres (Rantanen et al., 1993) have been demonstrated. Furthermore, the decreased CSA of type I and II muscle fibres and other structural changes in multifidus have been identified at the level of intervertebral disc herniation (Yoshihara et al., 2001). In terms of activity, both denervation and reinnervation have been shown in multifidus in long-term LBP with leg pain (Sihvonen, 1997). Evidence of specific denervation of DM was demonstrated in one subject who was about to undergo repeat microdiscectomy (Zoidl et al., 2003). Lindgren et al. (1993), using intramuscular electrodes at an unspecified location, demonstrated a reduction in the number of functional motor units in multifidus ipsilateral to the patients symptoms at a segment determined radiographically to be unstable. The temporal characteristics of multifidus activity have been investigated with surface electrodes in response to expected trunk loading (Leinonen et al., 2001). Unlike controls, subjects with LBP did not reduce the latency of the multifidus response when the loading was predictable. However, as surface electrodes were used to record multifidus activity these data are difficult to interpret. No studies have specifically investigated the control of DM in LBP, acute or chronic. Evidence supports the clinical belief that changes specific to the lumbar multifidus occur in LBP. These changes have been demonstrated to be confined to a single segment and to the side of pain in some (Lindgren et al., 1993; Hides et al., 1994; Zhao et al., 2000; Yoshihara et al., 2001) but not all cases (Kader et al., 2000). However, the evidence for specific changes in DM in LBP is limited (Zoidl et al., 2003) or based on qualitative judgements in a limited number of subjects (Laasonen, 1984; Hides et al., 1994; Kader et al., 2000). Investigation of DM activity in LBP is required.

7. Summary and clinical implications The neurophysiological, biomechanical and histological data considered in this review provide a detailed examination of the evidence that underpins the clinical beliefs regarding lumbar multifidus. Although some beliefs are supported by the literature, a range of questions remain unanswered. Anatomical and biomechanical studies convincingly argue that DM, SM and ES control segmental motion. Although studies refute the clinical belief that SM and ES are solely extensors/rotators of the lumbar spine, data suggest that DM has an advantage for the nervous system in that this muscle can control intervertebral shear and torsion without generating torque. Thus,


activity of this muscle does not require co-contraction of antagonists. This supports the use of therapeutic exercise programmes which target DM in the rehabilitation of patients with LBP. Consistent with biomechanical data, is the evidence of differential activation of DM and SM with postural perturbations. This has been argued to indicate that DM fine tunes intervertebral control whereas SM functions to counteract flexion torque to maintain spinal orientation. This differential activation of DM and SM supports the use of specific motor learning strategies in the design of therapeutic exercise programmes that target multifidus. EMG studies refute the belief that DM is tonically active during static postures, trunk movements and gait. It is, therefore, unlikely that training tonic activity of multifidus restores the normal function of this muscle. However, tonic DM activity may still be a necessary and beneficial characteristic of therapeutic exercise as it may be required to compensate for osseoligamentous deficiency. DM and TrA do not maintain tonic co-contraction. However, these muscles do share functional similarities. As with tonic activation of DM, training co-contraction of DM and TrA as part of therapeutic exercise programmes is unlikely to restore typical activation patterns, but may be required to compensate for an underlying osseoligamentous deficit to restore intervertebral control. DM, SM and ES all have a predominance of type I muscle fibres. Unfortunately, biopsy samples for DM have only been harvested in cadaveric and surgical specimens. It remains unknown whether there are any differences in fibre types between DM, SM and ES in healthy individuals. Thus, the implication of muscle fibre characteristics for clinical practice remains unclear. Morphological, histochemical and neurophysiological changes have been shown in the lumbar multifidus in subjects with LBP. However, findings demonstrating specific dysfunction in DM are limited. Furthermore, whether postural activity of DM is affected or not in LBP remains to be investigated. Although the evidence which underpins clinical beliefs regarding lumbar multifidus is incomplete, there is good evidence that exercises which target DM, at least in the early phases of management, are effective to reduce the recurrence rate of LBP following a first episode of acute LBP (Hides et al., 2001), in the treatment of patients with radiological evidence of spondylolysis and spondylolisthesis (O’Sullivan et al., 1997) and as a component of the multimodal management of moderately disabled patients with chronic LBP (Moseley, 2002). Evaluation of the literature has raised a number of implications for the design of therapeutic exercises targeting DM and SM in the management of the LBP, which may improve these already positive results.

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Acknowledgements Lorimer Moseley and Paul Hodges are supported by the National Health & Medical Research Council of Australia.

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ARTICLE IN PRESS


Original article

The relationship beween posture and back muscle endurance in industrial workers with flexion-related low back pain Peter B. O’Sullivana,, Tim Mitchellb, Paul Bulichb, Rob Wallerb, Johan Holteb a

School of Physiotherapy, Curtin University of Technology, Bentley, WA, Australia b Body Logic Physiotherapy, Wembley, WA, Australia

Received 13 June 2004; received in revised form 8 March 2005; accepted 7 April 2005

Abstract This preliminary cross-sectional study was undertaken to determine if there were measurable relationships between posture, back muscle endurance and low back pain (LBP) in industrial workers with a reported history of flexion strain injury and flexion pain provocation. Clinical reports state that subjects with flexion pain disorders of the lumbar spine commonly adopt passive flexed postures such as slump sitting and present with associated dysfunction of the spinal postural stabilising musculature. However, to date there is little empirical evidence to support that patients with back pain, posture their spines differently than pain-free subjects. Subjects included 21 healthy industrial workers and 24 industrial workers with flexion-provoked LBP. Lifestyle information, lumbo-pelvic posture in sitting, standing and lifting, and back muscle endurance were measured. LBP subjects had significantly reduced back muscle endurance ðPo0:01Þ. LBP subjects sat with less hip flexion, ðP ¼ 0:05Þ, suggesting increased posterior pelvic tilt in sitting. LBP subjects postured their spines significantly closer to their end of range lumbar flexion in ‘usual’ sitting than the healthy controls ðPo0:05Þ. Correlations between increased time spent sitting, physical inactivity and poorer back muscle endurance were also identified. There were no significant differences found between the groups for the standing and lifting posture measures. These preliminary results support that a relationship may exist between flexed spinal postures, reduced back muscle endurance, physical inactivity and LBP in subjects with a history of flexion injury and pain. r 2005 Elsevier Ltd. All rights reserved. Keywords: Posture; Low back pain; Back muscle endurance; Activity levels

1. Introduction Epidemiological studies report the lifetime incidence of low back pain (LBP) in industrial workers to be approximately 60% (Svensson and Andersson, 1983; Lee et al., 2001). Yearly incidence has been reported as high as 31% (Svensson and Andersson, 1983; Poppel

Abbreviations: LBP, Low back pain; BMI, Body mass index; ASIS, Anterior superior iliac spine Corresponding author. Tel.: +61 8 9266 3629; fax: +61 8 9266 3699. E-mail address: [email protected] (P.B. O’Sullivan). 1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.04.004

et al., 1998). A number of studies have investigated potential predictors of LBP including physical risk, psychosocial and physiologic factors. A study investigating various physical and psychosocial risk factors over a 1 year period could account for only 12% of serious LBP (Adams et al., 1999). Risk has been identified with prolonged sitting (Balague et al., 1988), prolonged standing (Macfarlane et al., 1997) and lifting (Lee et al., 2001), although the exact basis for the risk for sitting is still contentious. A reduction in back muscle endurance has been found to be significantly predictive for new episodes of LBP (Biering-Sorensen, 1984; Luoto et al., 1995; Stevenson

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Keypoints

LBP subjects with a history of a flexion-provoked pain sit with their lumbar spine closer to end of range flexion, and with a greater degree of posterior pelvic tilt than healthy controls. LBP subjects with flexion-provoked pain have lower back muscle endurance than healthy

et al., 2001). This may be explained by the evidence that the back muscles, which are known to reduce load on passive structures (Goel et al., 1993), act to maintain the erect posture of the spine throughout the day, as well as being active during many manual handling procedures including lifting and load carrying (Nicolaisen and Jorgensen, 1985). Increased spinal mobility (BieringSorensen, 1984), and decreased lumbar side flexion (Adams et al., 1999) have also been found to be predictors of LBP in men in single studies. Other studies have found no significance in spinal range of movement (Battie et al., 1990; Luoto et al., 1995). With regards to spinal posture, Adams et al., (1999), reported a loss of lumbar lordosis as a predictor of LBP. Otherwise, to date there is little evidence that lumbar spine posture plays a significant role in the presence or development of LBP. Recent research has established a relationship between the level of trunk muscle activity and different standing and sitting postures (O’Sullivan et al., 2002). Adopting ‘‘passive’’ postures such as sway standing and slump sitting results in lower muscle activity in the transverse abdominal wall and back muscles, when compared to more upright standing and sitting postures. It was hypothesised on the basis of this research that subjects who habitually adopt ‘‘passive’’ spinal postures may decondition their lumbar stabilising muscles (O’Sullivan et al., 2002), leading to increased passive system loading, injury and pain (Cholewicki and McGill, 1996). Specific trunk muscle dysfunction (Hides et al., 1994; Hodges and Richardson, 1996) and impaired spinal proprioception (Brumagne et al., 2000), have been reported in LBP populations. Recent research has documented a loss of lumbar spine neutral zone position sense in chronic LBP subjects with signs of clinical instability with a flexion pain pattern (O’Sullivan et al., 2003). It was hypothesised that these findings may represent a motor control deficit, secondary to pain and motor dysfunction of the spinal stabilising muscles, which in turn may result in increased passive system loading from repeated end range stress to the spine (O’Sullivan et al., 2003). To date, the relationship between spinal posture, trunk muscle dysfunction and LBP has not been proven

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controls, even when matched for physical conditioning. Decreased back muscle endurance is associated with habitually adopting passive sitting posture, reduced activity levels and LBP. The findings provide evidence for a relationship between passive sitting postures, inactivity, reduced back muscle endurance and LBP in subjects with flexion-provoked pain.

in clinical studies (Dieck et al., 1985; Raine and Twomey, 1994; Hartvigsen et al., 2000). Most postural studies are difficult to compare due to the lack of standardisation of postural assessment, and the difficulty in reproducing some assessment tools in the clinical setting (During et al., 1985; Wrigley et al., 1991). Furthermore, few studies have looked at a specific LBP population, which may explain the lack of significant findings. The aim of this preliminary study was to examine whether a relationship exists between spinal posture, back muscle endurance, activity levels and LBP in a specific sub-group of industrial workers who reported flexion-provoked pain.

2. Materials and methods 2.1. Subjects A cross-sectional study of industrial workers involving a control group and a specific LBP population group was conducted. Twenty-one control subjects with mean age 38.24 years (SD 9.33) and mean BMI 25.05 kg/ m2 (SD 3.32), and 24 LBP subjects with mean age 38.79 years (SD 9.24) and mean BMI 26.43 kg/m2 (SD 2.86) were volunteers from an industrial work setting. All1200 employees from a bauxite refinery were contacted via email and invited to volunteer for the study if they fitted into the inclusion criteria for either the control or LBP group. Volunteers were screened for exclusion criteria, and then allocated to the appropriate group according to their LBP history. All subjects were manual workers, engaged in similar work activities at the time of testing. Ethical approval and written informed consent were obtained. The control subjects were male industrial workers with a minimum of 2 years continuous employment in an industrial workplace. They had no history of significant LBP requiring medical intervention or time off work, and no history of low back ache in the preceding 3 months. Subjects in the control group were matched to the LBP subjects on the basis that they engaged in the same kind of work activity.


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The LBP subjects reported a flexion injury to the lumbar spine, with ongoing pain over the preceding 18 months related to flexion activities and/or postures related to their work. All LBP subjects were performing their pre-injury duties for at least 3 months prior to testing to ensure physical work conditioning matched with the control group. Subjects who reported the onset of back pain secondary to trauma (such as from a motor vehicle accident) or pain provoked by lumbar spine extension postures/activities were excluded. Subjects were also excluded who had radicular symptoms, or had undergone spinal surgery or posture retraining or specific stabilising muscle training as part of treatment for their LBP, to limit potential bias in the posture measures. Subjects with pain greater than 3/10 on a visual analogue scale during testing were excluded to limit the influence of pain impacting on the test results. Subjects who had a pending worker’s compensation claim were also excluded. 2.2. Measures and procedures Estimates of subject’s activity levels and commonly adopted postures, both at work and home were obtained by a questionnaire designed for this study. The authors were unable to locate a previously validated questionnaire, which enabled the required information, at the time of testing. Subjects were asked in an interview format to estimate how much time they spent at work and home engaged in activities that involved sitting, standing, lifting and strenuous physical activity. Each activity was given an individual rating. The number of hours per week spent sitting (watching television, computer use, driving/travel and sitting at work) and standing (walking, standing at work and light general activity), was classified into 0–12 h (low), 13–24 h (moderate) and 25+h (high). Lifting hours per week (at work and home) was broken down into 0–5h (low), 6–10h (moderate) and 11+h (high). Activity levels were based on time spent doing vigorous outdoor activities (brisk walking, sport and strenuous outdoor tasks) over an average week, and was broken down into 0–3h (low), 4–7h (moderate) and 8+h (high). From this information, subjects were given ratings of ‘‘low’’, ‘‘moderate’’ or ‘‘high’’ for amounts of time spent in each category.

postures, and lifting and maximal standing lumbar flexion postures. In the sitting postures, subjects’ knee and ankle position was standardised with an adjustable stool to allow for subject height variances to ensure the knees were at a 901 angle. Natural sitting posture was determined in a blind manner, whereby the subjects’ sitting posture was photographed when they first sat on the stool without them being aware of the role of the initial photograph. Subjects were then guided into their full slump sitting posture and another photograph was taken. For standing, subjects were asked to stand on a mark on the floor looking forwards, with no instruction how they stood. They were then positioned into their maximal sway standing posture by a consistent examiner The lifting posture involved a 12 kg box with handles being lifted 5 cm off the floor. Subjects were asked to lift using their ‘usual’ technique. The lift was below the recognised safe single lift limit for risk of low back injury (Waters et al., 1993). Measures of lumbar, hip and knee angles were recorded. Digital photographs were taken with a Canon Digital IXUS V camera (2.1 mega pixels). The posture photos were imported into Scion Image (Scion Corporation,

2.3. Posture measures Photo-reflective balls were taped to the bony landmarks of each subject’s left anterior superior iliac spine (ASIS), greater trochanter midpoint, lateral femoral condyle, lateral malleolus, and the spinous processes of T10, L2, L4 and S2. Subjects were photographed in their natural sitting and maximal slumped sitting postures (Fig. 1), natural standing and maximal sway standing

Fig. 1. Slumped sitting measure. Lumbar and hip angles shown.


Fredrick, USA), an image-processing programme that measures angles between manually marked positions on a digital image. The hip angle was calculated as the angle formed between the points of the ASIS, greater trochanter and lateral femoral condyle. The knee angle was the angle formed between the points of the greater trochanter, lateral femoral condyle and lateral malleolus. The lumbar angle was measured as the angle between the intersection of the tangents drawn through the T10/L2 markers and the L4/S2 markers, as shown in Fig. 1. To validate the measures of lumbar flexion and extension using anatomical markers, digital photography and Scion Image analysis software, a pilot study was conducted. Five subjects were measured in end of range lumbar flexion and sway standing. Lumbar angles were taken using the previously validated ‘two inclinometer’ method (Rainville et al., 1994), and compared to the digital photograph measures taken from the same position. Intraclass correlations revealed high levels of correlation between the two measures in sitting and standing postures ðICC ¼ 0:9320:98Þ. Reliability testing of the angles produced using the Scion Image Software programme was also conducted on 5 subjects repeating the measures three times. Intraclass correlations showed high levels of both inter-tester ðICC ¼ 0:9420:99Þ, and intra-tester reliability ðICC ¼ 0:9921:00Þ. 2.4. Back muscle endurance The Biering-Sorensen test was used to measure back muscle endurance (Moreau et al., 2001). Subjects lay prone over the edge of a couch, with the trunk unsupported. They were instructed to maintain a horizontal position of the trunk for as long as possible. Endurance time was recorded when the subjects deviated more than 101 from the lumbar neutral position. This angle was determined using a hand-held inclinometer (Cimed, Switzerland), at the thoraco-lumbar junction. The investigators taking the postural photographs and lumbar muscle endurance scores were blinded to the group allocation of the subjects during both testing and data management. 2.5. Statistical analysis A sample of 20 subjects was determined from previous lumbar muscle endurance data to be sufficient to detect an effect of moderate size with an alpha level of 0.05 and power level of 80%. No prior data was available for the posture measures, and 20 subjects was considered to be sufficient for this preliminary study. All data were coded and input into SPSS Student Version 10.0 (SPSS, Chicago USA). Data were analysed for normality. Paired t-tests were used to compare the difference between lumbar and hip angles in ‘usual’ and

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slump sitting postures and ‘usual’ and sway standing lumbar spine postures. Independent t-tests were used to compare hip angles, lumbar spine angles, and muscle endurance scores between the pain and control groups. Mann–Whitney U test were performed on the activity level data. Spearman’s correlations were used to test for relationships between lumbar muscle endurance, posture, activity level, sitting time data and LBP.

3. Results The mean, standard deviation and ‘‘P’’ values of the endurance scores, and the lumbar, hip, and knee angles in the test positions are shown in Table 1. The results showed normal distributions using the Shapiro–Wilk test. The LBP group showed significantly lower back muscle endurance compared to the pain-free controls, (tð43Þ ¼ 3:98, P ¼ o0:001). No difference was observed between the two groups when comparing their ‘usual’ sitting, standing and lifting lumbar flexion angles. However, the LBP subjects sat in greater posterior pelvic tilt than control subjects when assuming their ‘usual’ sitting posture, (tð43Þ ¼ 2:00, P ¼ 0:05). When comparing the lumbar angle difference between ‘usual’ sitting and maximal slumped sitting, the back pain group sat significantly closer to their end of range lumbar flexion in their ‘usual’ sitting posture (tð43Þ ¼ 0:32, P ¼ 0:02). There were significant correlations between decreased low back muscle endurance scores and increased posterior pelvic tilt during ‘usual’ sitting (rð43Þ ¼ 0:32, P ¼ 0:03), as well as between decreased low back muscle endurance and smaller differences in lumbar angles between ‘usual’ sitting and maximal slumped sitting (rð43Þ ¼ 0:36, P ¼ 0:01). The results from the activity questionnaires regarding sitting, standing, lifting and activity periods are shown in Table 2. When comparing the questionnaire results between the two groups, no significant difference was found, although LBP subjects sitting longer than the pain-free controls demonstrated a trend towards a statistical significance ðP ¼ 0:057Þ. Significant correlations did exist however, across all subjects, between lower back muscle endurance scores and higher sitting periods (rð43Þ ¼ 0:31, P ¼ 0:04). Correlation was also observed between low back muscle endurance scores and low activity levels (rð43Þ ¼ 0:31, P ¼ 0:04).

4. Discussion This preliminary study supports that reduced back muscle endurance is a common finding in this sub-group


268

Table 1 Lumbar, hip and knee angles and endurance scores Low back pain group

Stand (Lx) Sway (Lx) Stand (hip) Sway (hip) Sit (Lx) Slump (Lx) Sit–slump Difference (Lx) Sit (hip) Slump (hip) Flexion (Lx) Lift (Lx) Flexion (hip) Lift (hip) Flexion (knee) Lift (knee) Endurancec

Control group a

N

Mean

SD

N

Meana

SD

P-valuesb

24 24 24 24 24 24 24

154.18 148.98 154.83 158.26 187.13 192.80 5.67

7.43 10.36 12.65 12.59 7.61 5.90 5.29

21 21 21 21 21 21 21

153.32 148.25 149.61 152.20 183.92 193.83 9.91

5.90 5.27 9.01 10.61 10.87 7.97 6.08

0.67 0.76 0.12 0.90 0.25 0.62 0.02

24 24 24 24 24 24 24 24 24

109.09 111.90 200.42 189.86 110.73 90.81 176.37 106.55 121.12

19.32 17.11 5.94 12.20 15.88 27.73 6.51 45.08 43.69

21 21 21 21 21 21 21 21 21

98.57 103.00 202.22 192.17 104.81 88.51 178.84 109.42 167.76

15.32 13.68 6.31 13.93 15.10 22.22 6.56 44.85 33.27

0.05 0.06 0.33 0.56 0.16 0.76 0.21 0.83 o0.001

Lx ¼ Lumbar. Difference ¼ angles subtracted to give difference between 2 stated measures. a Mean ¼ Degrees. b P—values of LBP vs Control groups. c Endurance ¼ Seconds.

Table 2 Activity questionnaire time ratings Low back pain group

Sitting Standing Lifting Active

Control group

Low (%)

Medium (%)

High (%)

Low (%)

Medium (%)

High (%)

0.0 8.3 25.0 20.8

20.8 45.8 70.8 50.0

79.2 45.8 4.2 29.2

0.0 0.0 28.6 4.8

47.6 47.6 61.9 57.1

52.4 52.4 9.5 38.1

% of subjects in each category.

with flexion-related LBP. No subjects reported pain during the test procedures, supporting that the presence of pain did not directly bias the results of the study. These findings are consistent with a number of other studies that have also reported reduced back muscle endurance in other more heterogenous LBP populations (Nicolaisen and Jorgensen, 1985; Holmstrom et al., 1992; Hultman et al., 1993). This may reflect previous reports that flexion-related pain disorders are the most common disorders observed in clinical practice (O’Sullivan, 2000). In a bio-mechanical modelling study by Goel et al., (1993), it was proposed that lumbar spinal muscles impart stability to the ligamentous segment and also lead to a decrease in stresses in the vertebral body and the intervertebral disc. On the other hand, back muscle fatigue has been shown to be associated with reduced

spinal proprioception in both healthy and LBP subjects (Taimela et al., 1999). It is considered that these factors in turn may lead to increased passive system loading and resultant tissue strain (Cholewicki and McGill, 1996). Possible causes of reduced back muscle endurance might include disuse through inactivity (Moffroid et al., 1994), altered motor control patterns (O’Sullivan et al., 1997), or prolonged passive system loading associated with reduced activity of spinal stabilising muscles (O’Sullivan et al., 2002). Some of these associations are supported by the data in the present study. Poor back muscle endurance was correlated to increased periods of sitting and lower physical activity levels. This is supported by recent research which has shown a relationship between passive slumped sitting posture and reduced back muscle activity (O’Sullivan et al., 2002). A correlation has been previously reported


between the presence of LBP and time spent watching television in studies on adolescents (Balague et al., 1988, 1994). Balague et al. (1988, 1994) proposed that this association might be due to prolonged sitting and/or ‘poor’ posture and/or physical inactivity. The previously identified relationship between psychosocial factors such as depression and (LBP) (Leinoa and Magnib, 1993) may also be associated with this relationship and requires further investigation. There was no difference between the groups based on their lumbar spine posture angles in sitting. These findings are consistent with other literature (Raine and Twomey, 1994; Hartvigsen et al., 2000). However the LBP subjects sat with a greater degree of posterior pelvic rotation and with their lumbar spine closer to their end of range of available flexion compared to the control group subjects. By sitting with their lumbar spine towards the end of range flexion, recent research (O’Sullivan et al., 2002), suggests these subjects are adopting a more ‘passive’ posture. On average, the LBP subjects sat within 61 of their end of range spinal flexion. It is therefore likely that they are sitting with relative inactivity of their spinal stabilising muscles and towards their elastic zone of motion in spinal flexion. This hypothesis is supported by the association observed between reduced back muscle endurance and subjects sitting closer to the end range of spinal flexion. The findings of this study suggest that the measure of an individual’s ‘usual’ spinal posture relative to their end of range may be a more significant factor than simply comparing spinal flexibility or posture. There have been no previous posture studies identified by the present authors which have investigated the relationship between LBP and sitting posture in relation to end of range lumbar spine position. This manner of measuring spinal posture gives an insight into the posturing of the lumbar spine relative to its elastic zone of motion, where stress within the passive structures increases (Scannell and McGill, 2003). No significant differences in standing posture were detected between the groups. This is contrary to some previous studies (Itoi, 1991; Adams et al., 1999), but consistent with others (Battie et al., 1990; Raine and Twomey, 1994). There was a broad range of standing postures among the groups. Perhaps standing posture is not easily classified in the manner which we carried out, and thus may not be a predictor of LBP, as previous literature documents (Battie et al., 1990; Raine and Twomey, 1994). All LBP subjects in this study had pain associated with flexed spinal postures and activities, which did not involve upright standing or extension postures. Given this, it may be that extension postures of the lumbar spine, such as standing, may not be as relevant to flexion-related pain disorders. There was no significant difference between the groups for standing lumbar flexion or lifting measures.

269

These findings are consistent with other research (Raine and Twomey, 1994). The authors noted during testing that while performing the lifting measure, many of the subjects asked for directions regarding how to perform the lift, and some suggested that they would lift as they had been previously taught. Subjects in both groups equally adopted a variety of lifting postures including stooped (12), semi-squat (20) and full squat (13). It seems that the single lift measure used in this research setting was not sensitive enough to record ‘usual’ or ‘habitual’ lifting postures for these subjects. Future studies may require a different methodological model such as that described by McGill et al. (2003), to induce a ‘usual’ lifting/bending posture which subjects regularly employ in their natural work environment. 4.1. Clinical implications It should be noted that the LBP subjects reported pain associated with flexion postures and activities of the spine and yet they sat closer to their end range of spinal flexion. These findings do not support theories of fear avoidance behaviour in this group (Indahl et al., 1998), but rather indicate that the group with flexion-related LBP habitually posture their spines in a potentially more pain provocative manner. Habitual end range loading of pain sensitive tissue may in turn further sensitise nociceptive tissue thereby maintaining a chronic pain state. Consistent with these findings, McGill et al., (2003) reported that industrial workers with a history of back pain performed certain tasks that resulted in higher spinal load than subjects without LBP. Burnett et al. (2004), reported that cyclists with a flexion pain pattern presented with increased lower lumbar spine flexion and rotation and a loss of co-contraction of lumbar multifidus, that was associated with an increased (LBP) while cycling. O’Sullivan et al. (2003), reported that subjects with (LBP) with a flexion pain pattern had poor spinal repositioning sense within the neutral zone of spinal motion, with a tendency to position their spines closer to end range of spinal motion and away from neutral positions. This observed behaviour represents a possible mal-adaptive response to a pain disorder whereby a person adopts habitual spinal postures that in fact result in increased spinal tissue loading. This may represent a mechanism for ongoing tissue sensitisation and pain in these subjects. Further studies conducted in this population will be necessary to determine whether these factors correlate with altered spinal position sense both in sitting and in bending of the spine. This study highlights the multi-factorial nature of LBP with associations detected between flexion-related (LBP), reduced trunk muscle endurance, passive sitting postures, physical inactivity and time spent sitting. It is


P.B. O’Sullivan et al. / Manual Therapy 11 (2006) 264–271

not known whether these factors existed prior to and therefore pre-disposed to LBP in these subjects, or are a result of LBP in these subjects. Prospective studies are required to determine these factors. 4.2. Limitations The results of this preliminary study cannot be generalised over a broader, or older population, nor other sub-groups of LBP given the small sample size used and the inclusion of LBP subjects with flexionrelated injury and pain. Further research is currently being conducted in another LBP population to compare these findings with subjects with extension-related back pain to determine whether different physical characteristics are associated with different patterns of spinal pain provocation. A questionnaire was designed for this study to gain information regarding levels of physical activity and habitual postures (particularly sitting) over a range of locations, not just at work. We acknowledge that using a validated questionnaire would have been preferable, although we were unable to locate a questionnaire specific to the requirements of the study at the time. Although reliability and validity was shown in the measurement of spinal angles using photo-reflective markers, a more sensitive measurement tool may have provided greater accuracy and given greater understanding in terms of regional differences in flexibility across the lumbar spine. The results of this preliminary study suggest that some important physical characteristics in specific LBP sub-groups may be present, however further investigation with a larger sample size and more sensitive measures is required to allow generalisation of the results. 4.3. Conclusion This study provides preliminary evidence that there is a relationship between reduced lumbar muscle endurance, habitually posturing the lumbar spine close to end range flexion in sitting, reduced levels of physical activity and time spent sitting, in industrial workers with LBP who present with flexion-related pain disorders. Further research investigating these relationships is warranted.

Acknowledgements The authors would like to acknowledge with appreciation the valuable contribution of Dr. Marie Blackmore (Statistician) and Dr. Kathy Briffa of Curtin University of Technology, and Alcoa World Alumina Australia, for their assistance with research subjects.

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ARTICLE IN PRESS P.B. O’Sullivan et al. / Manual Therapy 11 (2006) 264–271 Macfarlane GJ, Thomas E, Papagerorgiou AC, et al. Employment and physical work activities as predictors of future low back pain. Spine 1997;22(10):1143–9. McGill S, Grenier S, Bluhm M, et al. Previous history of LBP with work loss is related to lingering deficits in biomechanical, physiological, personal, psychosocial and motor control characteristics. Ergonomics 2003;46:731–46. Moffroid M, Reid S, Henry S, et al. Some endurance measures in persons with chronic low back pain. Journal of Orthopaedic Sports and Physical Therapy 1994;2:81–7. Moreau C, Green B, Johnson C, et al. Isometric back extension endurance tests: a review of the literature. Journal of Manipulative and Physiological Therapeutics 2001;24:110–22. Nicolaisen T, Jorgensen K. Trunk strength, back muscle endurance and low-back trouble. Scandanavian Journal of Rehabilitation Medicine 1985;17:121–7. O’Sullivan P. Lumbar segmental ‘instability’: clinical presentation and specific stabilising exercise management. Manual Therapy 2000; 5(1):2–12. O’Sullivan P, Burnett A, Floyd A, et al. Lumbar repositioning deficit in a specific low back pain population. Spine 2003;28:1074–9. O’Sullivan P, Grahamslaw K, Kendell M, et al. The effect of different standing and sitting postures on trunk muscle activity in a pain free population. Spine 2002;27:1238–44. O’Sullivan P, Twomey L, Allison G. Dynamic stabilisation of the lumbar spine. Critical Reviews of Physical and Rehabilitation Medicine 1997;9:315–30.

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ARTICLE IN PRESS


Original article

Exercise therapy for low back pain: A small-scale exploratory survey of current physiotherapy practice in the Republic of Ireland acute hospital setting Karol Byrne, Catherine Doody, Deirdre A. Hurley School of Physiotherapy, Health Sciences Complex, University College Dublin, Belfield, Dublin 4, Republic of Ireland Received 9 May 2004; received in revised form 14 March 2005; accepted 1 June 2005

Abstract A small-scale exploratory cross-sectional survey investigated the current use of a range of exercise therapy approaches for low back pain (LBP) by outpatient physiotherapists in the acute hospital setting in the Republic of Ireland, where the majority of publicly funded treatment is delivered. Of the 120 postal questionnaires distributed to 24 physiotherapy departments, 87 were returned (72.5% response rate). The results showed specific spinal stabilization exercises were the most popular exercise therapy for acute (39%; n ¼ 35) and chronic (51%; n ¼ 48) LBP, followed by the McKenzie approach (acute LBP (ALBP) 35.6%; n ¼ 32: chronic LBP (CLBP) 17%; n ¼ 16), and abdominal exercise (ALBP 11.1%; n ¼ 10: CLBP 9.6%; n ¼ 9). The most popular forms of exercise therapy used by outpatient physiotherapists in acute hospital settings in Ireland lack support from evidence-based clinical guidelines, and further large-scale high quality randomized controlled trials of these approaches are warranted. Further research should also establish the use of exercise therapy and attitudes to clinical guidelines of physiotherapists in other countries and healthcare settings. r 2005 Elsevier Ltd. All rights reserved. Keywords: Exercise therapy; Survey; Low back pain; Physiotherapy

1. Introduction At the beginning of the 21st century low back pain (LBP) continues to exact a huge toll in terms of suffering and costs (Waddell, 2004). The lifetime and 1-year prevalence of LBP are approximately 60–80% (Torstensen et al., 1998), and 34% (Croft et al., 1999), respectively. While the majority of acute episodes resolve within 12 weeks, the recurrence rate is high; in a large-scale prospective cohort study one third of subjects reported persistent, disabling LBP 12 months after initial medical consultation (Thomas et al., 1999). In the Republic of Ireland (ROI) the treatment of LBP costs the Exchequer over h32 million per annum, and Corresponding author. Tel.: +353 1 7166516; fax: +353 1 7166501.

E-mail address: [email protected] (D.A. Hurley). 1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.06.002

represents 27% of disability payments at a cost of h500 M (Leech, 2004). While the ROI Health Strategy (2001) proposed the primary care setting as the central focus for the delivery of health and personal social services for the majority of patients’ in Ireland through the development of numerous inter-disciplinary community-based primary care teams that included physiotherapy, there have been significant delays in its implementation. Consequently, current physiotherapy services for publicly funded LBP patients are largely provided within the secondary care acute hospital setting (Moore and Hurley, 2004). In the current economic climate of limited resources for health care spending and growing waiting lists for physiotherapy, it is important to establish if the treatment provided to patients with LBP is supported by the current evidence base.

ARTICLE IN PRESS K. Byrne et al. / Manual Therapy 11 (2006) 272–278

Nonetheless, the evidence base is conflicting in terms of its support for exercise therapy in acute and chronic LBP (CLBP) conditions. Recent systematic reviews have concluded that exercise is a safe and effective therapy for improving flexibility, strength and function, and reducing pain in CLBP patients compared to usual care (van Tulder et al., 2000; Liddle et al., 2004; Rainville et al., 2004; van Tulder and Koes, 2004a). Available CLBP clinical guidelines advocate some form of exercise therapy, but the type and intensity of the exercise varies from a general active approach (Netherlands, Denmark), to intense exercises (Finland) and multimodal exercises (Germany; Koes et al., 2001). Conversely, systematic reviews of acute LBP (ALBP) have found the effects of back exercises either equivocal or more harmful than other conservative or inactive treatments (van Tulder et al., 2000; van Tulder and Koes, 2004b). Clinical guideline recommendations for ALBP show some variation; the recently developed European clinical guideline (van Tulder et al., 2002), and several national guidelines (i.e. Netherlands, UK, New Zealand, Australia, Sweden) only advocate exercise in the form of advice to stay active and do not support specific strengthening, flexibility, flexion or extension exercises (Koes et al., 2001). The American and Swiss guidelines state that low-stress aerobic exercises are a therapeutic option in ALBP, while the Danish guideline specifically mentions McKenzie exercises (Manniche, 1999). There is a broader consensus among guidelines recommending the use of physical reconditioning programmes for subALBP of at least 6 weeks duration (Koes et al., 2001; van Tulder et al., 2002). The inconsistency between both systematic reviews and clinical guidelines are partly related to differences in the definitions of ALBP and CLBP, as well as variation in the composition and methodology of review and guideline committees, and disparity in the availability and interpretation of the most recently published randomized controlled trials in the area. Furthermore, the development, reporting and content of primary care guidelines for LBP are not of uniform high quality (van Tulder et al., 2004), and the characteristics of guideline developers cannot be used as a reliable proxy for guideline quality (Eccles and Grimshaw, 2004). Previous postal surveys have established the physiotherapeutic management of patients with LBP in the ROI/Britain (Foster et al., 1999) and Northern Ireland (Gracey et al., 2002). The study by Foster et al. included a sample of physiotherapists working in Health Board and private settings in the ROI (36.3%; n ¼ 295), but did not distinguish between the findings for this subgroup and the remaining 64% from Britain. Details of the types of exercise therapy utilized by therapists were limited to the McKenzie approach (46.6% Foster et al., 1999; 71.4% Gracey et al., 2002), abdominal exercise (17.5% Foster et al., 1999), active exercise

273

(26.9% Gracey et al., 2002), and muscle re-education (8.1% Gracey et al., 2002), and failed to discriminate between patients with ALBP and CLBP. Therefore, the aim of the study was to explore the current use of a range of exercise therapy approaches by outpatient physiotherapists in acute hospital settings in the ROI by means of a postal questionnaire.

2. Methods 2.1. Survey instrument The survey instrument was developed following a literature review to enhance its content validity. A pilot study involving two physiotherapists working in private practice established its face validity and identified the need for minor amendments. The resultant questionnaire comprised three sections (i) ‘therapists’ (i.e. clinical grade, years experience and speciality), (ii) ‘LBP caseload’ (i.e. percentage of patients with LBP on therapists’ caseloads and the ratio of acute [0–3 months LBP] to chronic [43 months LBP] patients), and (iii) ‘exercise therapy’ (i.e. types of exercise therapy used in the current treatment of acute and CLBP, and the types preferred if resources were available). Respondents were asked to identify the exercise therapies they used in the treatment of both acute and CLBP from a list of 11 regimens (using a rating scale where ‘‘1’’ equalled ‘‘most frequently used’’, ‘‘2’’ was ‘‘second-most frequently used’’ etc. Ethical approval was not required for this study as it was a descriptive study not involving any change in clinical practice. 2.2. Sample The total study population was defined as all physiotherapists working in an outpatient setting in acute hospitals in the ROI. Physiotherapists working in private practice in the ROI or in Northern Ireland were excluded from the study. Secondary care acute hospital settings were selected to reflect current practice in the treatment of LBP in Ireland where the majority of cases are treated rather than in primary care settings as recommended by clinical guidelines (van Tulder et al., 2002). There are currently approximately 1500 practicing members of the Irish Society of Chartered Physiotherapists. Data is not available regarding the number of Physiotherapists working in hospital outpatient departments specifically. Thus, it was necessary to contact potential respondents through their workplace rather than directly. A list of all acute hospitals in the ROI was obtained from the Department of Health and Children (n ¼ 36). On the basis of an anticipated 60% response rate (Foster et al., 1999), 120 subjects were considered a


K. Byrne et al. / Manual Therapy 11 (2006) 272–278

sufficient sample to survey for this small-scale exploratory study. From this, a member of staff at the UCD School of Physiotherapy (DH) selected a random sample of 24 hospitals.

‘Orthopaedics’ (23%, n ¼ 20), ‘Sports Medicine’ (17%; n ¼ 17:2), ‘Hydrotherapy’ (6.9%, n ¼ 6), and ‘Rheumatology’ (6.9%, n ¼ 6). The remaining 13.7% (n ¼ 19) were employed in other areas for example ‘Respiratory’ (n ¼ 3) and ‘Women’s Health’ (n ¼ 2).

2.3. Procedure 3.3. Low back pain caseload In June 2003 the questionnaire packages comprising five questionnaires (24 5 ¼ 120), cover letters and prepaid envelopes were posted to the Physiotherapy Manager in each hospital. Each Physiotherapy Manager sought five volunteers involved in the management of LBP and working in an outpatient setting to participate in the study. A coding system was used to identify the number of questionnaires returned by each hospital. Reminders were sent to non-respondent hospitals after a 3-week period. 2.4. Data analysis This study was primarily descriptive, and data analysis was carried out using Microsoft Excel 2000. Data from all sections were entered into spreadsheets using Microsoft Excel 2000, checked by one of the authors (CD) for errors by comparison with the raw data, and cleaned as required. Missing data were not replaced with imputed values. Data were then analysed using descriptive statistics involving simple frequency distributions. The small sample size meant that crosstabulations to explore comparative relationships between variables were not possible.

3. Results 3.1. Survey response Of the total of 120 questionnaires distributed, 87 completed questionnaires (72.5% response rate) were returned. 3.2. Therapist information The majority of respondents 58.6% (n ¼ 51) worked at the level of Senior Grade, with 35.6% (n ¼ 31) working at Basic Grade level and the remaining 5.8% (n ¼ 5) working as clinical tutors or managers. The therapists were evenly distributed in terms of years since qualification; approximately 25% (n ¼ 22) of respondents were qualified for each of 1–3 years, 4–6 years, 7–10 years and over 10 years. In terms of years experience in the area of LBP, 20.7% (n ¼ 18) had 0–2 years experience, 33.3% (n ¼ 29) had 3–5 years, 25.3% (n ¼ 22) had 6–10 years and 20.7% (n ¼ 18) had over 10 years experience. The majority of the respondents specialized in ‘Outpatients’ (67%, n ¼ 59), followed by

Patients with LBP constituted on average 35% of therapists’ weekly caseloads with the mean percentages of acute and CLBP patients 32.5% and 67.5%, respectively. The majority of respondents (59.3%; n ¼ 51) saw patients with LBP for ‘7–10 treatments’, followed by ‘4–6 treatments’ (31.4%; n ¼ 27), ‘410 treatments’ (7%; n ¼ 6), and ‘1–3 treatments’ (2.3%; n ¼ 2). 3.4. Exercise therapy for acute low back pain Table 1 shows the number of first preferences assigned to each type of exercise therapy for ALBP management. Specific spinal stabilization exercises (38.9%; n ¼ 35) and the McKenzie Approach (35.6%; n ¼ 32) were by far the most popular. The ‘other’ forms of exercise therapy listed were flexibility exercises (n ¼ 5), Mayer’s Programme (n ¼ 3), American Physical Therapy Association Programme (n ¼ 1), Muscle energy techniques (n ¼ 1), myofascial release (n ¼ 1), and pelvic floor/ diaphragm (n ¼ 1). Also shown is the mean ranking given to each type of exercise therapy, derived from totalling the rankings given to each treatment and dividing by the number of rankings given to each. For example, if a treatment received 10 ‘‘1’’ rankings, the mean ranking was 1. The lower the mean ranking, the more commonly used the treatment, as therapists were asked to number the treatments from 1 to 11. These results showed that specific spinal stabilization exercises and the McKenzie Approach were again the most popular by some margin at 2.0 and 2.1, respectively and ‘‘other’’ exercises (2.4) Table 1 Use of exercise therapy for acute low back pain Preferred exercise therapy

Percentage

Number of responses

Mean ranking

Specific spinal stabilization exercises McKenzie approach General abdominal exercises Other Pilates General aerobic exercises Williams’ flexion exercises Hydrotherapy Swiss ball exercises Group exercise Circuit training

38.9

35

2.0

35.6 11.1 6.7 3.3 3.3 1.1 0 0 0 0

32 10 6 3 3 1 0 0 0 0

2.1 2.8 2.4 3.3 3.8 5.4 4.5 4.6 6.0 6.4


were the next most commonly used. Treatments with the higher number of first preferences were also those with lower mean rankings. One exception was general abdominal exercises, which received a higher number of first preferences than ‘‘other’’ treatments, but which had a higher mean ranking (2.8). Also interesting was group exercise, which was one of the least popular in the treatment of ALBP with no first preferences and a mean ranking of 6, but which ranked second highest in the ‘preferred exercise’ question (31.9% of respondents would use it if resources were available). 3.5. Exercise therapy for chronic low back pain The findings were broadly consistent with those for ALBP as illustrated in Table 2. Specific spinal stabilization exercise was again the most popular (51%; n ¼ 48), followed by the McKenzie Approach (17%; n ¼ 16), general abdominal (9.6%; n ¼ 9) and general aerobic exercises (9.6%; n ¼ 9), and Pilates (7.4%; n ¼ 7). The latter two treatments proved more popular for managing chronic than ALBP, with ‘‘other’’ treatments less so. The types of ‘other’ treatments listed were almost identical to the findings for ALBP. Specific spinal stabilization exercises again had the lowest mean ranking (1.9), but the McKenzie approach was only fourth most popular overall in terms of mean ranking, at 3.2. ‘‘Other’’ treatments were second most popular (2.7), ahead of general abdominal exercises (3.0), Pilates (3.3) and general aerobic exercises (3.4). 3.6. Group exercise classes and hydrotherapy In light of the growing evidence base for group exercise classes a more in-depth analysis of their provision in the ROI was conducted. 34 therapists (39%) stated that they conducted group exercise classes for LBP with an additional 31.9% (n ¼ 25) stating that

Table 2 Use of exercise therapy for chronic low back pain Preferred exercise therapy

Percentage

Number of responses

Mean ranking

Specific spinal stabilization exercises McKenzie approach General abdominal exercises General aerobic exercises Pilates Other Hydrotherapy Swiss ball exercises Group exercise Circuit training Williams’ flexion exercises

51.0

48

1.9

17.0 9.6 9.6 7.4 4.3 1.1 0 0 0 0

16 9 9 7 4 1 0 0 0 0

3.2 3.0 3.4 3.3 2.7 3.9 4.6 4.6 5.6 5.9

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they would carry out group exercise classes if sufficient resources were available. Only 2.9% (n ¼ 1) of respondents ran such classes in a hydrotherapy pool setting, and an additional 40.9% (n ¼ 27) would use hydrotherapy if facilities were available. Over 90% (n ¼ 31) said they conducted such classes in their hospital’s gym, while 6% (n ¼ 2) used private facilities.

4. Discussion This small-scale survey explored for the first time the use of a range of exercise approaches by outpatient physiotherapists in the acute hospital setting in the ROI for the management of both acute and CLBP. An excellent response rate of 72.5% was achieved, which compares favourably with previous physiotherapy surveys (Foster et al., 1999; Konstantinou et al., 2002). Nonetheless, the study is limited by its sampling method, small sample size and potential non-response bias that should be acknowledged in interpreting the findings. Non-response bias is an important problem in survey research that may limit the generalizability of these findings to all outpatient physiotherapists working in acute hospital settings in Ireland. It was not possible, due to the nature of the study design, to contact nonrespondents directly. Furthermore, the study relied on therapists to provide accurate data, but respondents had the potential to verify data provided against treatment charts. Finally, the exercise therapies investigated were those used in the treatment of LBP in a physiotherapy department and did not include physical activities such as walking, swimming and cycling advocated by clinical guidelines (van Tulder et al., 2002). The popularity of specific spinal stabilization exercises and the McKenzie approach conflicts with their lack of endorsement from LBP clinical guidelines (Koes et al., 2001; van Tulder et al., 2002). Their widespread use may be partly explained by the extensive availability of postgraduate courses in both approaches to spinal management. Recent widely publicized positive evidence of the efficacy of specific spinal stabilization exercises from laboratory-based research (Hodges and Moseley, 2003), and small-scale RCTs with pre-defined subgroups of LBP patients such as those with spondylolisthesis (O’Sullivan et al., 1997), or acute first-episode LBP (Hides et al., 2001) may have contributed to their uptake. However, subsequent larger trials in hospital settings with non-specific LBP subjects have found conflicting evidence of the effects of these exercises compared to advice and manual therapy (Cairns et al., 2000; Golby et al., 2000). The continued popularity of the McKenzie approach may be partly explained by its emphasis on selfmanagement, appealing to physiotherapists working in public hospital settings under considerable time



restraints (Foster et al., 1999). Two systematic reviews have reached conflicting conclusions regarding its efficacy; van Tulder et al. (2000) found there was strong evidence that extension exercises are not effective for ALBP and lack evidence of effectiveness for CLBP, while a more recent and comprehensive review by Clare et al. (2004) reported that McKenzie therapy resulted in a greater decrease in LBP and disability in the short term (3 months) than other standard therapies (i.e. NSAIDS, educational booklet, back massage and back care advice, strength training, and spinal mobilization and general exercises). The differences in conclusions are largely due to different inclusion criteria, search strategies and years of search, resulting in only one RCT common to both reviews (Cherkin et al., 1998). Furthermore, the evidence base for the McKenzie approach is limited by the variable quality of trials, and the lack of RCTs with long-term follow-up, placebo and ‘no treatment’ comparison groups. Therapists also expressed a desire to include hydrotherapy in their repertoire, if lack of resources could be overcome. Research into hydrotherapy has provided some evidence of its efficacy, but the quality of trials has been disappointing (Sjogren et al., 1997; McIlveen and Robertson, 1998) and there is no support from clinical guidelines. Therefore, further high methodological quality RCTs are needed to strengthen the evidence base for specific spinal stabilization exercises, the McKenzie approach and hydrotherapy to inform their inclusion in future guideline documents. Nonetheless, the gap between evidence-based guidelines and the physiotherapy management of LBP is well recognized in the literature (Foster et al., 1999; Gracey et al., 2002; Hurley et al., 2000; Li and Bombardier, 2001; Armstrong et al., 2003), and several studies have identified reasons for this discrepancy (Foster and Doughty, 2002; Overmeer et al., 2005). A recent crosssectional study in primary care in Sweden found that 42% of physicians and 37% of physiotherapists surveyed were unfamiliar with the content of LBP guidelines, while conversely stating they supported their usefulness in clinical practice (Overmeer et al., 2005). A qualitative study of musculoskeletal physiotherapists in Britain identified several barriers to guideline implementation, such as lack of emphasis on guidelines and research in practice settings, limited access to and education on information technology, lack of education in some interventions, some disagreement with the guidelines, and the belief that they are of limited use to physiotherapists (Foster and Doughty, 2002). Previous national LBP guidelines and the European guideline were developed by multidisciplinary teams, thus limiting their applicability and uptake in physiotherapy practice. In order to overcome this difficulty LBP physiotherapy guidelines were developed in the Netherlands (Bekkering et al., 2003a). However, a survey of

Dutch physiotherapists identified lack of knowledge and skills in the biopsychosocial model of assessment and management as one of the main barriers to their implementation (Bekkering et al., 2003b). Thus, regardless of whether the guideline is multidisciplinary or physiotherapy-specific clinicians still perceive barriers to their implementation. There is some evidence that implementation of evidence-based management of ALBP patients can produce a significantly greater reduction in pain and chronicity at lower costs, than usual medical care (McGuirk et al., 2001). Thus, the development and testing of effective implementation strategies is important. Grimshaw et al.’s (2004) recent systematic review of 235 different guideline dissemination and implementation strategies found that it is possible to change healthcare provider behaviour resulting in clinically important improvements in health care. However, they identified the need for further research to inform the choice of interventions in different health service settings. The Dutch physiotherapy guideline team have already developed an evidence-based implementation strategy based on multiple interventions, such as education, discussion, role-playing, feedback and reminders; the effectiveness and cost-effectiveness of which are under investigation (Bekkering et al., 2003b). The European clinical guidelines (van Tulder et al., 2002), and the evidence base support the use of group exercise classes incorporating the biopsychosocial model as a cost-effective therapy for patients with subALBP (Klaber Moffett et al., 1999), and CLBP (van Tulder et al., 2000; Rainville et al., 2004), particularly those with high fear avoidance traits (Klaber Moffett et al., 2004). Therefore, physiotherapists should be supported to provide group exercise classes for appropriately selected patients with LBP in Ireland’s public hospitals. Future research should investigate the use of exercise therapy in representative samples of therapists working in different countries and healthcare settings. Clinicians’ attitudes and beliefs towards various forms of exercise therapy and clinical guidelines for LBP should also be explored.

5. Conclusion The findings of this small-scale study have provided an insight into contemporary exercise therapy practice for LBP among a sample of physiotherapists working in the acute hospital sector in Ireland. Although lacking support from evidence-based clinical guidelines, specific spinal stabilization exercises and the McKenzie approach were the most commonly used forms of exercise therapy.


Acknowledgements The authors gratefully acknowledge the physiotherapists working in acute public hospitals in the Republic of Ireland who took part in this study.

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ARTICLE IN PRESS


Original article

Slump stretching in the management of non-radicular low back pain: A pilot clinical trial$ Joshua A. Clelanda,b,, John D. Childsc, Jessica A. Palmerd, Sarah Eberhartd a

Physical Therapy Program, Franklin Pierce College, 5 Chenell Drive, Concord, NH 03301, USA b Rehabilitation Services of Concord Hospital, Concord, NH 03301, USA c US Army-Baylor University Doctoral Program in Physical Therapy, 3151 Scott Rd. San Antonio, TX 78234, USA d Rehabilitation Services of Concord Hospital, Center for Sports Medicine, Concord, NH, USA Received 4 December 2004; received in revised form 2 June 2005; accepted 26 July 2005

Abstract The purpose of this study was to determine if slump stretching results in improvements in pain, centralization of symptoms, and disability in patients with non-radicular low back pain (LBP) with likely mild to moderate neural mechanosensitivity. Thirty consecutive patients referred to physical therapy by their primary care physician for LBP who met all eligibility criteria including a positive slump test but who had a negative straight-leg-raise test (SLR) agreed to participate in the study. All patients completed several self-report measures including a body diagram, numeric pain rating scale (NPRS), and the modified Oswestry Disability Index (ODI). Patients were randomized to receive lumbar spine mobilization and exercise (n ¼ 14) or lumbar spine mobilization, exercise, and slump stretching (n ¼ 16). All patients were treated in physical therapy twice weekly for 3 weeks for a total of 6 visits. Upon discharge, outcome measures were re-assessed. Independent t-tests were used to assess differences between groups at baseline and discharge. No baseline differences existed between the groups (P4:05). At discharge, patients who received slump stretching demonstrated significantly greater improvements in disability (9.7 points on the ODI, Po.001), pain (.93 points on the NPRS, P ¼ :001), and centralization of symptoms (Po.01) than patients who did not. The results suggest that slump stretching is beneficial for improving short-term disability, pain, and centralization of symptoms. Future studies should examine whether these benefits are maintained at a longer-term follow-up. r 2005 Elsevier Ltd. All rights reserved. Keywords: Low back pain; Neurodynamics; Slump test; Slump stretching

1. Introduction Disability associated with low back pain (LBP) continues to rise, contributing to a substantial economic burden that exceeds nearly 50 billion annually in the United States alone (Frymoyer, 1992). Health care expenditures among individuals with LBP are also 60% greater than those without LBP (Luo et al., 2004) $ Work should be attributed to the Physical Therapy Program, Franklin Pierce College, Concord, NH 03301. Corresponding author. Tel.: +1 603 464 2175 (home)/ +1 603 785 5576 (cell). E-mail address: [email protected] (J.A. Cleland).


with 37% of the costs a direct result of physical therapy services (Maniadakis and Gray, 2000). Physical therapists utilize a wide range of interventions in the management of LBP; however, evidence for the effectiveness of these interventions is limited (Philadelphia Panel, 2001). Given that LBP is a heterogeneous condition, it does not seem reasonable to expect that all patients will benefit from a single treatment approach. Rather, the key is to identify subgroups of patients with a high probability of achieving a successful outcome with a particular intervention. Evidence suggests that short- and longerterm outcomes are improved when a classification-based approach is used compared to decision-making based on


J.A. Cleland et al. / Manual Therapy 11 (2006) 279–286

clinical practice guidelines (Fritz et al., 2003). To date, evidence for several subgroups of LBP exist, such as patients likely to benefit from manipulation (Childs et al., 2004; Flynn et al., 2002), lumbar stabilization (O’Sullivan et al., 1997), and specific directional exercise (Long et al., 2004). One subgroup that has not been readily examined is patients with more distal symptoms whose symptoms are not improved with specific directional exercises (i.e. flexion- or extension-oriented exercise). These patients are commonly thought to be experiencing altered neurodynamics, the interaction between nervous system mechanics and physiology (Shacklock, 1995a, b). A number of neurodynamic tests have been purported to assess the mechanosensitivity of neurogenic structures (Cyriax, 1942; Kenneally et al., 1988; Maitland, 1985). Cyriax (1942) originally used neurodynamic testing, specifically the straight-leg-raise (SLR), to identify the presence of perineuritis. Maitland (1985) further refined the technique and described the slump test, which incorporated cervical flexion and ankle dorsiflexion which was believed to assess the mechanosensitivity of the neuromeningeal structures within the vertebral canal. Studies (Adams and Logue, 1971; Breig, 1978; Goddard and Reid, 1965) have supported the claims of Cyriax (1942) and Maitland (1985) by demonstrating that in the cadaver model, spinal flexion resulted in tension of the nerve roots and dural sleeve (Breig, 1978). Although it has often been stated that neurodynamic tests have limited diagnostic utility in the differentiation between neural and non-neural structures (Di Fabio, 2001), recent evidence demonstrated that pain of nonneural origin (experimentally induced) was not exacerbated by slump stretching (Coppieters et al., 2005). The authors suggested that the results of their study support the use of neurodynamic tests (including the slump) in the identification of altered neurodynamics. Since Maitland (1985) described the slump test it has been used as an assessment tool for the identification of possible altered neurodynamics and more recently has been suggested as a possible treatment technique (Butler, 2000). However, limited evidence exists to support the effectiveness of using the slump test as a treatment approach and has only been presented in the form of case reports or case studies (Cleland et al., 2004; Cleland and McRae, 2002; George, 2000, 2002). George (2002) recently described the outcomes in a subgroup of 6 patients hypothesized to respond favorably to slump stretching. Treatment was limited to those whose symptoms did not worsen or improve with lumbar flexion and extension movements and who exhibited a positive slump test in the absence of radicular signs. Although favorable outcomes were reported, the design of this study being a case series

precludes establishing a cause and effect relationship. Therefore, the purpose of this study was to determine whether slump stretching is beneficial for the subgroup of patients hypothesized to benefit from this form of treatment. We hypothesized that patients who received slump stretching plus lumbar spine mobilization and exercise would experience greater improvements in disability, pain, and centralization of symptoms than patients who received lumbar spine mobilization and exercise only.

2. Methods Participants were consecutive patients in primary care between 18 and 60 years of age with a chief complaint of LBP referred to physical therapy. Patients were required to have symptoms that referred distal to the buttocks, reproduction of the patient’s symptoms with slump testing, no change in symptoms with lumbar flexion or extension, and a baseline Oswestry score greater than 10%. Patients with ‘‘red flags’’ for a serious spinal condition (e.g. infection, tumors, osteoporosis, spinal fracture, etc.) were excluded. Individuals who were pregnant, has a history of spinal surgery, positive neurologic signs or symptoms suggestive of nerve root involvement (diminished upper or lower extremity reflexes, sensation to sharp and dull, or strength), osteoporosis, or exhibited a straight leg raise (SLR) test of less than 451 were also excluded. Patients with signs of nerve root involvement were excluded to assure that patients selected for this study were similar to those identified by George (2002) as likely responders to slump stretching. In addition, we speculated that patients presenting with more severe neural mechanosensitivity might be more likely to experience an adverse response to the slump stretching. The study was approved by the Institutional Review Board at Franklin Pierce College (Rindge, NH). All patients provided consent prior to participation. Patients completed a variety of self-report measures, followed by a standardized history and physical examination performed by a physical therapist. Selfreport measures included a body diagram to assess the distribution of symptoms, numeric pain rating scale (NPRS), modified Oswestry Disability Index (ODI), and Fear-Avoidance Beliefs Questionnaire (FABQ). Patients recorded the location of their symptoms on the body diagram to determine the extent to which centralization occurred after treatment, which was determined according to the procedures described by Werneke et al. (1999). The most distal extent of symptoms were coded as occurring in the low back, buttock/thigh, or distal to the knee by placing a transparent overlay of the scoring grid over the patient’s body diagram (Fig. 1). A score of (0) was given if there was no identification of symptoms,

ARTICLE IN PRESS J.A. Cleland et al. / Manual Therapy 11 (2006) 279–286

Fig. 1. Grid used to identify location of patient symptoms. Reprinted with kind permission from Werneke et al. (1999).

(1) if pain was isolated to the central low back, (2) if pain was indicated in the lateral low back, (3) if pain was located in the buttocks, (4) if pain was located in the upper leg, (5) if pain was located in the lower leg, and (6) if pain was located in the foot. This procedure has been shown to exhibit excellent reliability (k ¼ .92) (Werneke et al., 1999). The 11-point NPRS ranges from 0 (‘‘no pain’’) to 10 (‘‘worst pain imaginable’’) and was used to indicate the intensity of current pain and at its best and worst level over the last 24 h (Jensen et al., 1994). These 3 ratings were averaged to arrive at an overall pain score. The scale has been shown to have adequate reliability, validity, and responsiveness in patients with LBP when the 3 scores are averaged (Childs et al., 2004). The modified ODI was used to measure disability and

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consists of 10 questions. Each question is scored from 0 to 5, with higher scores indicating greater disability. The scores were then converted to a percentage out of 100. The test–retest reliability of the modified ODI has been shown to be high (ICC ¼ .90) (Fritz and Irrgang 2001). The FABQ was used to quantify the patient’s fear of pain and beliefs about avoiding activity (Waddell et al., 1993). Previous studies have found high level of test–retest reliability for both the Physical Activity (FABQPA) and Work (FABQW) subscales (Jacob et al., 2001). Fear avoidance beliefs have been associated with current and future disability and work loss in patients with acute (Fritz and George, 2002) and chronic (Crombez et al., 1999) LBP. This measure was collected to assess the potential confounding effects of fearavoidance beliefs on outcome. The standardized history consisted of demographic information including age, gender, past medical history, location and nature of symptoms, relieving/aggravating activities, prior episodes, occupation and leisure activities. The standardized physical examination included measurements of active lumbar range of motion, passive posteroanterior mobility of the lumbar spine (Maitland et al., 2000), myotomal testing, sensory examination to sharp and dull, muscle stretch reflex testing, the SLR test (Butler, 2000), and the slump test (Maitland, 1985). The slump test was performed as described by Maitland (1985) and is outlined in Table 1. For the purpose of this study, the slump test was considered positive if the patient’s clinical symptoms were reproduced during the performance of the slump test and these symptoms improved with structural differentiation, in this case, release of neck flexion. The interexaminer reliability of detecting a positive slump test has been shown to be high (k ¼ .83) (Philip et al., 1989). Following the baseline examination, patients were randomly assigned to receive lumbar spine mobilization and exercise or lumbar spine mobilization, exercise, and slump stretching. A computer-generated randomized table of numbers created prior to the beginning of the study was utilized to determine the randomization scheme. Group assignment was sealed in an opaque envelope and opened after the treating therapist completed the examination. All treatment was administered by 3 physical therapists with a mean of 2.3 years of clinical experience in outpatient orthopaedics. All patients were scheduled for treatment twice weekly for 3 weeks, for a total of 6 visits. 2.1. Mobilization and exercise group The lumbar spine mobilization and exercise intervention group performed a 5-min exercycle warm-up at the beginning of each treatment. Following the warm-up patients received lumbar spine mobilization and completed a standardized exercise regimen since a combination



Table 1 The slump testing sequence as described by Maitland (1985) Summary of slump test procedure 1. Patient was instructed to sit erect with knees in 901 of flexion. The presence or absence of symptoms was recorded. 2. Patients were instructed to ‘‘slump’’ shoulders and lower back while maintaining the cervical spine in neutral. The presence or absence of symptoms was recorded. 3. While maintaining the position described in step 2 the patients was instructed to tuck their chin to the chest and the clinician applied overpressure into cervical flexion. The presence or absence of symptoms was recorded. 4. While maintaining overpressure into cervical flexion the patient was instructed to extend the knee. The presence or absence of symptoms was recorded. 5. Position 4 was maintained while the patient was instructed to actively dorsiflex the ankle. The presence or absence of symptoms was recorded. 6. Overpressure of the cervical spine was released and the patients were instructed to return the neck to a neutral position. The presence or absence of symptoms was recorded.

The slump test is considered positive if the patient’s symptoms were reproduced in position 5 but alleviated when overpressure of the cervical spine was released.

of manual therapy and exercise have been shown to be effective in reducing disability in patients with chronic LBP (Aure et al., 2003). The physical therapist performed posteroanterior mobilizations to hypomobile lumbar spine vertebrae segments as determined on the initial evaluation. Grades III–IV mobilizations (Maitland et al., 2000) were selected based upon the patient response and the physical therapist’s clinical reasoning. Patients also completed a standardized exercise program consisting of pelvic tilts, bridging, wall squats, quadruped alternate arms/legs activities as described by Childs et al. (2004), which has been shown to result in clinically meaningful improvements in disability. Patients were asked to perform 2 sets of 10 repetitions of each exercise. The physical therapist progressed the patient’s exercise routine according to the patient’s symptoms. Patients were instructed to perform the exercises at home once daily, and to maintain their usual activity level and refrain from initiating any new forms of exercise during the study. 2.2. Slump stretching group Patients in the slump-stretching group completed the identical warm-up followed by lumbar spine mobilization and the identical standardized stabilization exercise program, but also received slump-stretching exercises that were provided by the physical therapist. Slump stretching was performed with the patient in the long sitting position with the patient’s feet against the wall to assure the ankle remained in 01 of dorsiflexion. The therapist applied over pressure into cervical spine flexion to the point where the patient’s symptoms were reproduced (Fig. 2). The position was held for 30 s. A total of 5 repetitions were completed. The time spent performing the slump stretching added only 3–4 min to the total treatment time, thus the potential for an attention effect to exist is extremely low.

Fig. 2. Slump stretching technique utilized in the clinic.

Patients in the slump stretching group completed a similar self-slump stretching home exercise program, except patients actively flexed their neck and applied overpressure using their upper extremities until symptoms were reproduced (Fig. 3). Patients completed 2 repetitions, maintaining this position for 30 s. The decision to use a treatment procedure that reproduced the patient’s symptoms was based on a case series reported by George (2002). In this study patients exhibiting a positive slump test in the absence of radicular symptoms were subjected to slump stretching following a brief warm-up, as a treatment protocol. A decrease in symptom intensity was observed following 5–12 treatment sessions. 2.3. Follow-up At the completion of 6 physical therapy sessions (3 weeks), an office assistant who was unaware of group


assignment or the nature of the study re-administered the self-report questionnaires. The potential for rater bias is further minimized based on the use of patientcompleted outcome measures. 2.4. Data analysis Sample size calculations were performed using SPSS statistical software (SPSS Inc., Chicago, IL). Calculations were based on detecting a 6-point difference between the groups in the 3-week Oswestry score, assuming a standard deviation of 5.5 points, a 2-tailed test, and an a-level equal to 05. A 6-point difference corresponds to the smallest magnitude of difference that would be considered clinically meaningful (Fritz and Irrgang, 2001). A sample size of 15 subjects per group provides greater than 80% power to detect both statistically significant and clinically meaningful differences between the groups.

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Key baseline demographic variables and scores on the self-report measures were compared between groups using independent t-tests for continuous data, and w2 tests of independence for categorical data (Table 2). The level of fear-avoidance beliefs between groups was considered as a potential covariate based on its having been shown to confound outcome and indicate a less favorable prognosis for recovery (Crombez et al., 1999; Fritz and George, 2002). The independent variable was group (mobilization and exercise vs. slump stretching), and the primary dependent variable was perceived disability as recorded by the ODI. Secondary dependent variables included centralization of symptoms and pain. Separate independent t-tests were used to assess differences between groups at discharge. The a-level was divided equally between dependent variables to maintain the family-wise a-level equal to .05, such that the per comparison a-level was .017. Data analysis was performed using the SPSS Version 10.1 statistical software package (SPSS Inc., Chicago, IL).

3. Results

Fig. 3. Slump stretching technique performed as the patient’s home exercise program.

One hundred and seventeen patients were screened for eligibility during an 18-month period from January 2002 to June 2003. Eighty-one patients (69%) did not satisfy the inclusion and exclusion criteria for the study. The high rate of ineligibility was due to the stringent inclusion criteria requiring symptoms distal to the buttock, a positive slump test, and the exclusion of patients with a positive straight leg raise. Six patients (5%) refused participation because they did not desire to be randomized. The remaining 30 patients, mean age equal to 38.7 (SD ¼ 11.6) (21 male), were randomized to receive the mobilization and exercise intervention (n ¼ 14) or the mobilization and exercise intervention combined with slump stretching (n ¼ 16).

Table 2 Baseline demographic and self-report variables for both treatment groups Variable

Mobilization and exercise group (n ¼ 14)

Slump stretching group (n ¼ 16)

P value

Age (years) Gender (# of female) Duration of current symptoms (median number of weeks) Oswestry Disability Index Numeric pain rating score Location of symptoms Number of previous episodes of back pain Fear-avoidance beliefs score—physical activity subscale Fear-avoidance beliefs score—work subscale Fear-avoidance beliefs score—total

40.0 10 18.5 24.4 3.8 4.3 2.5 8.8 13.2 22.1

39.4 11 14.5 26.2 4.0 3.9 2.1 8.2 12.4 20.5

.56 .88 .30 .47 .90 .83 .36 .69 .66 .51

Values represent the mean (SD), except where noted otherwise.

(12.2) (12.5) (6.3) (1.0) (.83) (1.2) (4.2) (4.9) (6.6)

(11.3) (8.0) (6.7) (.92) (.77) (1.3) (4.0) (4.4) (6.4)


284

Table 3 Discharge self-report variables, change scores for both groups and associated 95% confidence intervals, differences between groups with associated 95% confidence intervals and statistical significance Discharge mobilization and exercise group (n ¼ 14) Oswestry Disability Index

17.6 (6.1)

Change scores for mobilization and exercise group (95% CI) 6.9

Discharge slump stretching group (n ¼ 16)

7.9 (5.3)

(3.2, 10.6) Numeric pain rating score

2.7 (1.0)

1.2

3.0 (.92)

1.2 (.63, 1.8)

18.2

Mobilization and exercise versus slump stretching (95% CI)

P value

9.7 (5.4, 14.0)

o .01

(17.8, 18.6) 1.7 (.42)

(.47, 1.93) Location of symptoms

Change scores for slump stretching group (95% CI)

2.33

.93 (.35, 1.6)

.001

(1.4, 2.4) 2.0 (.68)

No differences in key demographic variables or baseline levels of pain, disability, and fear-avoidance behaviors were detected between groups (Table 2). Patients who received slump stretching exhibited significantly improved disability (Po.001), overall perceived pain (P ¼ :001), and centralization of symptoms (Po.01) (Table 3).

4. Discussion The results of our study confirm our hypotheses that slump stretching may be beneficial in the management of patients with non-radicular LBP. Slump stretching in addition to lumbar spine mobilization and exercise was beneficial in reducing short-term disability and improving pain and promoting centralization of symptoms in this subgroup of patients. Our results are similar to those of George (2002) who reported that a subgroup of patients with LBP might exist who have distal symptoms but whose symptoms do not improve with flexion- or extension-oriented exercises. The mean ODI scores for both groups were statistically equivalent at baseline (P4:05). It has been reported that reductions in the Oswestry of 6 points or greater are considered clinically meaningful (Fritz and Irrgang, 2001). The change scores for both groups in our study surpassed this clinically meaningful level (6.9, 95% CI 3.2, 10.6 in the mobilization and exercise group and 18.2 95% CI 17.8, 18.6 in the slump stretching group). It should be recognized that the change score for the mobilization and exercise group only marginally surpassed the clinically meaningful level while the change score in the slump stretching group greatly surpassed this level as did the lower bound estimate of the 95% CI. Perhaps the characteristics used as inclusion criteria suggest which patients are likely to

1.88 (1.4, 2.4)

1.0 (.41, 1.6)

.002

benefit from this form of treatment. Further research is necessary to examine this hypothesis. Centralization of symptoms in patients with LBP indicates a favorable prognosis (Aina et al., 2004; Werneke and Hart, 2001) and is typically used to guide treatment in patients with low back and lower extremity symptoms. However, the slump stretching technique used in this study was designed to reproduce the patient’s symptoms, which sometimes resulted in a peripheralization of their symptoms. The decision to proceed with treatment despite the peripheralization of symptoms in this group is consistent with the treatment approach used by George (2002) . In our study, slump stretching resulted in significant improvements in disability and pain and centralization of symptoms compared to a lumbar spine mobilization and exercise program without slump stretching. Therefore, perhaps centralization is not prognostic for a favorable outcome among all subgroups of patients with LBP. A few studies (Cleland et al., 2004; Cleland and McRae, 2002; George, 2000, 2002; Kornberg and Lew, 1989; Scrimshaw and Maher, 2001) have investigated the effects of neural mobilization techniques on patients with LBP and lower extremity symptoms. However, with the exception of 2 studies (Kornberg and Lew, 1989; Scrimshaw and Maher, 2001) the others have been single case reports or a case series. Scrimshaw and Maher (2001) investigated the effects of neural mobilization following lumbar dissection, fusion, or laminectomy. The results of a 12-month follow-up demonstrated that neural mobilization did not provide additional benefits to traditional postoperative care. However, the patients in this study exhibited a straight leg raise range of motion that was within normal limits suggesting that perhaps performing neural mobilizations on patients with a normal straight leg raise may not be beneficial in decreasing pain and disability. Kornberg and Lew


(1989) determined that slump stretching combined with hamstring stretching in a group of Australian Rules football players expedited return to sport following a hamstring strain compared to patients who only received hamstring stretching exercises. However, this study was performed in individuals without LBP. Although the slump test is used clinically to investigate the presence of altered neurodynamics there is currently a lack of evidence suggesting that any particular neurodynamic treatment technique results in changes of the mechanical or physiological function of nerve tissues. Determining the mechanism for why patients receiving slump stretching improved to a greater extent is beyond the scope of this study. However, it is useful to consider plausible physiological explanations for our findings. Perhaps the slump stretching was effective in reducing the patients pain by dispersing intraneural edema, thus restoring pressure gradients, relieving hypoxia and reducing associated symptoms (Cowell and Phillips, 2002). Slump stretching may also have resulted in improved outcomes by reducing antidromic impulses generated in C-fibers at the dysfunctional site which result in the release of neuropeptides and subsequent inflammation in the tissues supplied by the nerve (Shacklock, 1995a). Hence if normal neurodynamics are restored by alleviating any sites of neural compression, excessive friction or tension, antidromically evoked impulses may perhaps be eliminated. It is also possible that slump stretching may have resulted in a reduction of scar tissue, which had adhered to neural tissue and its associated connective tissue structures (Turl and George, 1998). Although preliminary evidence exists in support of the validity of the slump test in identifying neural tissue involvement (Coppieters et al., 2005), the possibility that the source of pain was derived from structures other than the neural tissues cannot be eliminated. Further research is necessary to examine the sensitivity and specificity of neurodynamic tests as well as the effectiveness of using such techniques in the management of altered neurodynamics. A few limitations should be considered. First, we excluded patients with a SLR less than 451, thus potentially excluding patients with more severe neural mechanosensitivity, thus the results may not be generalizable to this patient population. We incorporated this exclusion criteria to enroll patients similar to those described by George (2002). This was also done based on the concern that patients with more severe neural mechanosensitivity might be more likely to experience an adverse response to slump stretching. In addition, our sample size was small, and data were collected at a single outpatient orthopaedic physical therapy clinic, limiting the generalizability of the findings. Future studies should investigate the prognostic value of the characteristics used in this study to guide decision-

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making regarding the use of slump stretching in a larger patient population with LBP.

5. Conclusion Slump stretching is beneficial for improving shortterm disability, decreasing pain, and centralization of symptoms compared to treatment without slump stretching in a subgroup of patients hypothesized to benefit from this form of treatment. These data provide preliminary evidence supporting the notion that patients with distal symptoms who are unable to centralize their symptoms may be a distinct subgroup of patients with LBP that benefit from slump stretching exercise. Future studies should examine whether these benefits are maintained at a longer-term follow-up. References Adams CBT, Logue V. Studies in cervical spondylitic myelopathy: movement of the cervical roots, dura and cord, and their relation to the course of the extrathecal roots. Brain 1971;94:557–68. Aina A, May S, Clare H. The centralization phenomenon of spinal symptoms—a systematic review. Manual Therapy 2004;9: 134–43. Aure OF, Hoel NJ, Vasseljen O. Manual therapy and exercise therapy in patients with chronic low back pain: a randomized, controlled trial with 1-year follow-up. Spine 2003;28:525–31. Breig A. Adverse mechanical tension in the central nervous system: an analysis of cause and effect. Stockholm: Almqvist and Wiskell International; 1978. p. 23–60. Butler DS. The sensitive nervous system. Adelaide: Noigroup Publications; 2000. p. 256–310 [chapters 10–11]. Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, Delitto A. A clinical prediction rule to identify patients likely to benefit from spinal manipulation: a validation study. Annals of Internal Medicine 2004;141:920–8. Cleland JA, Hunt G, Palmer JA. Effectiveness of neural mobilization in the treatment of a patient with lower extremity neurogenic pain: a single-case design. Journal of Manual and Manipulative Therapy 2004;12:143–51. Cleland J, McRae M. Complex regional pain syndrome I: management through the use of vertebral and sympathetic trunk mobilization. Journal of Manual and Manipulative Therapy 2002;10:188–99. Coppieters MW, Kurz K, Motensen TE, Richards NL, Skaret IA, McLaughlin LM, Hodges PW. The impact of neurodynamic testing on the perception of experimentally induced muscle pain. Manual Therapy 2005;10:52–60. Cowell IM, Phillips DR. Effectiveness of manipulative physiotherapy for the treatment of neurogenic pain syndrome: a single case study—experimental design. Manual Therapy 2002;7:31–8. Crombez G, Vlaeyen JW, Heuts PH, Lysens R. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain 1999;80:329–39. Cyriax J. Perineuritis. British Medical Journal 1942;1:500–78. Di Fabio RD. Neural mobilization: the impossible. Journal of Orthopaedic and Sports Physical Therapy 2001;31:224–5. Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Butler B, Rendeiro D, Garber M, Allison S. A clinical prediction rule for classifying patients with low back pain who demonstrate short term improvement with spinal manipulation. Spine 2002;27:2835–43.



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Luo X, Pietrobon R, Sun SX, Liu GG, Hey L. Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine 2004;29:79–86. Maitland G, Hengeveld E, Banks K, English K. Maitland’s vertebral manipulation, 6th ed. Oxford: Butterworth-Heinemann; 2001. p. 325–83 [chapter 12]. Maitland G. The slump test: examination and treatment. The Australian Journal of Physiotherapy 1985;31:215–9. Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain 2000;84:95–103. O’Sullivan PB, Phyty GD, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine 1997;22:2959–67. Philadelphia Panel. Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for low back pain. Physical Therapy 2001;81:1641–74. Philip K, Lew PC, Matyas T. The inter-therapist reliability of the slump test. The Australian Journal of Physiotherapy 1989;35:89–94. Scrimshaw SV, Maher CG. Randomized controlled trial of neural mobilization after spinal surgery. Spine 2001;26:2647–52. Shacklock MO. In: Moving in on pain. Chastwood: ButtersworthHeinemann; 1995a. p. 123–31. Shacklock MO. Neurodynamics. Physiotherapy 1995b;81:9–16. Turl SE, George KP. Adverse neural tension: a factor in repetitive hamstring strain? Journal of Orthopaedic and Sports Physical Therapy 1998;27:16–21. Waddell G, Newton M, Henderspm I, Somerville D, Main CJ. Fearavoidance beliefs questionnaire and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain 1993;52: 157–68. Werneke M, Hart DL. Centralization phenomenon as a prognostic factor for chronic low back pain and disability. Spine 2001;26: 758–64. Werneke M, Hart DL, Cook D. A descriptive study of the centralization phenomenon. A prospective analysis. Spine 1999;24: 676–83.

ARTICLE IN PRESS


Original article

Abdominal and pelvic floor muscle function in women with and without long lasting pelvic girdle pain Britt Stugea,, Siv Mørkvedb, Haldis Haug Dahlb, Nina Vøllestada a

University of Oslo, Section for Health Science, P.O. Box 1153, Blindern, N-0318 Oslo, Norway Department of Community Medicine & General Practice, Norwegian University of Science and Technology, Trondheim, Norway

b

Received 1 September 2004; received in revised form 1 June 2005; accepted 26 July 2005

Abstract Approximately 5–20% of postpartum women suffer from long-lasting pelvic girdle pain (PGP). The etiology and pathogenesis of PGP are still unclear. The aim of this study was to examine whether subjects with and without persisting PGP and disability differed with respect to their ability to voluntarily contract the deep abdominals (TrA and IO) and to the strength of the pelvic floor muscles (PFM). Twenty subjects (12 with persisting PGP, 8 recovered from PGP) were examined. Contractions of the deep abdominal muscles (TrA and IO) were imaged by real-time ultrasound. Vaginal palpation and observation were used to assess the women’s ability to perform correct a PFM contraction. PFM strength was measured by a vaginal balloon catheter connected to a pressure transducer. The active straight leg raise test was used to assess the ability of load transfer. The results showed no statistical significant difference between the groups in increase of muscle thickness of the deep abdominal muscles (TrA; P ¼ 0:87 and IO; P ¼ 0:51) or regarding PFM strength (P ¼ 0:94). The ability to voluntarily contract the deep abdominal muscles and the strength of the PFMs are apparently not associated to PGP. However, the results are based on a small sample and additional studies are needed. r 2005 Elsevier Ltd. All rights reserved. Keywords: Postpartum pelvic girdle pain; Pelvic floor; Deep abdominals; Ultrasound

1. Introduction Low back and pelvic girdle pain (PGP) during pregnancy is a common ailment (Endresen, 1995; Kristiansson et al., 1996; Ostgaard et al., 1991). After childbirth, the pain disappears in most cases within 6 months (Kristiansson et al., 1996; Ostgaard et al., 1996, 1997). However, about 5–20% suffer from long-lasting pain and disability (Albert et al., 2001; Larsen et al., 1999; Wu et al., 2004). The etiology and pathogenesis of PGP is still not clear. Hypermobility of the pelvic joints has been described to be a causative factor of PGP (Hagen, 1974; Snijders et al., 1995), even though mechanical hypermobility has not been demonstrated (Sturesson et al., 1999; Walheim, 1984). However, pain Corresponding author. Tel.: +47 22 85 84 18; fax: +47 22 85 84 11.

E-mail address: [email protected] (B. Stuge). 1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.07.003

and disability seem to correlate with asymmetric laxity of the left and right sacroiliac joint (SIJ) (Buyruk et al., 1999; Damen et al., 2001, 2002), which could be caused by asymmetric muscle tone (De Groot et al., 2004). It has been suggested that PGP is related to insufficient stability of the lumbopelvic region. According to a model of SIJ function, stability is claimed to be obtained by a combination of form and force closure (Snijders et al., 1995; Vleeming et al., 1997). It is thought that SIJ shear may be prevented by friction (form closure), and dynamically influenced by muscle force and the integrity of facial structures and ligament tension (force closure). Impairment of form and force closure may be associated with pain disorders of the lumbopelvic region (Mens et al., 1999; Snijders et al., 1993; Vleeming et al., 1992). The transversus abdominis (TrA), internal oblique (IO), diaphragm, and the pelvic floor muscles (PFM) work together to produce and


B. Stuge et al. / Manual Therapy 11 (2006) 287–296

control intraabdominal pressure (Critchley, 2002; Hodges and Richardson, 1996; Neumann and Gill, 2002; Richardson et al., 2002; Sapsford and Hodges, 2001), and thereby increase stiffness of the lumbar spine (Hodges et al., 2003a, 2005). The PFM may thus indirectly contribute to lumbopelvic stability. A recent study based on a biomechanical model revealed that simulated tension in the PFM increased the stiffness of the SIJs in female specimens (Pool-Goudzwaard et al., 2004). Furthermore, co-activation of the abdominal and the PFM have been reported (Bø and Stien, 1994; Critchley, 2002; Neumann and Gill, 2002; Sapsford et al., 2001). However, as discussed by Bø et al. (2003) one may question to what extent these results can be generalized. The neuromuscular system contributes to motor control and dynamic stability of the lumbopelvic joints. Several studies have demonstrated altered motor control strategies in subjects with pain related to the SIJ region (Avery et al., 2000; Hungerford et al., 2003; O’Sullivan et al., 2002; Sturesson et al.,1997; Wu et al., 2002). One hypothesis is that a dysfunction of the PFM causes a deficit in the force closure mechanism of the SIJ (O’Sullivan et al., 2002). When pelvic stability is compromised, load transfer may be impaired. The functional integrity of the force closure mechanism may be examined clinically by use of the active straight leg raise (ASLR) test, which has been found to be a reliable measure of the ability of load transfer through the lumbopelvic region (Mens et al., 2001). A positive ASLR test has been associated with a descent of the pelvic floor and an altered motor control of the diaphragm (O’Sullivan et al., 2002). Also, a significantly increased activity and shorter endurance time of the PFM have been found in lumbopelvic pain patients than in healthy subjects (Pool-Goudzwaard et al., 2005). Decreased laxity of the SIJ has been demonstrated during contraction of the TrA muscle (Richardson et al., 2002). In a randomized controlled trial, we included 81 women with postpartum PGP and compared physical therapy with a focus on specific stabilizing exercises with individualized physical therapy without specific stabilizing exercises (Stuge et al., 2004a). The stabilizing exercise group demonstrated statistically and clinically significant lower pain intensity, and lower disability and higher quality of life than the comparison group one and 2 years after delivery (Stuge et al., 2004a, b). However, a large variability in improvement was seen in both groups. Some subjects completely recovered, while others exhibited significant disability. In an attempt to understand why some suffer from long-lasting PGP we took advantage of having the access to these subjects. The aim was thus to examine whether subjects with and without persisting PGP and disability, independent of the preceding treatment, differed with respect to the

ability to voluntarily contract the deep abdominal muscles (TrA and IO) and to the strength of the PFM. We examined whether there was any association between the ability to voluntarily contract the TrA and the strength of the PFM. In addition, we examined whether subjects with and without positive ASLR tests revealed any differences in the voluntary contractions of the deep abdominal muscles and the PFM.

2. Materials and methods 2.1. Subjects The study group consisted of women with PGP who had participated in a randomized controlled trial (n ¼ 81) with a 2-year follow-up study, evaluating the effect of two different physical therapy interventions to treat postpartum PGP (Stuge et al., 2004a, b). Based on their reported pain and disability scores 2 years postpartum, two groups of women were invited to participate in the present study: a recovered group with no or minimal pain (VASo30 mm) and disability (Disability Rating Index (DRI) scoreso4) and a group with persistent PGP reporting moderate to serious disability (DRI425). Categorization by pain and disability were chosen because they are commonly used aspects in clinic and research. Thirty-nine women fulfilled these criteria and were thus invited. Twentyfour of them agreed to participate. However, four reported inconsistent scores on PGP and were excluded, thus 20 subjects remained for this study, 12 with pain and disability (PGP group) and eight without (recovered group) (Fig. 1). The subjects were also categorized as ASLR positive or ASLR negative. There were no significant differences regarding pain and disability 2 years postpartum between the 20 included subjects and 2 out 41 CG

39*

31*

11

40 SEG

39*

34*

13

81 PGP

2 out

pain 8 no pain1 pain 4 no pain 7

12 PGP 8 Recovered

Baseline 20 weeks 1 yr 2 yr 2.5 yr postpartum Fig. 1. Eighty-one women with postpartum PGP, included in a RCT, received physical therapy with or without stabilizing exercises for 20 weeks and follow-up data were collected 1 and 2 years postpartum. Subjects were included in present study on average 2.5 years postpartum, based on pain and disability reported on the questionnaire 2 years postpartum. *Those having a new pregnancy and those not fulfilled the 2-year questionnaire were excluded. PGP ¼ pelvic girdle pain, CG ¼ control group, SEG ¼ specific exercise group

ARTICLE IN PRESS B. Stuge et al. / Manual Therapy 11 (2006) 287–296

the 15 subjects who did not agree to participate (P40:17). 2.2. Measurements and equipment The women completed a short questionnaire addressing weight, height, pain location, functional status, symptoms of urinary incontinence and other pelvic floor complaints, physical activity level and age of youngest child. The measurement procedure was standardized. After the questionnaire was completed, ultrasound assessment of the deep abdominal muscles, measurements of the pelvic floor, the ASLR test and the posterior pelvic pain provocation (P4) test were executed. The two researchers (SM, HHD) performing the assessments were blinded to the patients’ symptoms, history of treatment and the results of the other assessor’s assessments. As an additional background description of the included subjects, the scores of the Hopkins Symptoms Check List (Rickels et al., 1976), obtained 2 years postpartum are given to describe emotional distress by the subjects. All participants gave written consent to participate, and the study was approved by the regional ethics committee. The following measurements were obtained: Pain and disability: Pain intensity was measured on a 100 mm VAS scale. Disability was measured by RolandMorris Disability Questionnaire (Roland and Morris, 1983) and DRI (Sale`n et al., 1994). Contractions of the deep abdominals (TrA and IO) were measured using ultrasound, with the subject in a comfortable supine position with a small pillow under her head, about 301 hip flexion, aiming at a neutral lumbar position. The subject was instructed to relax and to inhale, exhale, and gently and slowly draw in the lower abdomen (Richardson et al., 1999). In order to prevent feedback effects, the subject was unable to view the scanner screen. Real-time ultrasound images were made with a B-mode 7–10 MHz, linear array (Vingmed System Five) at the end of expiration. The measurements alternated between left and right side. The transducer was placed transversely across the abdominal wall, about 1/5 along a line drawn from anterior superior iliac spine (ASIS) to processus xiphoideus, measured from ASIS. However, the position of the probe was adjusted to ensure that the distance from the medial edge of TrA was at a standardized distance from the medial edge of the ultrasound image when the subject was relaxed. The location of the transducer was marked so that the identical position was used for all measurements. In addition we standardized the transducer state by holding at right angle to the fibre orientation, and avoided to tilt the probe. Images were recorded on prints and videotapes. The thickness of TrA and IO were measured at three sites, 5 mm apart, and the average was used. Calculation of TrA and IO muscle

289

thickness was based on the average of three contractions on each side and two measures in relaxed situation. The thickness of TrA during contraction was divided by the thickness of TrA in relaxed position to get a ratio. External oblique was not assessed because ultrasound measurements of this muscle have not been found to be valid for estimating muscle activity (Hodges et al., 2003b). Pelvic floor muscle (PFM) contraction: Vaginal observation and palpation was used to assess each woman’s ability to perform correct PFM contractions (Bø et al., 1990; Kegel, 1956). An inward movement of the perineum and a palpable vaginal squeeze was considered a correct PFM contraction. Furthermore, the PFM contractions were to be performed without observable synergistic contractions of hip adductors and gluteal muscles, or pelvic tilt. The women were in a supine position (with straight legs). One finger was used for palpation. Measurement of pelvic floor muscle strength: A vaginal balloon catheter (balloon size 6.7 1.7 cm) connected to a pressure transducer (Camtech Ltd. 1300 Sandvika, Norway) was used to measure vaginal squeeze pressure during PFM contractions. The balloon was positioned with the middle of the balloon about 3.5 cm inside the introitus vagina. PFM contractions with observed inward movement of the balloon catheter were classified as correct and used in the data analysis. Apart from one subject, all were able to perform correct contractions repeatedly. The mean pressure (measured as cm H2O) of 10 correct contractions was used as a measure of PFM strength. The method has been found to be reliable and valid (Bø et al., 1990). Physical tests: The ASLR test was performed with the subject in a supine position with straight legs. The subject was asked to raise one leg after the other 20 cm above the couch, and then asked to score the difficulty of raising the leg on a 6-point scale from 0 (‘‘not difficult at all’’) to 5 (‘‘unable to do’’). Scores from both legs were added, giving a summed score ranging from 0 to 10 (Mens et al., 2001). The intention of the ASLR test is to examine the ability to transfer loads from the legs to the trunk. Mens et al. (2001) found a test-retest reliability of 0.87, a sensitivity of 87% and specificity of 94%, when using self-reported history of PGP as external criterion. In addition to scoring the level of difficulty, the women were asked about pain when performing the ASLR test. The performance was also videotaped and the subjects later divided into groups according to their compensation patterns; this division was carried out by two physical therapists, blinded to the history of the patients. The main compensation strategies were categorized as bracing, bulging or rotation. It was considered a compensation strategy when prior to initiation of lifting either leg, a clearly observable bracing of the upper abdomen (the thorax was compressed) or bulge of



than .05 were considered significant. The statistical software program used for statistical analysis was SPSS (version 11) for Windows.

the upper and lower abdomen, or rotation of the pelvic girdle relative to the thorax was observed. When none of these patterns was obvious, the strategy was categorized as no compensation. The posterior pelvic pain provocation (P4) test was performed to assess localized pain deep in the gluteal area on the provoked side (Ostgaard et al., 1994a).

3. Results The subjects in the two groups were comparable regarding background variables and had their last delivery on average 2.5 years ago (Table 1). No pain or disability as determined by DRI and Roland Disability Questionnaire was seen in the recovered group. The women in the PGP group reported moderate pain intensity and mild to moderate disability. Pain was located over the SIJs and the sacrum, but also over the pubic symphysis. As shown in Table 1, the physical tests showed clear differences between the groups. The thickness of the deep abdominal muscles was similar for the PGP group and the recovered group at rest (Table 2). Furthermore, no statistically significant differences were seen in increase of muscle thickness

2.3. Statistics Except for background variables, all results are given as median values with 95% confidence intervals (CI). Because the data were not normally distributed, the Mann-Whitney two sample tests were used to test the differences between groups for PFM strength and increase in muscle thickness. Wilcoxon’s signed rank test for matched pairs was used for comparison between TrA and IO. Pearson chi-square test was used for correlation between deep abdominals’ muscle thickness (relative to rest) and PFM strength. Fisher exact test was used for frequency of urinary incontinence. P values less

Table 1 Description of the subjects (n ¼ 20) Recovered group (n ¼ 8)

PGP group (n ¼ 12)

‘‘Background’’ (mean, SD), (n, %) Weight (kg) Height (cm) Body mass index Age of youngest child (months) Regular exercise during last year

69.5 (11.7) 169.6 (3.6) 24.1 (3.3) 29.5 (2.9) 5 (63%)

67.3 (13.6) 164.5 (5.4) 25.0 (5.4) 29.6 (3.6) 7 (58%)

Functional status (median, CI) Disability rating index (DRI) score Roland morris disability questionnaire score

1 (0, 12) 0 (0, 1)

42 (25, 59) 7 (2, 10)

Pain VAS 0– 100 mm (median, CI) Morning pain intensity at worst Evening pain intensity at worst

0 (0, 0) 0 (0, 0)

32 (11, 56) 61 (21, 75)

Pain location (n, %) Symphysis Right sacroiliac joint region Left sacroiliac joint region Over sacrum

0 0 0 0

7 9 8 9

Physical tests (median, CI),(n, %) Active Straight Leg Raise (ASLR) test Sum score left and right (0–10) Positive (41) Asymmetric Pain Compensation patterns Posterior pelvic pain provocation (P4) test (n, %) Positive left and/or right Emotional distress (median, CI) Hopkins symptom check list (HSCL)c a

n ¼ 7. n ¼ 11. c The scores are based on the questionnaire 2 years postpartum. b

(58%) (75%) (67%) (75%)

a

0 0 2 1 4

(0, 1) (25%) (13%) (50%)

4 (2, 5) 10 (83%) 9 (75%) 7 (58%) 10 (83%)

0a

5 (46%)b

1.3 (1.0, 2.0)

1.5 (1.3, 2.4)


during contraction (relative to resting thickness) between the two groups (TrA; P ¼ 0:87 and IO; P ¼ 0:51) (Fig. 2). Furthermore, as shown in Table 3, there were no significant group differences for thickness of left and right TrA and IO, and no significant side difference between left and right TrA (P ¼ 0:54) or IO (P ¼ 0:88). When the subjects were categorized according to the ASLR test (positive or negative), no significant difference in muscle thickness was found (Table 4). Moreover, there was a statistical significant difference in increase of thickness during contraction between the TrA (57%) and the IO (20%) (P ¼ 0:001). Regarding PFM strength, no significant difference (P ¼ 0:94) was found between the PGP group (median: 18.0 cm H2O, 95% CI: 16.4, 28.8) and the recovered group (median: 18.4 cm H2O, 95% CI: 0, 45.4). However, the number of women with urinary incontinence was significantly higher in the PGP group (75%) than in the recovered group (13%) (P ¼ 0:02) (Table 5). Frequent leakage, difficulties in emptying the

Recovered group (n ¼ 8)

PGP group (n ¼ 12)

P value

2.4 2.8 5.8 6.0

2.7 2.9 6.3 5.3

0.39 0.97 0.64 0.28

(1.9, (2.3, (4.8, (5.1,

3.7) 3.7) 7.6) 7.3)

(2.3, (2.5, (4.7, (4.3,

2.9) 3.2) 7.0) 6.4)

Data are given as median (95% confidence interval). PGP ¼ pelvic girdle pain. TrA ¼ transversus abdominis. IO ¼ internal oblique.

Table 3 Muscle thickness of TrA and IO during contraction relative to rest (ratio)

TrA right (ratio) TrA left (ratio) IO right (ratio) IO left (ratio)


PGP group (n ¼ 12)

P value

1.6 1.5 1.2 1.2

1.5 1.5 1.2 1.2

0.82 0.62 0.56 0.59

(1.0, (1.2, (1.0, (1.1,

2.0) 1.8) 1.6) 1.3)

(1.3, (1.3, (1.1, (1.2,

1.8) 1.9) 1.7) 1.5)

Data are given as median (95% confidence interval). PGP ¼ pelvic girdle pain. TrA ¼ transversus abdominis. IO ¼ internal oblique.

ASLR positive (n ¼ 10) TrA ratio IO ratio PFM strength (cmH2O)

2.2

2.2

2.0

2.0

1.8 1.6 1.4 1.2

ASLR negative (n ¼ 9)

1.5 (1.4, 1.8) 1.6 (1.2, 1.8) 1.2 (1.2, 1.8) 1.2 (1.1, 1.4) 18.2 (13.8, 44.0) 18.0 (9.6, 44.8)

P value

0.87 0.51 0.71

Data are given as median (95% confidence interval). TrA ¼ transversus abdominis. IO ¼ internal oblique. PFM ¼ pelvic floor muscles. ASLR ¼ Active straight leg raise. Data for TrA and IO are based on average of left and right side.

OI thickness (relative to rest)

TrA thickness (relative to rest)

bladder, frequent visits to the bathroom at night, and regular pain in the lower abdomen were reported by less than half of the women in the PGP group (see Table 5).

Table 4 Muscle thickness of TrA and IO during contractions relative to rest (ratio) and PFM strength in ASLR positive and negative subjects

Table 2 Muscle thickness of TrA and IO at rest

TrA right (mm) TrA left (mm) IO right (mm) IO left (mm)

291

1.8 1.6 1.4 1.2

1.0

1.0 Recovered

PGP

Recovered

PGP

Fig. 2. Muscle thickness of the deep abdominals (TrA, IO) during contraction relative to the resting thickness, in a group of women with long-lasting pelvic girdle pain (PGP) (n ¼ 12) and a group of women recovered from pelvic girdle pain (recovered) (n ¼ 8). Data are based on average of left and right side, and are given as median (middle line) with 10th and 90th percentiles at the ends. TrA ¼ transversus abdominis. IO ¼ internal obliquus.


292

Table 5 Complaints related to the pelvic floor region (n, %)

Urinary incontinence Frequent leakages Urinary infection last year Difficulties in emptying the bladder Frequent visits the bathroom at night Regular pain in the lower abdomen


PGP group (n ¼ 12)

1 (13%) 0 0b 0 0

9 2 1 4 2

0

5 (46%)a

(75%) (17%) (8%) (33%) (17%)

Data are given as median (95% confidence interval). PGP ¼ pelvic girdle pain. a n ¼ 11. b n ¼ 7.

70 Recovered PGP

PFM strength (cm H2O)

60 50 40 30 20 10 0 1.0

1.2

1.4 1.6 1.8 2.0 TrA thickness (relative to rest)

2.2

difference in the ability to voluntarily contract the deep abdominals or in PFM strength. Neither was any association found between the increases in average thickness of TrA and the PFM strength. Thus, our results do not support a hypothesis that PGP patients suffer from dysfunction of voluntary muscle contraction of the local muscles. 4.1. Subjects As far as can be ascertained, no other studies have compared the voluntary contraction of local muscles in women with PGP, an ailment that is understood to be different from LBP (Ostgaard et al., 1994a, b). Our classification was based on self-reported pain and disability with strict cut-off values. To reduce the possibility of misclassification, we excluded four women with uncertain scores. The subjects in the PGP group reported mild to moderate pain and disability, and had scores comparable to those in other studies of PGP (Mens et al., 2000; Nilsson-Wikmar et al., 2003; Padua et al., 2002; Stuge et al., 2004b). One important limitation in the present study is the small sample size and there is thus a need for a larger study to provide more conclusive evidence. However, as illustrated in Fig. 3, the two groups showed almost complete overlap and similar distributions in increase in muscle thickness and in PFM strength. Based on the means and standard deviations of the present study, about 200 subjects are needed to detect the difference of 0.1 in TrA thickness with 80% power and 5% significance level. 4.2. Local muscle function

Fig. 3. Association between the increase in thickness of muscle transversus abdominis (TrA) during contraction and pelvic floor muscles (PFM) strength. Data for TrA are based on average of left and right side. Data for women with long-lasting pelvic girdle pain (PGP) and for women recovered from pelvic girdle pain (recovered).

No such complaints were described in the recovered group. No statistical significant association was found between the increase in thickness of the TrA and the PFM strength (r ¼ 0:25). As shown in Fig. 3, the data were distributed equally with similar ranges and distributions for the PGP and the recovered group. Furthermore, there was no statistical significant association between increase in IO thickness and PFM strength (r ¼ 0:05). These data suggest that the ability of low graded activity of the deep abdominal muscles is unrelated to the strength of the PFM.

4. Discussion Comparison between the groups of recovered women and women with persistent PGP showed no significant

Our results revealed no difference between groups in increase of TrA thickness. This contrasts to studies examining TrA in LBP patients (Critchley and Coutts, 2002; Ferreira et al., 2004). These studies, however, looked at two different tasks. The subjects (n ¼ 44) in the study by Critchley and Coutts (2002) were scanned during low abdominal hollowing in four-point kneeling whereas the subjects (n ¼ 20) in the study by Ferreira et al. (2004) were scanned when performing isometric knee flexion or extension. Critchley and Coutts (2002) found a significantly smaller increase in TrA thickness in patients than in healthy controls. Interestingly, both our groups (PGP and recovered women) demonstrated similar increase and variations in TrA thickness as the healthy group in the study by Critchley and Coutts (2002). There are no established norms regarding normal increase in thickness of TrA. However, the LBP patients demonstrated less than half of the increase in muscle thickness than the healthy group and our groups, yet with wide variation. Ultrasound assessment of TrA is reported to be a reliable and valid method of isometric muscle contraction


and motor control of the deep abdominals (Bunce et al., 2002; Ferreira et al., 2004; Hodges et al., 2003b; McMeeken et al., 2004; Pietrek et al., 2000). However, several aspects may influence the results. Even though a comfortable supine position for measurements was chosen, the starting position may not have been optimal for all subjects, as the most suitable position to be able to contract the TrA may be individual (Beith et al., 2001; Bunce et al., 2002; Richardson et al., 1999). We also standardized the verbal instruction, since, different commands are shown to give individually different responses (Critchley, 2002). It is important to note that the women were instructed to contract the abdominal muscles, and voluntary contraction does not necessarily represent the automatic strategy for recruitment of the trunk muscles. Hence, we cannot rule out the possibility that the automatic response during a movement task or during functional activity might be different (Bunce et al., 2004; Critchley and Coutts, 2002). In a recent comparison with healthy controls, Cowan et al. (2004) showed that in subjects with long-standing groin pain the onset of TrA contractions was significantly delayed when performing the ASLR task . When a muscle or a group of muscles is not adequately activated, compensation by changes in the pattern of motor activity of other muscles may occur (Edgerton et al., 1996). Thus, we also assessed the activity of IO. We found, however, no difference in either TrA or IO between the groups. A trend towards increased thickening of the IO compared with the TrA was found in a LBP study (Critchley and Coutts, 2002) and greater EMG activity in rectus abdominis than in IO was found in another study (O’Sullivan et al., 1997). In the study by O’Sullivan (1997), however, the lower fibres of IO medial to the ASIS were measured. Medial to the ASIS the IO and the TrA are thought to run parallel to one another with a similar fibre orientation, (Williams et al., 1989), suggesting that the muscles act in a similar manner and possibly a different function from the upper obliquely oriented fibres. Whether any part of the muscles is more important for stability of PGP patients is an open question. Regional variations in morphology of the deep abdominals may reflect functional differentiation between regions of TrA (Urquhart et al., 2005). We used a measuring point between the ASIS and the ribs, which is commonly utilized in LBP patients. However, this may not be optimal for PGP. The medial edge of TrA was often more lateral for our subjects compared to what was found for LBP patients and healthy persons in a study by Dahl (2000). This could be related to a slightly higher average body mass index among our subjects or to a possible rectus abdominis diastases; however, only three of the included revealed diastases 1 year postpartum. No difference was found in PFM strength between groups with and without PGP. PFM strength is difficult

293

to measure and the reliability and validity of many methods have been discussed (Bø et al., 2003; Hahn et al., 1996; Peschers et al., 2001; Shull et al., 2002). Because many patients do not understand verbal instructions and perform PFM contractions incorrectly (Bø et al., 1988; Dietz et al., 2001; Thompson and O’Sullivan, 2003), a visually observable inward movement of the perineum was used as a criterion for valid PFM contraction (Bø et al., 1990). Nevertheless, an important question is whether vaginal squeeze pressure is the optimal way to assess the role of the PFM related to pelvic girdle stability. Other parameters may be more relevant. According to Hodges and Richardson (1996) timing of the muscle contraction in significant muscle groups is the important issue related to low back pain, and a similar assumption should be studied in relation to PGP. Evidence indicates that TrA is anticipatory and no direction-specific in its activation (Hodges and Gandevia, 2000; Hodges and Richardson, 1997; Moseley et al., 2002). Some evidence also exists for an anticipatory PFM contraction related to increase in abdominal pressure (Constantinou and Govan, 1982). However, Neumann and Gill (2002) found no precontraction of the PFM compared to abdominal muscles during voluntary activities in healthy subjects. In the present study, significantly more women with persistent PGP reported urinary incontinence and other complaints related to the pelvic floor than the recovered women. These findings are in keeping with findings by others (Mørkved, 1998; O’Sullivan et al., 2002; PoolGoudzwaard et al., 2005). In one study an increased pelvic floor descent was apparent in patients with pain over the SIJ region during the ASLR test (O’Sullivan et al., 2002). It was speculated that the pelvic floor descent reflects a primary motor dysfunction of the PFM. Again, we measured a voluntary PFM contraction, and the ability to perform a correct vaginal squeeze may represent a different phenomenon than holding a contraction during a functional task. In the present study, different measures and analyses for assessing local muscle contractions have been used with consistent findings of no group differences. An increase in thickness of TrA and PFM strength were apparently not associated to each other or to PGP. 4.3. Other possible mechanisms for PGP Another explanation could be that persistent PGP is not related to physical impairment. All women included in this study had a history of PGP (included according to strict criteria) (Stuge et al., 2004a), but the inclusion for the present study was based on self-reported pain location, intensity and disability, not based on physical tests. Thus, it is conceivable that those with pain were suffering more from fear and anxiety, than from physical impairments. However, the scores obtained by



the Hopkins Symptom Check List 2 years after delivery, showed normal scores in both groups, even though the scores tended to be higher in the PGP group (Table 1). The P4 test was positive in five of the women in the PGP group, versus none in the recovered group, indicating a posterior pelvic pain problem in 46% of the PGP group. The ASLR test was positive only in the PGP group. This may indicate that the subjects were suffering from a load transfer problem related to lack of stability of the pelvic girdle (Mens et al., 1999, 2001; O’Sullivan et al., 2002). Thus, it is likely that physical impairment is a major contributor to the condition. In the neuromuscular systems, muscle synergies most probably exist where changes in a given muscle activation level rarely occur in isolation but rather are associated with changes in other muscles as well. A significant reduction in segmental multifidus crosssectional area has been reported in patients with acute unilateral back pain (Hides et al., 1994). We did not examine the multifidus, but it is possible that a dysfunctional multifidus or lack of synergetic activity may have an influencing factor on lumbopelvic stability and persisting PGP. However, while many believe that the local muscles are crucial for lumbopelvic stability, others state that the global larger muscles play a role. Recent studies have concluded that no single muscle dominates in the enhancement of spine stability, and their individual roles change continuously across tasks (Cholewicki and VanVliet, 2002; Kavcic et al., 2004). According to these authors the larger global muscles are better able to alter spine stability than the smaller, intersegmental muscles. Isometric contractions of global muscles have also been shown to increase the stiffness of the SIJs (Wingerden et al., 2004), and a delayed onset of activation of the gluteus maximus has been found in subjects with unilateral pain over the SIJ region (Hungerford et al., 2003). Appropriate and coordinated muscle recruitment patterns are most likely important for adequate lumbopelvic stability (McGill, 2004). It might be that those suffering from long-lasting pain and disability have inadequate motor control strategies of different muscles during functional tasks. Thus, focusing on a single muscle, or a few, appears to be insufficient if the goal is to ensure lumbopelvic stability.

5. Conclusion This study revealed no significant difference in increase of muscle thickness by voluntary contraction of the deep abdominal muscles and PFM strength between women recovered from PGP and women with long-lasting PGP. The ability to voluntarily contract the deep abdominal muscles and the strength of the PFMs are apparently not associated to PGP. However, the

results are based on a small sample and additional studies are needed.

Acknowledgements The study is supported by the Norwegian Foundation for Health and Rehabilitation and The Sofies Minde Foundation. The authors thank Diane Lee for help in categorizing the strategies used by the subjects based on the videotapes of the ASLR test.

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ARTICLE IN PRESS


Original article

Comparison of the effectiveness of a behavioural graded activity program and manual therapy in patients with sub-acute neck pain: Design of a randomized clinical trial Jan J.M. Poola,b,, Raymond W.J.G. Osteloa,c, Albere J. Ko¨ked, Lex M. Boutere, Henrica C.W. de Veta a

Institute for Research in Extramural Medicine, VU University Medical Centre, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands b Medical Centre Impact, Zoetermeer, The Netherlands c Research Group ‘‘Allied Health Care’’, Amsterdam School of Allied Health Care Education, The Netherlands d Rehabilitation Centre ‘‘Hoensbroeck’’, Hoensbroeck, The Netherlands e Pain Management and Research Centre, University Hospital Maastricht, The Netherlands Received 18 June 2004; received in revised form 10 June 2005; accepted 26 July 2005

Abstract The objective is to present the design of a randomized clinical trial (RCT) on the effectiveness and cost effectiveness of a behavioural graded activity programme compared with manual therapy in patients with sub-acute neck pain. Sub-acute is defined as pain existing for 4–12 weeks. The behavioural graded activity programme is a time-contingent increase in activities from baseline towards pre-determined goals. Manual therapy consists mainly of specific spinal mobilization techniques and exercises. The primary outcomes are global perceived effect and functional status. Secondary outcomes are kinesiophobia, distress, coping, depression and somatization. The intensity and persistence of the pain and its interference with activities are also assessed. Direct and indirect costs are measured by means of cost diaries. Measurements take place at baseline and 6 and 12 weeks after randomization. To assess the long-term effect, measurements will also take place after 6 and 12 months. Finally some challenges are discussed concerning the use of a behavioural graded activity programme, manual therapy and outcomes. r 2005 Elsevier Ltd. All rights reserved.

1. Introduction Neck pain is a common musculoskeletal disorder. The point prevalence for neck pain in the general population of The Netherlands varies between 9% and 22% (Borghouts et al., 1999; Picavet and Schouten, 2003), and approximately one-third of all adults will experience neck pain during the course of 1 year (Croft et al., 2001). Some 5–10% of the neck complaints will develop into a Corresponding author. Institute for Research in Extramural Medicine, VU University Medical Centre, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands. Tel.: +31 20 4449829; fax: +31 20 4448181. E-mail address: [email protected] (J.J.M. Pool). URL: http://www.emgo.nl.


chronic pain disorder (Borghouts et al., 1999). Once non-specific neck pain becomes chronic, defined as pain existing for more than 12 weeks, 44% of the patients consult their general practitioner (GP) annually (Borghouts et al., 1999). The main feature of neck pain is pain in the cervical region, often accompanied by restriction of the range of motion and functional limitations (Ariens et al., 1999). The pain may originate from many structures in the cervical region, especially the spine and soft tissues, but there is no conclusive evidence regarding specific pathology in the majority of cases of acute or chronic neck pain (Bogduk and Barnsley, 2000). Consequently most cases are labelled as non-specific neck pain or neck pain of unknown origin (Bogduk and Barnsley, 2000). Risk factors for the occurrence of neck


J.J.M. Pool et al. / Manual Therapy 11 (2006) 297–305

pain are physical load factors such as vibration, flexion of the neck, sitting posture and heavy lifting (Ariens et al., 1999), but psychological and social factors are also reported to aggravate and perpetuate neck pain (Ariens et al., 1999; Linton, 2000). Hence, neck pain is a bio-psychosocial problem, in line with the definition of pain formulated by the International Association for the Study of Pain (IASP, 1986). High pain intensity and a previous history of neck pain is strongly and consistently associated with an unfavourable prognosis (Croft et al., 2001; Hoving et al., 2002). Although neck pain is often self-limiting within a few weeks of onset, 40% of the patients contact their GP; 30% are referred for further diagnosis to a medical specialist and 32% for physiotherapy, manual therapy (MT) or some other type of conservative therapy (Borghouts et al., 1999; Picavet and Schouten, 2003). The evidence regarding the effectiveness of these conservative therapies for neck pain is still inconclusive. A review performed by Aker et al. (1996) showed no benefit from stretching, laser therapy, traction, exercise or neck school for acute neck pain. Gross et al. (2002a, b) concluded that MT is effective for neck pain in the short term, if used in combination with types of other treatment (e.g. exercises). The updated Cochrane review of Gross et al (2004) concluded that there was strong evidence for manipulation and/or mobilization when used in combination with exercises. Manipulation and/or mobilization alone were not beneficial. For chronic neck pain, randomized controlled trials (RCTs) have reported beneficial effects in favour of physical therapy, acupuncture and MT (van Tulder et al., 2000; Gross et al., 2002a, b). Bronfort (Bronfort et al., 2004) concluded that their was moderate evidence that spinal manipulative therapy and/or mobilization was superior to general practice medical care and physical therapy in the short term for improving physical function in patients with chronic neck pain. For patients with acute neck pain the evidence was inconclusive. Hoving (Hoving et al., 2001) concluded, after an extensive review of reviews, that there is no conclusive evidence for or against any of these treatments. However, recently published results of an RCT carried out by Hoving et al. (2002) in patients with sub-acute or chronic neck pain showed a significant difference in effectiveness in favour of MT, compared to both physiotherapy or usual care from the GP, both for short and long-term follow-up. One of the shortcomings of a review seems to be the focus on the methodological quality of the trials. The quality of the trials is in most cases poor and there is hardly any focus on the content of the therapy used. If the definition of manipulation and/or mobilization is common, trials are included in the review without knowing if the used techniques are properly used, if there is a treatment protocol and if the techniques are

generally used in daily practice. Despite that MT seems to be an effective therapy. Among some patients neck pain still becomes chronic. One possible explanation could be the role of psychological and social factors in the awareness of pain. During recent decades there has been an increasing interest in the psychological and social aspects of acute and chronic pain. In addition, psychological and social factors are believed to play a role in the transition from acute to chronic pain and disability (Gatchel, 1996; Linton, 2000). Consequently for patients with sub-acute and chronic pain the emphasis is increasingly focussed on behavioural treatment, based on operant, cognitive or respondent techniques (Turner and Keefe, 2000; Vlaeyen and Linton, 2000; Ostelo et al., 2000; van Tulder et al., 2000). Behavioural treatment focuses on reducing disability through the modification of environmental contingencies and cognitive processes. Also a transition of a similar trend can be observed for sub-acute and chronic neck pain. Identification of the underlying specific pathology is no longer the primary focus. For this, several reasons are mentioned: (a) medical examinations fails to find specific underlying pathology in the majority of neck pain cases (Bogduk and Barnsley, 2000), (b) the degree of physical disability can be due to inactivity rather than a result of the physical condition (Ko¨ke and Thomassen, 2003), (c) the pain can depend on cognitive processes (Cioffi, 1991) and negative thoughts (Dolce et al., 1986), and (d) the patient’s condition can depend on the degree of kinesiophobia (Kori et al., 1990). This model suggests possible pathways by which neck pain patients, similarly to low back pain patients or patients with other pain conditions, become enmeshed in a downward spiral of increasing avoidance, disability and pain. Specially in patients who interpret pain as threatening (pain catastrophizing) and exhibit kinesiophobia or fear of movement (Vlaeyen and Linton, 2000; Nederhand et al., 2004). In literature this model has been a topic for research, especially in low back pain patients but not in neck pain patients so far. Although there are some promising results regarding the effect of cognitive behavioural therapy (CBT) on back pain, arthritis pain, cancer pain and mixed chronic pain (Turner and Keefe, 2000; Keefe, 2000), the effectiveness of CBT for neck pain in a primary care setting is still unknown. Therefore, we hypothesize that the above mentioned factors are also involved in neck pain patients and we suggest that CBT is also a useful therapy for patients with sub-acute neck pain. A CBT programme is based on the bio-psychosocial model, which means that not only the nociceptive structures are held responsible for the pain awareness of the patient. Pain can also be seen as an emotion

ARTICLE IN PRESS J.J.M. Pool et al. / Manual Therapy 11 (2006) 297–305

according to the International Association for the Study of Pain’s (IASP) definition of pain. This can lead to a response in one of the following three response systems that characterize emotional experiences (Vlaeyen et al., 1995; Ostelo et al., 2000; Ko¨ke, 2002): (i) the psychophysiological system such as feelings, increase muscle tension, etc.; (ii) the cognitive system, such as thoughts, catastrophizing, fear, etc.; and (iii) the motor system such as pain behaviour, disuse syndrome, etc (Linton and Ryberg, 2001). Physical therapists are not trained to treat cognitive processes, so a full CBT program is not realistic. Pain behaviour, however, can be treated by PTs using a graded activity (behavioural graded activity, BGA) programme as incorporated in other trials (Lindstrom et al., 1992; Ostelo et al., 2000). The focus is on the motor system and the PT can use operant principles and can act as a coach (Lindstrom et al., 1992; Jensen et al., 1995). The evidence of this BGA programme is still questionable; however, it is widely practiced in low back pain patients. Some studies are not positive (Ostelo et al., 2003; Steenstra, 2004) others are more promising in improving the level of physical activity at work compared to usual care (Staal, 2003). However, for neck pain patients the affect of a BGA programme is still unknown. In our opinion it is a challenge to assess the effectiveness of this programme in patients with subacute neck pain. In summary, MT, a typical hands-on therapy is an effective therapy for neck pain. It is hypothesized that psychological and social aspects play an important role in the transition from sub-acute to chronic pain. BGA, a typical hands-off therapy, can influence pain behaviour and pain intensity by focussing on those aspects, and shows promising results in other pain conditions. In order to assess the effects of BGA for neck pain we designed an RCT assessing the following hypothesis: A BGA programme is more effective than MT in patients with sub-acute neck pain. Secondly we will assess whether the severity of complaints influences. The study protocol was approved by the Medical Ethics Committee of the VU University Medical Centre in Amsterdam.

2. Methods 2.1. Selection of patients The participants in the study are patients with subacute non-specific neck pain, defined as pain in the cervical region existing for at least 4 weeks, but no longer than 12 weeks. The neck pain may radiate to the shoulder region or the upper extremities, or be

299

accompanied by headache, but the main complaint must concern the neck. The inclusion criteria are: nonspecific neck pain, age between 18 and 70 years, and a new episode of pain (defined as no neck pain in the previous 4 months). The patients must not have had any therapy for neck complaints in the previous 4 months. The exclusion criteria are specific neck pain, for example due to rheumatoid arthritis, disc herniation, neurological diseases or malignancy. Patients with whiplashassociated disorders are included unless they have an unsettled insurance claim running during the intake period. During the first GP consultation these criteria are assessed and the patient is informed about the study. Eligible patients who are interested in participation are referred to the research assistant, who informs them further about the consequences of participation and rechecks the inclusion criteria. Patients who are eligible and agree to participate are asked to sign the informed consent form and the baseline measurement is performed.

2.2. Randomization procedure After the baseline measurement the patients are randomly assigned either to the MT treatment or to the BGA programme. The treatment sessions take place in the private practices of the participating therapists. A colleague from the research department who is not involved in recruitment, treatment or data-collection, generated a random list based on a computer-generated sequence. The randomization was pre-stratified for severity of the complaints and age of the patient. Four strata are constructed with a cut-off point for age of 40 years and a cut-off point for severity of the main complaints of 7 on a 0–10 numerical rating scale. The treatment allocation is concealed, as numbered opaque sealed envelopes based on the computer generated list are used, and the research assistant who deals with the inclusion of the patients, is unaware of the content of the envelopes.

2.3. Blinding The patients are aware of the treatment they receive, so it is not possible to blind them but the research assistant who is responsible for the baseline and the follow-up measurements will be blinded for the treatment allocation. Prior to the measurements, the patients are asked by the research assistant not to mention the treatment to which they were allocated. To evaluate the blinding procedure, at the end of the follow-up period the research assistant will record which treatment she thinks the patients received.


300

Consultation General Practitioner

Screening for eligibility

Check inclusion, informed consent and baseline assessment at research centre

Randomisation

MT treatment (n=90)

BGA treatment (n=90)

Sequentially: 6,12,26 and 52 weeks assessment Fig. 1. The study design, patient flow. MT: manual therapy; BGA: Behavioural Graded Activity program.

2.4. Drop-outs All efforts will be made to avoid drop-outs, such as extra telephone calls and/ or mails and if necessary a visit at the patient’s home address. 2.5. Sample size The study aims to include 90 patients per treatment arm. Although arbitrary this is based on the expectation that in the MT group 70% of the patients will recover (Hoving et al., 2002). To detect a difference of 20% between the two treatment groups, which is considered as clinically important, 84 patients are required for each treatment group. This calculation is based on the dichotomized primary outcome measure ‘‘perceived recovery’’, defined as the percentage of patients who are reported to have recovered. The sample size calculation concerns an a of 0.05 and a power (1b) of 90%. To compensate for drop-outs during follow up, we planned to include 90 patients per treatment group. To obtain the required sample size, patients will be recruited by 70 GPs (Fig. 1).

3. Description of the interventions 3.1. Manual therapy In the Netherlands, MT is a specialization of physiotherapy. The manual therapists in this study followed 3-year post-graduate courses in manipulation and/or specific mobilization techniques to become

certified and registered by the Royal Dutch Society for Physical Therapy (KNGF) as a manual therapist. The aim of MT is to recognize and interpret tissue and organ-specific dysfunctions on a local and segmental level. During the physical examination, the musculoskeletal system is examined, while accepting asymmetrical morphology and function and respecting the related individual preference of function. A biomechanical assessment is made to obtain detailed information about the relevant joints, muscles, and surrounding soft tissue. (Van der El and Wagemaker, 1993).The assessment of the cervical spine includes three-dimensional tests within or at the limit of the range of motion of the joints. The aim of the treatment is to restore restricted movement, stimulating natural recovery and adaptive processes in relation to the functionality of movement. Furthermore, the treatment also aims to reduce pain, to increase the patient’s level of activities and participation, and to prevent recurrences (Van der El, Wagemaker, 1993; Baumgarten et al., 1996). The treatment consists of manipulation and specific mobilization techniques. A manipulation is a passive movement of a joint beyond its active and passive limit of motion, but within the limit of its anatomical integrity. It is usually a localized thrust which is a quick movement of small amplitude led by the therapist. The aim of the manipulation is to regain motion, to restore function and to reduce pain. A mobilization utilizes skilled low-grade passive movement with large amplitude. Passive mobilization can be repetitive or not, varying in amplitude. The aim of mobilization is to restore movement and to relieve pain. The specific technique that is chosen depends on the therapist, and is not yet a topic for research.

ARTICLE IN PRESS J.J.M. Pool et al. / Manual Therapy 11 (2006) 297–305 Table 1 The content of manual therapy treatment, assessed by manipulative therapist on a registration form (Hoving et al., 2002) Manual therapy in neck pain patients (n ¼ 60)

Median (IQR)a

Number of sessions Physical examination Muscle techniques Specific articular mobilisation techniques Frequently used:

6 6 5 6

(5, (5, (3, (4,

6) 6) 6) 6)

Type: traction/translation, 2/3 dimensional specific techniques

Location: 2e–3e cervical segment, cervico-thoracic junction-thoracic spine and costo-vertebrale articulations (1st rib) Co-ordination and stabilisation techniques Instruction and exercises a

3 (0, 4) 4 (3, 6)

IQR (Inter Quartile Range of treatment sessions).

Similar to the Hoving trial (Hoving et al., 2002), MT did not include high velocity thrust techniques in the cervical region. This technique was excluded for ethical reasons because of reported complications of spinal manipulations, and especially vertebrobasilar complications (Assendelft et al., 1996). Despite this exclusion, the overall effect of the MT intervention was promising in favour of MT. Dutch manual therapists use knowledge, methods, and techniques considered unique to MT. In daily clinical practice, physical therapy and MT are often less distinct, because the same person, i.e., the physical therapist with a specialization in MT, provides both. So it is standard practice to use additional exercises and give advice as well in a MT treatment. These are patient tailored and the aim of the exercises is mobilization, stabilization and coordination. This is illustrated by Table 1 which shows the registered content of the MT in the Hoving trial (Hoving et al., 2002). The content of MT in this trial will be the same as in the Hoving trial. In summary, in the current RCT the MT intervention is similar to the intervention described in the Hoving trial, which consisted of MT techniques, exercises and advice, we will refer to this therapy as MT. The therapists are also asked to fill in a registration form after each session. The therapists are allowed to provide a maximum of six treatment sessions within 6 weeks. The duration of a single treatment session is 30–45 min. 3.2. Behavioural graded activity programme (BGA) To emphasize the behavioural component, compared with physical training, the term BGA was introduced (Ostelo et al., 2000). In general, the focus of the treatment is on function and not on the underlying pathology or biological aspects of pain. Physiotherapists

301

are already trained to treat functional recovery in patients with all kinds of limitations, and they are properly equipped to conduct the intervention in the current trial after a special 2-day training. All PTs participating in this trial have had additional courses in biopsychosocial approach of pain problems. All PTs had more than 10 years of clinical experience. To solve all existing problems and to monitor the treatments, regular days of reflection are organized, furthermore registration forms are used to get insight in the treatments. The therapists’ attitude is checked using a health care providers questionnaire, which was adapted for neck pain. (Ostelo et al., 2003; Houben et al., 2004). The BGA programme, as applied in the present study, is based on time-contingent management, as described in more detail by Fordyce (Fordyce et al., 1973) and applied by Lindstrom and Ostelo (Lindstrom et al., 1992; Ostelo et al., 2000). The emphasis of the treatment in this trial is the operant strategy. Core elements of this programme are: (1) decrease in the pain behaviour and increase in ‘‘well’’ or ‘‘healthy’’ behaviour; (2) improving function and not the reduction of pain; (3) the patient is responsible for the treatment and has an active role; and (4) the therapist acts as a coach. The BGA treatment can be divided into three phases which will be discussed separately. 3.3. Initial phase The initial phase first concerns a reconceptualization of the patient’s pain model. Central in this is the understanding that pain is not solely the result of underlying tissue damage, but is also influenced by the patient’s expectations, beliefs, and fear, as well as activity levels and home and work environment. The patient is then taught that it is safe to move the cervical spine or other parts of the body. Subsequently, the three main complaints are formulated at baseline (Ko¨ke et al., 1999). A main complaint is defined as an activity that is very important to the patient, implying that improvement of these activities is highly desirable. During the initial phase the patient is asked to perform these activities until the pain becomes too dominant, in other words pain-contingent. The level, duration or frequency of activities, is registered on a performance chart. A baseline level is constructed, based on these performance charts, thereby determining the average level of each specific activity. From baseline level the patient has to set his/her own individual treatment goals. For example, the patient wants to be able to read his documents for 12 min during work (see example). Once the goal is determined, and knowing the baseline level, quotas are set in order to achieve this predetermined treatment goal within a predetermined time-span (time-contingent) (Fig. 2).


302

3.4. Treatment phase

setting only, but one should also generalize the goals into working or home situations. In this phase the frequency of treatment sessions will be diminished and self-efficacy will be strongly encouraged. The BGA treatment within the trial period will consist of a maximum of 18 sessions of approximately 30 min.

Once the treatment phase starts, activities and exercises are no longer performed on a pain-contingent basis, but follow the predetermined quotas. Therefore the key element of the treatment phase is timecontingency, meaning that despite the pain or discomfort the quotas will be adhered to. Initial quotas are set in such a way that they are slightly below the baseline level, to ensure that the first treatment session will be a successful one (Vlaeyen et al., 1995; Kole-Snijders et al., 1999; Ko¨ke, 2002). During treatment, the therapist stimulates and encourages the patient and gives positive reinforcement if the quotas are achieved.

The demographic variables as well as primary and secondary outcomes are measured at baseline. Table 2 gives an overview of the data collection.

3.5. Generalization phase

4.1. Demographic variables

The aim of this phase is to encourage the patients to proceed with their healthy behaviour during activities of daily living. It is not sufficient to train in a treatment

Demographic variables, such as age and gender, will be registered. Furthermore, disease characteristics such as history of the neck pain, possible cause of the complaint, duration of the complaint, irradiation to shoulder or extremity, accompanying headache, shoulder or back pain, will be assessed.

14 12

4. Measurements

min.

10

4.2. Primary outcome measurements

8 6 4 2 0 1

3

5

7

9 days

11

13

15

Fig. 2. Example of constructing a baseline measurement of a main complaint.

Global perceived effect (GPE) (Feinstein, 1987; Beurskens et al., 1996) is measured by self-assessment on a 7-point scale, 1 ¼ completely recovered, 2 ¼ much improved, 3 ¼ little improvement, 4 ¼ no change at all, 5 ¼ slightly worse, 6 ¼ much worse and 7 ¼ worse than ever. The neck-specific functional status is measured according to the Neck Disability Index (Vernon and Mior, 1991). The Dutch translation was found to be a sufficient validly instrument (Heijmans et al., 2002).

Table 2 Overview of data collection Instrument

Baseline

Inclusion/exclusion Demographic data

X X

Primary outcome Perceived recovery Neck pain disability index (NDI) Secondary outcome Tampa scale of Kinesiofobia (TSK) Pain coping and cognition list (PCCL) 4 Dimensions of psychological symptomatology questionnaire (4DSQ) Numerical rating scale for pain (NRS) Patient specific questionnaire (PSQ) Graded chronic pain scale (GCPS) Sort form 36 (SF-36) EuroQol Cost-diary

6 weeks

12 weeks

26 weeks

52 weeks

X

X X

X X

X X

X X

X X X X

X X X X

X X X X

X X X X

X X X X

X X X

X X X X

X X X X

X X X X

X X X X


4.3. Secondary outcome measurements These measurements will evaluate all domains of the psychological and social aspects of pain defined in the introduction. Fear of movement is measured according to the Tampa Scale for Kinesiophobia (TSK) (Kori et al., 1990). The Dutch translation of the TSK has a fair and consistent internal validity (Goubert et al., 2000). Pain catastrophizing, pain coping and pain control (external and internal control) is measured by means of the Pain Coping and Cognition List (PCCL) (Stompvan der Berg et al., 2001). The 4 Dimensions of Psychological Symptomatology Questionnaire (4DSQ) measures factors such as distress, depression, fear and somatization as intermediate factors (Terluin, 1996, 1998). Within the Numeric Rating Scale (NRS) for pain, the patients score their average and maximum pain in the past week and current pain on an 11-point rating scale. The NRS is a valid and responsive scale (Rosier et al., 2002). The Graded Chronic Pain Scale (GCPS) is designed to assess the intensity, interference with activities and persistence of pain. In the current trial it is used to assess neck pain. All items are either scored on a NRS scale or expressed in days (Von Korff et al., 1992; Von Korff, 2000). The Patient Specific Questionnaire (Beurskens et al., 1996; Beurskens et al., 1999; Ko¨ke et al., 1999) is used to score the three most important disabilities on an 11-point numerical rating scale (0 no disability-10 not able to perform this activity). Health status is evaluated with the Short Form 36 (SF-36). The Dutch translation showed satisfactory validity and reproducibility (Aaronson et al., 1998). Quality of life is measured according to the Euroqol-5D (Feinstein, 1987; The EuroQol Group, 1990). Furthermore, the patients will record any costs due to their neck pain, visits to the therapists, absenteeism from work and use of medication, in a cost diary (Goossens et al., 2000).

5. Analysis The baseline scores of the patient’s demographic (e.g. age, gender, duration of complaints, history of complaints and trauma), primary and secondary outcomes will be used to compare the two intervention groups. Differences between baseline and follow-up measurements will be calculated, and compared between the two intervention groups. If necessary, adjustments for baseline variables will be made, using analysis of covariance. Considering the longitudinal context of the data and possible confounding on the level of the therapist a generalized linear mixed model will be used. The statistical analyses will be performed on the basis of the intention-to-treat principle, i.e. patients will be

303

analysed in the treatment group to which they were randomly allocated. Missing data will be replaced by a linear interpolation method for missing measurements, and by a ‘last measurement carried forward’ method for drop-outs (Twisk and de Vente, 2002). Worse-case scenarios and best-case scenarios for patients with and without missing values for the end-point variables will be compared for the total study population and per treatment group.

6. Discussion Publishing the design of a study before publishing the results is important for several reasons. Firstly, it yields an opportunity to reflect critically on the design, independently of the study outcomes. Secondly, if the design is published any deviations from the original design can be identified when the study results are published. Thirdly, it may counteract possible publication bias (Dickersin, 1990), because authors of future systematic reviews can identify the study even if its results are never published. MT seems to be an effective treatment for patients with neck pain (recent reviews of literature). But the exact content of MT is not always clear. In The Netherlands MT consists of specific manual techniques, exercises and advice and is frequently used to treat patients with neck pain. This approach seems to be an effective treatment for these patients (Hoving et al., 2002). However, in a majority of patients with neck pain the complaints are persistent or have recurrences. Cognitive and behavioural factors seem to play an important role (Keefe, 2000). BGA focuses on these factors, but the evidence of the effectiveness of BGA is lacking. Therefore a randomized controlled design was designed to compare the effectiveness of BGA versus MT. Challenges of this design are: Treatment BGA: The BGA program used in this trial is an operant therapy based on the principles of the biopsychosocial model. Although physical therapist are skilled to treat patients with neck pain it is not self evident that they are able to provide a BGA program and change their attitude from a pain contingent approach to time contingent approach. To ensure that these principles are adequately used a 2-day training program is provided, supervised by an experienced behavioural therapist and a psychologist. This program consists of a theoretical part in which all the principles of a BGA program are discussed, and a practical part. Although it might be desirable to train PTs more extensively, we choose to train PTs according to the training courses that are normally provided in this approach. The advantage of this strategy is that if this trial provides evidence in favour of the BGA,


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the results can easily be implemented. The use of the BGA program by the therapists is evaluated during the trial using a registration form. Manual therapy: There is an ongoing discussion concerning the content of MT used in trials (Rothstein, 2002). The reaction of many readers of BMJ to the article describing the Hoving trial confirms this (Korthals-de Bos et al., 2003). In the Dutch situation MT is a combination of manipulative therapy, specific mobilization techniques, exercises and advice. In this trial the different components of MT will be described in detail, which will benefit the interpretation of the results. Outcome measures: Patient satisfaction can be measured using different scales or questionnaires. We choose GPE as a primary outcome measure even though there are some concerns about the reliability and validity of global rating scales. Global ratings typically are correlated with the patient’s present status and are not an unbiased measure of change (Norman et al., 1997). However, most authors regard global rating scales as clinically relevant and valid and responsive to measure patient’s perceived recovery. From the patient’s point of view this subjective scale is perhaps the most sensible method of assessment. This study is designed as a RCT. The first challenge is to investigate whether BGA is more effective than MT, with focus on a comparison between a mainly hands-on approach, based on the bio-medical model, and a handsoff approach. The second challenge lies in the fact that the study population consists of patients with sub-acute neck pain. The behavioural approach has mainly been tested in chronic pain patients, in whom it is expected that psychological and social factors become more dominant over time. The turning point in pain behaviour, from more nociceptive dominance to more psychological and social dominance, is still unknown, although is it hypothesized that approximately 7–8 weeks after the onset the behavioural factors become dominant (Gatchel, 1996). So the question remains whether MT or a BGA program can prevent sub-acute pain patients from chronicity. The results of this RCT may be of value for the clinician in choosing the right therapy strategy for each individual patient. Furthermore, this RCT can be used to update systematic reviews, and may contribute to the development of evidence-based clinical guidelines in this field.

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ARTICLE IN PRESS


Original article

Predictors for the immediate responders to cervical manipulation in patients with neck pain Yuh-Liang Tsenga, Wendy T.J. Wanga,, Wen-Yin Chena, Tsun-Jen Houb, Tzu-Ching Chenc, Fu-Kong Lieuc a Institute and Faculty of Physical Therapy, National Yang-Ming University, Taipei, Taiwan Department of Rehabilitation Medicine, Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan c Department of Rehabilitation Medicine, Cheng-Hsin Rehabilitation Medical Center, Taipei, Taiwan

b

Received 7 November 2004; received in revised form 4 July 2005; accepted 8 August 2005

Abstract Cervical manipulation has been considered an effective treatment for managing neck pain. However, clinical observation showed that cervical manipulation was not effective for every patient. Development of clinical prediction rules for identifying patients with neck pain who are likely to respond to cervical manipulation may improve clinical decision-making and the treatment success rate. The purpose of the study was to identify predictors for the immediate responders to cervical manipulation treatment in patients with neck pain. One hundred patients with neck pain (34 males and 66 females, mean age ¼ 46711 years) participated in the study. Patient’s demographic data, symptom aggravating or easing factors, pain, and disability level were obtained through an initial assessment. A series of physical examinations were also administered. After receiving a single session of cervical manipulation, the patient was re-evaluated immediately to determine if a successful response to treatment was obtained. The successful response was determined by improvements seen in one of the three outcome variables that included reduction of pain intensity, significant perceived improvement, and high satisfaction level. From these judgment criteria, patients were classified into either responders or nonresponders to the cervical manipulation. Univariate analyses were used to assess if the treatment responders and nonresponders were different in their clinical presentations. The clinical factors that showed significant differences between two groups were then entered into a stepwise multiple logistic regression analysis to identify significant predictors and the prediction rule for treatment responders. Six predictors including ‘‘initial scores on Neck Disability Index o11.50’’, ‘‘having bilateral involvement pattern’’, ‘‘not performing sedentary work 45 h/day’’, ‘‘feeling better while moving the neck’’, ‘‘without feeling worse while extending the neck’’, and ‘‘the diagnosis of spondylosis without radiculopathy’’ were identified to significantly predict the immediate responders. The presence of four or more of these predictors increased the probability of success with manipulation to 89%. We concluded that using favourable predictors to identify treatment responders before administering cervical manipulations could significantly increase the probabilities of a successful treatment. This study finding may enhance the efficacy of clinical decision-making in using cervical manipulation intervention. r 2005 Elsevier Ltd. All rights reserved. Keywords: Outcome predictor; Cervical manipulation; Neck pain; Clinical prediction rule

1. Introduction

Corresponding author at: Faculty of Physical Therapy, National Yang-Ming University, 155, Sec 2, Li-Nong Street, Pei-Tou District, Taipei, Taiwan 112. Tel.: 886 2 28267000x5005; fax: 886 2 28201841. E-mail address: [email protected] (W.T.J. Wang).


Neck pain and related problems occur frequently in modern societies and have a considerable impact on individuals and the society (Hagberg and Wegman, 1987; Borghouts et al., 1998). Spinal manipulation is one of the manual techniques for treating mechanical neck

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pain. Although the pain relieving effect of cervical manipulation has been demonstrated in many studies (Vernon et al., 1990; Cassidy et al., 1992; Rogers, 1997; Jordan et al., 1998; Pikula, 1999; Bronfort et al., 2001; Evans et al., 2002), it was reported not to be particularly effective in others (Sloop et al., 1982; Hurwitz et al., 1996; DiFabio, 1999; Gross et al., 2002). Some authors believed that the effectiveness of the manipulation for neck pain was doubtful (Nordemar and Thorner, 1981; Sloop et al., 1982). One explanation of the disagreements among the reviewed studies may be the heterogeneity of the subject population. Studies showing positive effects of cervical manipulation might have included more patients with prognostic factors favouring cervical manipulation. On the other hand, studies that failed to show the positive effect of cervical manipulation might have included fewer patients with such prognostic factors. Without knowing the detailed characteristics of those subjects in previous studies, our hypothesis could not be supported. However, studies on the predictors to identify suitable subjects for cervical manipulation have not been reported yet. In the recent decades, discovering the prognostic factors for health problems has been emphasized in many medical professions (Klenerman et al., 1995; Skargren and Oberg, 1998; Eriksen et al., 1999; Hermanek, 1999; Leclerc et al., 1999; Flynn et al., 2002; Kjellman et al., 2002). Many patients’ first concern about their treatments relates to the prognosis of their problems. In order to provide patients with more information, clinicians need to be aware of factors associated with treatment prognosis (Borghouts et al., 1998). Prognostic factors of manipulation for low back pain have been discussed to some extent (Singer et al., 1987; Lanier and Stockton, 1988; Coste et al., 1994; Klenerman et al., 1995; Cherkin et al., 1996; Flynn et al., 2002). However, the literature contains insufficient information addressing the prognostic factors related to specific treatment methods such as cervical manipulation for mechanical neck pain (Shekelle and Coulter, 1997; Borghouts et al., 1998; Skargren and Oberg, 1998; Kjellman et al., 2002). In order to ensure efficient clinical decision-making for utilizing cervical manipulation to treat mechanical neck pain, more studies should be carried out to identify the favourable factors. Therefore, the purpose of this study was to identify the predictors for patients with neck pain who would respond immediately to the cervical manipulation treatment.

2. Materials and methods This was a prospective cohort study. All patients were recruited from the Outpatient Department of Rehabilitation Medicine of two regional hospitals.

307

2.1. Subjects Patients who were referred to physical therapy for treatment of their neck pain were recruited in this study. The diagnoses included (1) cervical spondylosis with or without radiculopathy; (2) herniated disc of the cervical spine; (3) myofascial pain syndromes; (4) cervicogenic headache. Informed consent of participation was obtained from each patient before starting the data collection. Exclusion criteria included diagnoses of vertebral basilar insufficiency, progressive neurological deficits, severe osteoporosis, history of cervical fracture or surgery, diagnoses of psychological disorders, systemic diseases, or other problems that were contraindications to cervical manipulation. All potential study participants were initially screened by their referred physicians. 2.2. The assessor and manipulators All assessments were performed by an independent assessor who was not involved with the treatment of the study subjects. Cervical manipulation treatments were provided by two experienced manual physical therapists (one was both a manual physical therapist and chiropractor and has practiced for 13 years; the other was a physical therapist who received postgraduate masters level of training in manual therapy and has been practicing for six years) in two different hospitals. At the beginning of this study, a standardized manipulation protocol was established by both therapists in order to obtain comparable results (see Appendix A). 2.3. Initial evaluation Baseline information for the patients was obtained via an interview. A series of physical examinations were performed by the assessor before the treatment. 2.3.1. Interview Demographic information including gender, age, height, weight, and body mass index (BMI) were obtained. Health and illness-related data were also collected, including diagnoses, area(s) of complaints, onset patterns, stages of symptoms, and unilateral or bilateral involvement patterns. Symptom aggravating and easing activities or movements were also assessed. Current and worse pain intensity (11-point numeric rating scale) and the score of Neck Disability Index were recorded for the current impairment and functional disability (Vernon and Mior, 1991). The subjects also filled out a 12-item Chinese Health Questionnaire (CHQ12) that was constructed to evaluate their psychosocial wellbeing (Cheng and Williams, 1986). The validity and reliability of CHQ12 has been established and reported in the literature (Chong and Wilkinson,


Y.-L. Tseng et al. / Manual Therapy 11 (2006) 306–315

2.3.2. Physical examinations Physical examinations consisted of testing for the cervical range of motion (Youdas et al., 1991), cervical compression and distraction (Magee, 1997), and cervical segmental sidegliding (Greenman, 1996). The interrater and intrarater reliabilities of these physical examinations were generally acceptable and reported in previous studies (Viikari-Juntura, 1987; Tseng et al., 2003; Wainner et al., 2003).

point at ‘‘X4 (much improved)’’. Patients who rated the improvement score as X4 after receiving the manipulation were considered the treatment responders. For the satisfaction level, the cutoff point for a successful treatment was set at ‘‘very satisfied’’ with the cervical manipulation. The patients who reported ‘‘very satisfied’’ with the manipulation were considered the treatment responders. Responding to treatment was determined by the improvement seen in one of the three outcome variables of pain reduction (X50%), perceived improvement (X4), and patient satisfaction (very satisfied) of the manipulation. Those patients who did not meet any of the above three criteria were considered as nonresponders to the treatment.

2.4. Cervical manipulation intervention

2.6. Statistical analyses

Two manual therapists provided cervical manipulation treatment to the study subjects according to a standardized procedure. Before manipulation, a test of vertebral basilar artery insufficiency of each patient was conducted by the therapists (see Appendix B). If any symptom such as nystagmus, dizziness, lightheadedness, or visual disturbance was noted during the test, the patient was excluded from the study. During the treatment, the therapists first glided each segment of the entire cervical spine of the patient in order to identify the hypomobile segments. Then, cervical manipulations were performed on these segments to gap the facet joints (Appendix A).

Univariate analyses were used to identify potential predicting factors which were significantly different between the responder and nonresponder groups. The significance level for each of the tests for determining the group difference was set at po0:10. This liberal statistical significance level was utilized in order not to miss any potential predicting factor. Once the significant factors were identified from the univariate analyses, they were then entered into a stepwise multiple logistic regression analysis in order to further construct a prediction model. Statistical significance for the multivariate logistic regression was set at po0:05. Accuracy analyses including sensitivity, specificity, and positive likelihood ratio (PLR) were calculated for prediction models based on the number of clinical factors present. The PLR was calculated by the formula of sensitivity/(1–specificity). The value of PLR indicated how much a given prediction model could raise the probability of obtaining the outcome (Sackett, 1992). In addition, a nomogram was plotted for each number

1989; Chen et al., 2000). People with the CHQ12 score of 4 or higher (maximum at 12) were considered to suffer a minor psychiatric disorder (Chong and Wilkinson, 1989; Yang et al., 2003).

2.5. Outcome assessment criteria The post-manipulation assessment was executed immediately following the cervical manipulation. The patient was asked by the independent assessor to rate their pain intensity (11-point numeric rating scale), perceived improvement (a 15-point Likert scale from the worst grade of 7 to the best grade of +7) (Jaeschke et al., 1989; Juniper et al., 1994; Stratford et al., 1996; Wyrwich et al., 1999), and the satisfaction level (‘‘very satisfied’’, ‘‘somewhat satisfied’’, ‘‘no opinion’’, ‘‘somewhat unsatisfied’’, and ‘‘very unsatisfied’’) (Gemmell and Hayes, 2001). For a significant change in pain intensity, the cutoff point was set at pain reduction X50% after cervical manipulation. If the pain reduction was equal or greater than 50%, the cervical manipulation was considered successful. The 15-point global rating scale ranged from 1 (a little bit, almost the same) to 7 (a very great deal worse), or +1 (a tiny bit) to +7 (a very great deal better). Absolute global improvement ratings of 4 or more were classified as reflecting a moderate to large clinically important change (Jaeschke et al., 1989; Juniper et al., 1994; Wyrwich et al., 1999). For judging the immediate effect on the general perceived improvement, we set the cutoff

Table 1 Baseline characteristics of the study subjects ðN ¼ 100Þ Gender Age (years), mean7SD (range) Body mass index (kg/m2), mean7SD (range) Current pain intensity, mean7SD (range) Initial score of Neck Disability Index, mean7SD (range) Duration of current episode Acute (o 3 weeks) Subacute (3 weeks–3 months) Chronic (43 months) Working status Employed, full-time Employed, part-time Unemployed or retired

34 males, 66 females 46711 (21–73) 23.373.4 (17.6–37.6) 5.471.8 (2–10) 11.776.3 (3–26)

32% 24% 43% 54% 7% 39%


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Table 2 Comparison of patients’ demographic data, diagnoses, pain & symptom presentations, and disability between the nonresponder and responder groups Variables

All subjects ðN ¼ 100Þ

Non-responder group ðN ¼ 40Þ

Responder group ðN ¼ 60Þ

p value

Age, yrs Female gender (%)

45.6711.0 66.00

43.4711.1 70.00

47.1710.7 63.30

0.11 0.49

Work load Sedentary work45 h/day (%)

18.00

30.00

10.00

0.01*

Diagnosis (%) Cervical spondylosis without radiculopathy Cervical spondylosis with radiculopathy Myofascial pain syndrome Cervical disc herniation Cervicogenic headache Chinese Health Questionnaire X4 (%) Current pain intensity (0–10) Neck Disability Index (0–50)

17.00 63.00 73.00 10.00 3.00 52.00 5.4 (1.8) 11.7 (6.3)

7.50 70.00 75.00 12.50 2.50 55.00 5.7 (1.9) 13.8 (7.3)

23.30 58.30 71.70 10.00 3.30 50.00 5.2 (1.8) 10.3 (5.2)

0.04* 0.24 0.71 0.70 0.81 0.62 0.26 0.01*

Symptom onset Sudden (%) Gradual (%) Traumatic (%) Stages of symptoms o 3 wks (%) 3 wks–3 mo (%) 43 mo (%) Bilateral involvement (%)

9.00 88.00 3.00

15.00 85.00 0.00

5.00 90.00 5.00

0.09* 0.45 0.27

32.00 24.00 43.00 60.00

30.00 17.50 50.00 45.00

33.30 28.30 38.30 70.00

0.73 0.21 0.25 0.01*

Neck flexion Better (%) Worse (%)

3.00 53.00

0.00 65.00

5.00 45.00

0.27 0.05*

Neck extension Better (%) Worse (%)

3.00 49.00

2.50 65.00

3.30 38.30

0.81 0.01*

Turning head Better (%) Worse (%)

6.00 49.00

0.00 52.50

10.00 46.70

0.08* 0.57

Stationary Better (%) Worse (%)

30.00 57.00

2.50 62.50

3.30 53.30

0.81 0.36

Moving neck Better (%) Worse (%)

22.00 31.00

10.00 42.50

30.00 23.30

0.02* 0.04*

Initial cervical range of motion Sagittal plane: Flexion+extension (deg) Frontal plane: Left+right sideflexion (deg) Horizontal plane: Left+right rotation (deg)

124.972.3 90.3716.5 147.9721.3

122.9723.4 91.2717.2 146.1722.9

126.3717.9 89.8716.2 149.0720.3

0.42 0.68 0.50

Compression tests (% of tested positive) Flexion Extension Right or left sideflexion Distraction test (% of tested positive)

10.00 49.00 36.00 46.00

15.00 60.00 35.00 45.00

6.70 41.70 36.70 46.70

0.17 0.07* 0.87 0.87

Side gliding tests (% of tested hypomobile) C0/1 C1/2

23.00 31.00

22.50 40.00

23.30 25.00

0.92 0.11



Table 2 (continued ) Variables C2/3 C3/4 C4/5 C5/6 C6/7 C7/T1

All subjects ðN ¼ 100Þ 69.00 65.00 67.00 70.00 78.00 65.00

Non-responder group ðN ¼ 40Þ 75.00 67.50 67.50 75.00 77.50 60.00

Responder group ðN ¼ 60Þ 65.00 63.30 66.70 78.30 68.30 68.30

p value 0.28 0.67 0.93 0.37 0.92 0.39

Data are presented as % or mean7SD; *significant between-group difference at po0:10.

Table 3 Predictors for the immediate responders to cervical manipulation (stepwise multiple logistic regression) Predictor

Coefficient

Odds ratio

95% Confidence interval

p value

Initial Neck Disability Index o11.50 Bilateral involvement pattern Not performing sedentary work 45 h/day Feeling better while moving the neck Without feeling worse while extending the neck Diagnosis of spondylosis without radiculopathy

1.35 1.48 2.21 2.24 1.77 1.98

3.84 4.40 9.07 9.42 5.85 7.22

1.24–11.85 1.44–13.45 1.94–18.52 2.15–41.37 1.85–18.52 1.40–37.33

0.019 0.009 0.005 0.003 0.003 0.018

of predictors present to illustrate the effect of the likelihood ratios in converting pre- to post-prediction probabilities, the PLRs, and the post-prediction probabilities (Fagan, 1975; Sackett, 1992). Data management and statistical analyses were performed by using the SPSS 11.0 software (SPSS Inc., 444 N Michigan Avenue, Chicago, Illinois 60611, USA).

3. Results Baseline characteristics of the 100 subjects are listed in Table 1. According to the criteria of judging the successful treatment, 60 patients (60%) were classified as responders to the cervical manipulation, and 40 (40%) were nonresponders. No significant difference of the success rates of cervical manipulation was found between the two manipulators (66% vs. 49%, w2 ¼ 2:93, w2 -test, p ¼ 0:1). 3.1. Univariate analyses Univariate analyses of all variables between the responder and nonresponder groups are presented in Table 2. Eleven potential predicting factors were found different between two groups. Results indicated that the potential predicting factors associating with successful cervical manipulation were ‘‘not performing sedentary work 45 h/day’’ ðp ¼ 0:01Þ, ‘‘diagnosis of cervical spondylosis without radiculopathy’’ ðp ¼ 0:04Þ, lower score of the Neck Disability Index ðp ¼ 0:01Þ, ‘‘not sudden onset’’ ðp ¼ 0:09Þ, ‘‘bilateral involvement

pattern’’ ðp ¼ 0:01Þ, ‘‘without feeling worse while flexing the neck’’ ðp ¼ 0:05Þ, ‘‘without feeling worse while extending the neck ðp ¼ 0:01Þ’’, ‘‘feeling better while turning the head’’ ðp ¼ 0:08Þ, and ‘‘feeling better while moving the neck’’ ðp ¼ 0:02Þ, ‘‘without feeling worse while moving the neck’’ ðp ¼ 0:04Þ and ‘‘negative findings of the compression tests in the extended position’’ ðp ¼ 0:07Þ. For the disability variable, the ‘‘score of the Neck Disability Index’’ was found to be significantly different between the responders and nonresponders ðp ¼ 0:01Þ. In order to change the ‘‘score of the Neck Disability Index’’ into a dichotomous variable, we constructed a ROC curve to identify the most optimal cutoff point. Results indicated that a cutoff of 11.50 was most appropriate with a sensitivity level of 0.67, a specificity level of 0.60, and an area under the ROC curve of 0.64. The proportion of patients with the ‘‘score of the Neck Disability Index o11.50’’ was significantly greater in the responder group than in the nonresponder group (responder vs. nonresponder ¼ 66.7% vs. 40.0%, p ¼ 0:01). 3.2. Stepwise multiple logistic regression analysis Eleven potential predicting factors identified through the univariate analyses were entered into the stepwise multiple logistic regression analyses. Among them, six were combined to significantly predict the immediate responders of the cervical manipulation (Table 3). ‘‘Score of the Neck Disability Index o11.50’’, ‘‘bilateral involvement pattern’’, ‘‘not performing sedentary work


45 h/day’’, ‘‘feeling better while moving the neck’’, ‘‘without feeling worse while extending the neck’’, and the ‘‘diagnosis of spondylosis without radiculopathy’’ emerged in the final prediction model as significant predictors for predicting successful cervical manipulation. The cumulative adjusted coefficient of determination (R2) of this regression model was 0.50 (model w2 ¼ 45:9, df ¼ 6, p ¼ 0:000, Nagelkerke R2 ¼ 0:50). No subjects were positive for all six predictors at baseline (Table 4). Fifty of 60 subjects with 3 or 4 predictors present were in the responder group. Of subjects with less than 2 predictors present, 28 of 40 were in the nonresponder group.

311

4. Discussion This study worked on identifying important predictors for patients with neck pain who subjectively responded to the cervical manipulation treatment. In order to classify the treatment responders and the nonresponders, we used three different outcome criteria

3.3. Accuracy analyses for each level of the prediction model According to the pre-prediction probability obtained from those patients who were classified as responders to the cervical manipulation in the study (60%), the PLR and the post-prediction probability were calculated for each level of the prediction model (Sackett, 1992). The results of accuracy analyses including sensitivity, specificity, PLR, and post-prediction probability of successful cervical manipulation for each level of the model are shown in Table 5 and Fig. 1. Table 4 Number of subjects in the responder and nonresponder groups at each Level of the prediction model Number of predictors present

Number of subjects in the non-responder group

Number of subjects in the responder group

6 5 4 3 2 1 0

0 0 3 9 17 10 1

0 4 24 26 5 1 0

Fig. 1. The nomogram of the prediction model for successful cervical manipulation with a cutoff of number of predictors.

Table 5 Accuracy analyses (with 95% confidence interval) for each level of the prediction model Number of predictors present

Sensitivity

Specificity

Positive likelihood ratio

1

0.02 (0.02–0.05) 0.08 (0.01–0.15) 0.43 (0.31–0.56) 0.40 (0.28–0.52) 0.07 (0.00–0.13)

0.75 (0.62–0.88) 0.57 (0.42–0.73) 0.78 (0.65–0.90) 0.93 (0.84–1.00) 1.00 (1.00–1.00)

0.07 (0.01–0.50) 0.20 (0.08–0.49) 1.93 (1.01–3.67) 5.33 (1.72–16.54) Infinite

2 3 4 5+

Probability of successful manipulation (%) 10 23 74 89 100



which were considered clinically important. Among them, reduction of the pain intensity and perceived improvement have been widely accepted as cardinal outcome measures for treating spinal disorders (Vernon et al., 1990; Cassidy et al., 1992; Rogers, 1997; Borghouts et al., 1998; Jordan et al., 1998; Skargren and Oberg, 1998; Pikula, 1999; Bronfort et al., 2001; Evans et al., 2002; Kjellman et al., 2002). Based on a review article of the prognostic factors for neck pain (Borghouts et al., 1998), Borghouts et al. found that decrease of pain intensity from clinical intervention ranged from 22% to 79% with a median of 46%. Therefore, we set the cutoff point at X50% of pain reduction to classify the patients into the responder group in this study. To avoid small improvement benefited from a placebo effect, we classified those patients who rated above ‘‘much improved’’ in the perceived improvement or ‘‘very satisfied’’ in the patient satisfaction level into the responder group. Although pain is an important treatment outcome, it is usually not the only dimension a successful outcome could be judged from (Solomon et al., 1997; Fritz et al., 1998; Mead and Bower, 2002). Clinical supremacy dictates that patients’ perceptions are likely to be of utmost importance in assessing outcomes. The patientcentred focus in the clinical setting has prompted researchers to include perceived effects and satisfaction as outcome indicators beyond pain reduction (Phillips, 1999). In a systematic review of manual therapy for mechanical neck disorders, Gross et al. (2002) used three outcome determinants (pain, function and patient satisfaction) to examine available randomized trials for the treatment effectiveness from manual therapy in adults suffering from neck disorders. Later, Gross (2004) again published a Cochrane review of manipulation and mobilization for mechanical neck disorders. They assessed randomized trials to determine whether manipulation and mobilization could relieve pain or improve function/disability, patient satisfaction, and global perceived effect in adults with mechanical neck disorders. Patient satisfaction and perceived effect become important criteria that needs to be appraised in the literature to judge the treatment outcome (Gross et al., 2002, Gross, 2004). Perceived improvement reflects the improvement of all symptoms that occurred after a treatment (Hoving et al., 2002; Bronfort et al., 2004). Since different patients exhibit different symptoms about which they may have different concerns, they will only consider a treatment as successful if their individual concerns are addressed and improved by the treatment. For example, a patient may be more concerned about neck stiffness than pain per se; this patient’s perceived improvement may not be pain reduction but a relief of neck stiffness, improved neck mobility, or decreased muscle tension, etc. In other words, perceived improvement could be a

sensitive indicator to reflect one of the dimensions of the treatment outcome (Hoving et al., 2002). Patient satisfaction is another outcome measure that is centering on the individual patient (Deyo and Diehl, 1986; Hurwitz et al., 2004). It can be assessed with a broader scope besides treatment efficacy: care quality, interpersonal consideration, confidence on the treatment, and accountability of the health care providers (Phillips, 1999). A satisfied client or patient will always return to continue receiving care from this health care provider even if the immediate pain reduction X50% is not achieved. Pain reduction, perceived improvement, and patient satisfaction are three outcomes that are not mutually exclusive. In fact, those could mean the very same thing to some patients. However, using only one outcome may not address all the concerns in different patients and combining all three of them all together can be too restricted or partial. We had already set a high standard for each criterion, that was why we believed meeting one of the three criteria would be sufficient to define treatment success for this study. This study identified six important predictors including the ‘‘score of the Neck Disability Index o11.50’’, ‘‘having bilateral involvement pattern’’, ‘‘not performing sedentary work 45 h/day’’, ‘‘feeling better while moving the neck’’, ‘‘without feeling worse while extending the neck’’, and the ‘‘diagnosis of spondylosis without radiculopathy’’ for immediate responders to the cervical manipulation treatment. According to the odds ratios found in the regression analysis, the odds for patients with the initial Neck Disability Index score o11.50 obtaining a successful treatment are 3.84 times the odds for those who score 411.50, for a given combination of levels of the other characteristics. The odds of a successful single spinal manipulation for patients with bilateral involvement pattern were 4.40 times higher than for those without the bilateral pattern. ‘‘Sedentary work 45 h per day’’ came as an adverse prognostic factor in patients who received the cervical manipulation treatment (OR ¼ 9.07). With regards to the movement related factors, ‘‘feeling better while moving the neck’’ and ‘‘without feeling worse while extending the neck’’ were significantly associated with better treatment outcome (OR ¼ 9.42, 95% CI ¼ 2.15–41.37 and OR ¼ 5.85, 95% CI ¼ 1.85–18.52, respectively). Another significant predictor that was positively associated with immediate response to a single cervical manipulation was ‘‘without feeling worse while extending the neck’’. This means that patients who felt worse while extending the neck might not obtain immediate relief from the cervical manipulation. The odds of obtaining a successful manipulation for patients with a diagnosis of spondylosis without radiculopathy were 7.22 times higher than for those who had other diagnoses.


Previous literature has reported various factors associating with good prognosis for clinical course of neck pain, which included younger age, male gender, less pain, shorter duration of current episode, lower disability status at entry, not stressful work-related factors, and lower psychological stress (Hagberg and Wegman, 1987; Borghouts et al., 1998; Kjellman et al., 2002). Our results also revealed that lower disability status at entry, i.e. lower score of the Neck Disability Index, and the work demands not requiring prolonged sedentary work were significant factors for predicting immediate success of using cervical manipulation. However, age, gender, pain intensity, and duration of current episode, and psychological status did not show significant predictability in our study. Similar to the previous studies, most predictors were identified from the self-reported individual factors (Borghouts et al., 1998; Skargren and Oberg, 1998; Leclerc et al., 1999; Croft et al., 2001; Kjellman et al., 2002). Factors from physical examinations were relatively less powerful in predicting clinical course or treatment outcome in neck pain (Haas et al., 2003). Haas and colleagues found endplay assessment did not contribute to the same-day pain and stiffness relief observed in patients with neck pain receiving spinal manipulation. Further investigation is needed to determine the relationship between each predictor and the effects of cervical manipulation. The cumulative adjusted coefficient of determination (R2) of our final regression model was 0.50. The R2 value represents the percentage of the total variance in the dependent variable that can be explained by the independent variables. In other words, the six predictors explained 50% of the variance that determined whether the subject might benefit from a single session of cervical manipulation. The other half, or the unexplained variance may come from information not revealed in this study. It was interesting to note that psychosocial factors appeared unimportant in this study. It could be that the psychosocial aspects of neck pain were not related to the manipulative outcome in our subjects, or that the psychological instrument (CHQ12) used in the study was not sensitive to the neck pain sufferers. In this study, we used PLRs, pre- and post-prediction probability statistics to express the strength of the prediction model. PLR indicated the chance of the given finding on a test would occur in a patient with, as opposed to a patient without, the target outcome (Sackett, 1992; Dujardin et al., 1994). In our study, 60% of the study participants obtained immediate effects from a single manipulation treatment session. This meant that the pre-prediction probability of success of the treatment was 60%. In other words, the success rate of cervical manipulation on patients with neck pain in this study was 60%. If 3 predictors were present (PLR ¼ 1.93), the success probability could be raised to 74%. Furthermore, using 4 or more of the 6 identified

313

predictors from the initial evaluation (PLR ¼ 5.33), the post-prediction probability of successful manipulation would be raised to above 89%. These results implied that when a patient has at least 3 of the predictors identified in this prediction model, cervical manipulation should be attempted because the patient may have a chance of over 74% to respond immediately to the treatment. The increase of the response probability for the successful cervical manipulation can therefore be expected by using the prediction model. Our study has several limitations. First, reliability of the physical tests was not established on this specific study sample due to the nature of the study. Most patients came to the clinic seeking symptoms relief. Receiving no treatments for two visits was not acceptable to many of those who were suffering bodily pain. Although the reliability data might be sample specific, the assessor of the study performed all the tests according to standardized procedures reported in the previous study (Tseng et al., 2003) and was expected to perform the tests with similar reliability for this study sample. Second, the prediction rule derived in this study should only be applied to the immediate responses right after a single session of cervical manipulation. Particular interest in this study was to identify factors to help clinicians decide whether they should try cervical manipulation on the patient and how much the successful rate would be. Therefore, a single manipulation was chosen to avoid contamination of treatment effect with multimodal treatments (soft-tissue management, exercise, education, etc.) that usually followed. The result should not be generalized to predict the effect of a multimodal treatment regimen which is a more commonly practice model and is considered more beneficial to patients with neck pain (Gross et al., 2002). Third, the follow-up period was not sufficiently long. Studies exploring long-term effects need to be conducted in the future to identify the predictors in different follow-up periods after receiving cervical manipulation or any multimodal treatment combinations. This study was a first step towards identifying predictors for a single successful cervical manipulation. Further studies may include validation of this prediction rule with other samples, using a randomized controlled design to contrast predictors for manipulating the responders vs. nonresponders, or to assess the effectiveness of cervical manipulation vs. a sham treatment with different follow-up periods. Blindness of the outcome assessor is also needed to reduce measurement bias.

5. Conclusion Six important predictors were identified for predicting immediate responders of cervical manipulation in our



study. Some of them were similar to previous reports on prognostic factors for neck pain, but others emerged as new predictors. Dramatic increases of the responded probabilities of successful cervical manipulation were revealed by having 3 or more predictors identified from the prediction model in this study. These predictors and the prediction rules may significantly enhance the efficacy of clinical decision-making for selecting cervical manipulation as an appropriate intervention for patients with neck pain.

Appendix A. Cervical manipulation procedure 1. The patient laid down on the treatment table and relaxed as much as possible. 2. The manipulator glided each segment to either side of the entire cervical spine from the occiput to C7 in order to identify the manipulable lesions (i.e. the hypomobile segments). 3. Once a hypomobile segment was localized, the manipulator carefully flexed and sidebent the patient’s neck to lock the facet joints of other spinal segments until the barrier was reached. 4. A specific cervical manipulation with a high-velocity, low-amplitude thrust force was then exerted on the specific, manipulable lesion to gap the facet. 5. The manipulator continued to locate and perform the thrust technique to all the other hypomobile segments. 6. Only one thrust could be performed to each direction of the manipulable segment. 7. A treatment session usually ended within 5–10 min. Note: If any abnormal responses occurred, the treatment was stopped immediately for safety concerns.

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ARTICLE IN PRESS


Original article

A perspective for considering the risks and benefits of spinal manipulation in patients with low back pain John D. Childsa,, Timothy W. Flynnb, Julie M. Fritzc a

US Army-Baylor University Doctoral Program in Physical Therapy, 3151 Scott Rd., Rm 2307, Fort Sam Houston, TX 78234, USA b Department of Physical Therapy, Regis University, USA c Division of Physical Therapy, University of Utah and Clinical Outcomes Research Scientist, Intermountain Healthcare, USA Received 19 May 2004; received in revised form 30 July 2005; accepted 21 September 2005

Abstract The purpose of this study was to determine if patients who do not receive manipulation for their low back pain (LBP) are at an increased risk for worsening disability compared to patients receiving an exercise intervention without manipulation. One hundred and thirty-one consecutive patients with LBP were randomly assigned to receive manipulation and an exercise intervention (n ¼ 70) or an exercise intervention without manipulation (n ¼ 61). Patients were classified as to whether they had experienced a worsening in disability upon follow-up. Relative risk and number needed to treat (NNT) statistics and associated 95% confidence intervals (CI) were calculated. Patients who completed the exercise intervention without manipulation were eight (95% CI: 1.1, 63.5) times more likely to experience a worsening in disability than patients who received manipulation. The NNT with manipulation to prevent one additional patient from experiencing a worsening in disability was 9.9 (95% CI: 4.9, 65.3) and 4 weeks with manipulation was 11.6 (95% CI: 5.2, 219.2). The results of this study offer an additional perspective for considering the risks and benefits of spinal manipulation and help to inform the integration of current evidence for spinal manipulation into healthcare policy. Published by Elsevier Ltd. Keywords: Relative risk; Physical therapy; Manual therapy; UK BEAM

1. Introduction Studies examining the outcomes of spinal manipulation have resulted in relatively small effect sizes of modest clinical importance (Assendelft et al., 2003). For example, despite evidence from the United Kingdom Back Pain Exercise and Manipulation trial (UK BEAM) supporting the cost-effectiveness of incorporating spinal manipulation into best general practice care for patients with low back pain (LBP), the treatment effect was small (UK Beam Trial Team, 2004a, b). This raises concerns about the magnitude of the benefit to be gained if large healthcare delivery networks such as the National

Corresponding author. Tel.: +1 210 364 7410; fax: +1 210 579 2637.

1356-689X/$ - see front matter Published by Elsevier Ltd. doi:10.1016/j.math.2005.09.002

Health Service (NHS) were to implement the findings of this trial into routine clinical practice. The magnitude of the benefit to be gained by integrating manipulation into routine clinical practice for patients with LBP can be viewed from different perspectives and expressed with various statistics (McQuay and Moore, 1997). Reporting mean differences between groups characterizes the magnitude of the benefit of routinely offering manipulation for patients with LBP. An alternative perspective is provided by considering the magnitude of the risk of a public policy that does not routinely offer manipulation for patients with LBP. Examining the number needed to treat (NNT) statistic can enhance the interpretation of the results of a clinical trial by incorporating the level of risk to patients who do not receive manipulation therapy and the risk reduction that would be accomplished if

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policy were changed to provide patients with manipulation therapy (Nuovo et al., 2002). Another perspective to consider is that a small, but statistically significant effect size in a large sample such as the UK BEAM trial likely indicates that some patients improved substantially, while others improved little or not at all from the treatment. If the patients likely to receive substantial improvement from manipulation could be identified a priori, public policy incorporating a manipulation benefit could be made more efficient by directing practitioners to apply the treatment to those patients likely to achieve the best response. Many patients experience rapid improvement following an onset of LBP; however, some patients, perhaps as high as 75%, experience recurrent or worsening pain and disability (Croft et al., 1998; Carey et al., 1999). The primary risk to patients associated with an episode of LBP, therefore, appears to be experiencing prolonged or worsening disability. Given the enormity of direct and indirect costs associated with prolonged LBP disability (Hashemi et al., 1998; Fritz and George, 2002), examining the impact of an intervention such as manipulation on this risk would provide additional insight into its effectiveness and the potential implications associated with its implementation. We recently completed a randomized trial (Childs et al., 2004) that examined short- and long-term reductions in disability between patients receiving an intervention that included manipulation and exercise vs. patients receiving only an exercise intervention. Had we simply compared the overall outcomes of manipulation vs. an exercise intervention without manipulation, our results would have been similar to that of the UK BEAM study—detection of a statistically significant, but modest effect favouring manipulation. However, we examined our results from an alternative perspective that considered a subgroup of patients with LBP who were identified as either likely or unlikely to benefit from manipulation based on a clinical prediction rule. The treatment effects were about 70% greater in the subgroup of patients who fit the rule for predicting a favourable response to manipulation. These improvements were maintained at a 6-month follow-up and were associated with decreased healthcare utilization (Childs et al., 2004), prompting us to further examine the results. We performed a secondary analysis using data from our previously published randomized trial (Childs et al., 2004) to determine whether patients with LBP who do not receive manipulation are at an increased risk for worsening disability compared to patients who receive manipulation. The results may offer an additional perspective for considering the risks and benefits of spinal manipulation and help to inform the integration of current evidence for spinal manipulation into healthcare policy.

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2. Materials and methods One hundred and thirty-one patients between the ages of 18 and 60 with a primary complaint of LBP and who did not display ‘‘red flags’’ for a serious spinal condition were enrolled. At baseline, patients completed the Oswestry disability questionnaire and underwent a standardized physical examination that incorporated the assessment of each patient’s status on the spinal manipulation clinical prediction rule (Childs et al., 2004). Patients were randomly assigned to receive spinal manipulation plus an exercise intervention (manipulation group) or an exercise intervention without manipulation (exercise group). Patients in both groups were given advice to maintain usual activity within the limits of pain and received a total of five physical therapy sessions (Childs et al., 2004). Treatment received by the manipulation group differed from the exercise group only during the first two sessions, during which time the patients received a standardized manipulative technique and a range of motion exercise only (Childs et al., 2004). Beginning on the third session patients in the manipulation group completed the same exercise intervention as patients in the exercise group. The exercise intervention consisted of a lumbar spine strengthening programme targeting trunk musculature identified as important stabilizers of the spine and a low-stress aerobic exercise programme (Childs et al., 2004). According to intentionto-treat principles, we included all 131 patients in the analysis by carrying forward the last observation. More patients dropped out of the exercise group before both the 1-week (6 vs. 0 patients) and 4-week (4 vs. 2 patients) follow-ups (P ¼ :007). However, all patients reported non-study-related reasons for dropping out (i.e. time constraints, family issues, etc.) (Childs et al., 2004). To examine the risk of worsening disability, all patients were classified as to whether they experienced a worsening in disability. Patients whose Oswestry disability score increased 6 points or more, which corresponds to the minimum clinically important difference for this instrument (Fritz and Irrgang, 2001), were classified as having experienced worsening disability. Two-by-two contingency tables were generated based on treatment assignment (manipulation group vs. exercise group) and disability outcome (worsened vs. not worsened). We calculated w2 statistics, relative risk (RR) estimates, and absolute risk reduction (ARR) estimates and associated 95% confidence intervals (CI) to illustrate the risk of worsening disability from different perspectives (Simon, 2001; Barratt et al., 2004a). NNT statistics with 95% CI were calculated to determine the number of patients with LBP and a clinician must treat with manipulation to prevent one patient from experiencing a worsening in disability (Barratt et al., 2004b; Weeks and Noteboom, 2004). Similar procedures were repeated considering only the


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subgroup of patients who were positive on the prediction rule in an attempt to characterize the change in risk of worsening disability when considering only the subgroup of patients with a high probability of achieving a successful outcome from manipulation.

3. Results No differences were observed between treatment groups for any baseline variables (Childs et al., 2004). Among patients in the exercise group, 11% (7/61) experienced a worsening in disability at the 1-week follow-up compared to only 1% (1/70) in the manipulation group (P ¼ :017). The RR associated with a worsening in disability at the 1-week follow-up among patients who received exercise as compared to the group receiving manipulation was 8.0 (95% CI: 1.1, 63.5). The ARR at the 1-week follow-up was 10% (95% CI 2–21%). A similar pattern was observed at the 4-week outcome, but the results did not reach significance (Table 1). Among patients in the exercise group, 11% (7/ 61) were classified as having experienced a worsening in disability after 4 weeks, compared to 3% (2/70) of patients who received manipulation (P ¼ :052). The NNT with spinal manipulation to prevent one additional patient from experiencing a worsening in disability at the 1-week follow-up was 9.9 (95% CI: 4.9, 65.3) and this persisted at 4 weeks. The CIs around our risk estimates and NNT statistics are wide since our trial was not powered for this analysis. No one who was positive on the spinal manipulation clinical prediction rule and received manipulation experienced a worsening in disability; thus, the risk estimate and NNT statistic considering only this subgroup were indeterminate.

4. Discussion These data suggest that when viewed from an alternative perspective of reducing the risk of worsening disability, the decision not to provide manipulation for patients with LBP does not appear to be innocuous or

‘‘conservative’’. Furthermore, the results recognize the potential value of matching the use of manipulation to the subgroup of patients most likely to benefit. No patients who were positive on the prediction rule and received manipulation experienced a worsening in disability; thus, RR estimates and NNT statistics for this subgroup cannot be determined. The fact that no patients who were positive on the rule and received manipulation experienced a worsening in disability may be partially attributable to the relatively small number of patients meeting these criteria (n ¼ 23). Based on mere chance or some other confounding factor, we would expect that over time, the occurrence of worsening disability in a patient who is positive on the rule and receives manipulation would be observed. However, the implications are that not offering manipulation for at least this subgroup may be inconsistent with current best evidence and contribute to increased healthcare utilization and costs (Childs et al., 2004). In general, patients with LBP who received only exercise without manipulation were eight times more likely to experience a worsening in disability after 1 week than patients who received manipulation (Table 1). In addition to the RR, the risk difference, or ARR, provides another estimate of risk and represents the proportion of patients expected to experience a worsening in disability if they do not receive manipulation. The ARR at the 1-week follow-up was 10% (95% CI 2–21%). Viewed from this perspective, a 10% difference in effect might be considered modest; however, the magnitude of the proportional difference should be viewed in context of other factors such as the risk of harm, which is extremely low. It remains that for every 100 patients with LBP who receive manipulation, approximately 1–2 patients will experience a worsening in disability, compared to 11–12 patients that will worsen if they do not receive manipulation. The NNT suggests that only 10 patients need to be treated with manipulation to prevent one patient from experiencing a worsening in disability after 1 week. The risk of worsening disability among patients not receiving manipulation also did not substantially diminish over time. Patients receiving exercise without manipulation

Table 1 Number (per cent) of patients in each group who worsened in their clinical status at the 1- and 4-week follow-up 1 week

4 weeks

Worseneda

Did not worsen

Worsenedb

Did not worsen

Manipulation group (n ¼ 70)

1 (1%)

69 (99%)

2 (3%)

68 (97%)

Exercise group (n ¼ 61)

7 (11%)

54 (89%)

7 (11%)

54 (89%)

Improvement and worsening were defined as changes X6 points and p6 points in the ODQ, respectively. Otherwise, patients were classified as unchanged. Relative risk (RR) estimates and absolute risk reduction (ARR) statistics are reported. a 2 w ¼ 5:7 (P ¼ :017), RR ¼ 8.0 (95% CI: 1.1, 63.5) (EG vs. MG), RR ¼ .125 (95% CI: .02, .98) (MG vs. EG), ARR ¼ 10% (95% CI 2–21%). b 2 w ¼ 3:8 (P ¼ :052), RR ¼ 4.0 (.87, 18.6) (EG vs. MG), RR ¼ .249 (.05, 1.2) (MG vs. EG), ARR ¼ 9% (95% CI 0–20%).

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were still four times more likely to experience a worsening in disability 4 weeks after baseline (Table 1). Although this result was not statistically significant (P ¼ :052), a risk increase of this magnitude is likely of clinical importance. To assist primary care practitioners in quickly determining which patients are most likely to benefit from manipulation care, we analysed the rule’s accuracy considering only those criteria likely to be routinely assessed in primary care (acuity and location of symptoms). Patients with symptoms for less than 16 days and who did not have symptoms distal to the knee still had a 86% probability (positive likelihood ratio equal to 7.2) for achieving at least a 50% reduction in disability over a 1week period (Fritz et al., 2005). In our trial, 28% of patients in our trial met both of these criteria, suggesting that many patients may benefit from decision-making based on the rule in this practice setting (Fritz et al., 2005). This figure is likely conservatively low since the likelihood of meeting the criteria related to acuity would be greater in a primary care vs. physical therapy referral setting. Using a modified rule is particularly compelling in a busy primary care setting since this information can be easily gathered from a patient’s history in just a few seconds. Lack of practitioner training has been suggested to be a potential barrier for recognizing manipulation as a standard health benefit for patients with LBP. For example, it has been suggested that there are a lack of trained manipulative practitioners in the United Kingdom willing to work in the NHS (UK Beam Trial Team, 2004a), questioning the feasibility of making manipulation care generally available for all patients with back pain in the NHS. Access to a practitioner skilled in manipulation at the point of entry into the system would be ideal; unfortunately, only modest benefits have been shown when primary care physicians are trained to provide manual therapy interventions (Curtis et al., 2000). In light of recent evidence suggesting that practitioners with manual therapy specialty training tend to utilize these techniques more often (Hurley et al., 2005), referral processes should be streamlined to insure timely access to spinal manipulation if practitioners skilled in manual therapy are not available at the point of entry. However, if manipulation care is limited to the subgroup of patients most likely to experience the greatest improvement (roughly one-third of patients with back pain) (Childs et al., 2004; Fritz et al., 2004), this would eliminate the burden to make this treatment generally available for all patients with back pain. Another consideration in the effort to reduce barriers to accessing manipulation care is that many patients may not require multiple manual therapy techniques to achieve optimal results. The potential advantage is that practitioners could become proficient with a limited number of ‘‘core’’ techniques in a short amount of time. For example, patients in our trial assigned to the

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manipulation group only received two sessions of manipulation using a single, standardized technique performed by a physical therapist (Childs et al., 2004). Training in our study was limited to a brief hands-on training session, followed by a recommendation they practice the technique on their patients. The technique takes less than 30 s to perform, making it suitable for busy practice settings. We have also demonstrated that having more manual therapy experience in general, or previous experience with the specific technique used in our trial, did not contribute to improved outcomes (Whitman et al., 2004). Nonetheless, if manipulative practitioners are not available at the point of entry, patient care processes should be streamlined to insure timely access to manipulation care. Manipulation in general remains underutilized by some practitioners whose scope of practice includes manipulation (Armstrong et al., 2003), with concern regarding the risks being offered as the most common reason for infrequent utilization (Adams and Sim, 1998). However, the risk of serious complication from manipulation of the lumbar spine is extremely low (Assendelft et al., 1996), with estimates suggesting the risk of cauda equina syndrome is less than 1 per 100 million lumbar spine manipulations (Assendelft et al., 1996). In light of this information, combined with the recent data from the UK BEAM trial (UK Beam Trial Team, 2004a, b) and data from our study (Childs et al., 2004), an overly cautious position regarding the use of spinal manipulation for patients with back pain is not supported by the evidence.

5. Conclusion The results of this secondary analysis lend evidence to support the notion that the solution to small treatment effects lies in the development of subgrouping mechanisms that match patients to the treatment (or nontreatment) most likely to benefit them. Specifically, these data provide preliminary evidence suggesting that a health benefit that does not routinely offer spinal manipulation for patients with LBP may actually increase the likelihood for patients to experience a worsening in disability. Consideration of subgroups is necessary when considering the risks and benefits of spinal manipulation. These data may help to inform the integration of current evidence for spinal manipulation into healthcare policy and prompt practitioners to evaluate their current management algorithms for patients with LBP and make appropriate adjustments if warranted.

Acknowledgements The authors would like to acknowledge the physical therapy staff at the following sites for their assistance


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with data collection: (1) Wilford Hall Medical Center, Lackland Air Force Base (AFB); (2) Malcolm Grow Medical Center, Andrews AFB; (3) Wright-Patterson Medical Center, Wright-Patterson AFB; (4) Eglin Hospital, Eglin AFB; (5) Luke Medical Clinic, Luke AFB; (6) Hill Medical Clinic, Hill AFB; (7) F.E. Warren Medical Clinic, F.E. Warren AFB; and (8) University of Pittsburgh Medical Center Health System’s Centers for Rehab Services. This study was supported by a grant from the Foundation for Physical Therapy Inc. and the Wilford Hall Medical Center Commander’s Intramural Research Funding Program. Conflict of Interest. None of the authors of this manuscript have any relevant conflict of interest, financial or otherwise. Disclaimer. The opinions or assertions contained herein are the private views of the author (JDC) and are not to be construed as official or as reflecting the views of the US Air Force or Department of Defense.

References Adams G, Sim J. A survey of UK manual therapists’ practice of and attitudes towards manipulation and its complications. Physiotherapy Research International 1998;3(3):206–27. Armstrong MP, McDonough S, Baxter GD. Clinical guidelines versus clinical practice in the management of low back pain. International Journal of Clinical Practice 2003;57(1):9–13. Assendelft WJ, Bouter LM, Knipschild PG. Complications of spinal manipulation: a comprehensive review of the literature. Journal of Family Practice 1996;42(5):475–80. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies. Annals of Internal Medicine 2003;138(11):871–81. Barratt A, Wyer PC, Hatala R, McGinn T, Dans AL, Keitz S, et al. Tips for teachers of evidence-based medicine: 1. Relative risk reduction, absolute risk reduction and number needed to treat. Canadian Medical Association Journal 2004a;171(4):1–8. Barratt A, Wyer PC, Hatala R, McGinn T, Dans AL, Keitz S, et al. Tips for teachers of evidence-based medicine: 1. Relative risk reduction, absolute risk reduction and number needed to treat. Canadian Medical Association Journal 2004b;171(4):1–8. 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(2):157–64.

Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, et al. A clinical prediction rule to identify patients with low back pain who will benefit from spinal manipulation: a validation study. Annals of Internal Medicine 2004;141(12):920–8. Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E, Silman AJ. Outcome of low back pain in general practice: a prospective study. British Medical Journal 1998;316(7141):1356–9. Curtis P, Carey TS, Evans P, Rowane MP, Mills GJ, Jackman A. Training primary care physicians to give limited manual therapy for low back pain: patient outcomes. Spine 2000; 25(22):2954–60. Fritz JM, George SZ. Identifying psychosocial variables in patients with acute work-related low back pain: the importance of fearavoidance beliefs. Physical Therapy 2002;82(10):973–83. Fritz JM, Irrgang JJ. A comparison of a modified Oswestry low back pain disability questionnaire and the Quebec back pain disability scale. Physical Therapy 2001;81(2):776–88. Fritz JM, Childs JD, Flynn TW. Determining which patients with low back pain are likely to respond quickly to a physical therapy manipulation intervention. BMC Family Practice 2004. Fritz JM, Childs JD, Flynn TW. Pragmatic application of a clinical prediction rule in primary care to identify patients with low back pain with a good prognosis following a brief spinal manipulation intervention. BMC Family Practice 2005;6(1):29. Hashemi L, Webster BS, Clancy EA. Trends in disability duration and cost of workers’ compensation low back pain claims (1988–1996). Journal of Occupational and Environmental Medicine 1998;40(12): 1110–9. Hurley DA, McDonough SM, David BG, Dempster M, Moore AP. A descriptive study of the usage of spinal manipulative therapy techniques within a randomized clinical trial in acute low back pain. Manual Therapy 2005;10(1):61–7. McQuay HJ, Moore RA. Using numerical results from systematic reviews in clinical practice. Annals of Internal Medicine 1997; 126(9):712–20. Nuovo J, Melnikow J, Chang D. Reporting number needed to treat and absolute risk reduction in randomized controlled trials. Journal of the American Medical Association 2002;287(21): 2813–4. Simon SD. Understanding the odds ratio and relative risk. Journal of Andrology 2001;22(4):533–6. UK Beam Trial Team. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: cost effectiveness of physical treatments for back pain in primary care. British Medical Journal 2004a;329. UK Beam Trial Team. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. British Medical Journal 2004b;329. Weeks DL, Noteboom T. Using the number needed to treat in clinical practice. Archives of Physical Medicine and Rehabilitation 2004;85:1729–31. Whitman JM, Fritz JM, Childs JD. The influence of experience and specialty certifications on clinical outcomes for patients with low back pain treated with a standardized physical therapy management program. Journal of Orthopaedic and Sports Physical Therapy 2004;34(11):662–72.

ARTICLE IN PRESS


Technical and measurement report

Inter-tester reliability of passive intervertebral and active movements of the cervical spine Sara R. Pivaa,, Richard E. Erhardb,c, John D. Childsd, David A. Browderd a

School of Health and Rehabilitation Sciences, Department of Physical Therapy, University of Pittsburgh, 6035 Forbes Tower, Pittsburgh, PT 15260, USA b University of Pittsburgh Medical Center Health System’s Spine Specialty Center, USA c School of Health and Rehabilitation Sciences, Department of Physical Therapy, University of Pittsburgh, USA d Department of Physical Therapy, Wilford Hall Medical Center, San Antonio, TX, USA Received 4 February 2004; received in revised form 1 August 2005; accepted 21 September 2005

Abstract Measurements of active range of motion (AROM) and passive intervertebral movements (PIM) of the cervical spine are frequently used for patients with neck pain. However, there is a paucity of studies that investigate the psychometric properties of these measurements. Objectives of this study were to: (1) determine the inter-tester reliability of PIM, AROM, and the effects of AROM on symptom provocation; (2) establish the minimal detectable change (MDC) in cervical AROM; and (3) determine the association between AROM and disability. Thirty subjects (age 41712) with neck pain participated in this study. Two masked examiners performed the measurements during the same testing session. PIM was assessed manually and recorded as hypomobile or normal. AROM was measured in degrees with a gravity goniometer. The effect of AROM on patient’s symptoms was recorded as no change, decreased, increased, centralization, or peripheralization. Measures of AROM had moderate to substantial reliability (.78–.91) and resulted in a MDC adequate for clinical use (from 91 to 161). The effect of AROM on symptom provocation resulted in Kappa values that ranged from slight to substantial (.25–.87). Measures of PIM resulted in substantial and moderate reliability of assessing occipital–atlas mobility, tenderness of the transverse processes of atlas, and symptom provocation during PIM testing of the lower cervical segments. Fair Kappa values were observed during judgment of mobility in the C2 segment and symptom reproduction during PIM of C2 and C5. The additional PIM had Kappa values that ranged from none to slight. Low prevalence of positive findings likely resulted in an artificial deflation of the Kappa statistic during some PIM measures. Measures of AROM in saggital and transverse planes were associated with disability scores (r ¼ :43 and :40; respectively). Findings are relevant to the planning of future studies to establish the criterion validity of these tests to guide the selection of interventions and establish prognosis in patients with neck pain. r 2005 Elsevier Ltd. All rights reserved. Keywords: Consistency; Measurement; Neck pain; Repeated measures study

1. Introduction Measurements of active range of motion (AROM) and passive intervertebral movements (PIM) of the cervical spine are routinely used as part of the physical Corresponding author. Tel.: +1 412 383 6712; fax: +1 412 383 6629. E-mail address: [email protected] (S.R. Piva).


examination of patients with neck pain. Tests of AROM and PIM are used to identify impairment in motion and possible segmental level that may be the source of the patient’s complaint.(Magee, 1997) Measurements of AROM are performed to determine limitations in motion, patient’s willingness to move, and to identify the range of movement in which the patient reports symptoms. During AROM examiners note the quantity, quality, and provocation of the patient’s complaints in


S.R. Piva et al. / Manual Therapy 11 (2006) 321–330

each direction of movement. (Magee, 1997) The effect of each movement on the patient’s symptoms is also useful to guide treatment decisions (i.e. knowing whether the symptoms increase or decrease or whether the symptoms centralize or peripheralize, etc.) (McKenzie, 1990; Werneke and Hart, 2001). It helps clinicians understand which movements should be avoided and which movements should be used during treatment. For example, centralization of the patient’s symptoms during flexion provides some indication that exercises in a flexed position may be beneficial. PIM are performed to assess the amount of motion available at each spinal segment and the provocation of symptoms during movement of each segment of the cervical spine. PIM are necessary for normal physiologic a range of motion to occur. (Maitland, 1986) It is believed that the decreased PIM motion (hypomobility), which may be caused by muscle spasm or ligamentous tightness, may be associated with neck dysfunction. (Erhard, 1996; Childs et al., 2003) In general, previous studies examining the reliability of AROM measurements of the cervical spine have demonstrated acceptable levels of reliability. (Jordan, 2000; Mannion et al., 2000; Petersen et al., 2000; Solinger et al., 2000) However, many of these studies investigated reliability in asymptomatic individuals, (Youdas et al., 1991; Nilsson, 1995; Hole et al., 2000) others performed inappropriate statistics to estimate reliability, (Kadir et al., 1981; O’Driscoll and Tomenson, 1982; Capuano-Pucci et al., 1991) some used only visual estimation of movements, (Viikari-Juntura, 1987; Pool et al., 2004) and some used measurement tools not practical for clinical use (Rheault et al., 1992). Few studies used simple measurement tools such as the universal goniometer or gravity goniometer (Tucci et al., 1986; Youdas et al., 1991). Furthermore, these studies have not reported the precision or the error associated with these measurements. A systematic review that evaluated 21 studies that assessed the reliability of tools to measure cervical range of motion concluded that more rigorous studies were necessary (Jordan, 2000). A more recent study reported acceptable reliability for measures of cervical AROM when a gravity goniometer was used and, to our knowledge, this is the only study that determined the error associated with their measurements (Wainner et al., 2003). Not many studies have investigated the reliability of assessing PIM. To date, only one study investigated the inter-observer reproducibility of the patient’s pain response to movement, and a small number of studies have reported on the reliability of PIM. Pool et al. (2004) performed a study in which an 11-point numerical rating scale was used to report pain response during movement. In addition to assess the reliability of patient’s pain response, Pool et al. studied the consistency of assessing PIM from the occiput to T2. They

reported Kappa values from .09 to .63. However, definitions of the assessment techniques were not clear. They only described that movements between the occiput and atlas used a flexion technique, assessment of atlas/axis mobility used a rotation technique, and segments from C2 to T2 included fixation of the lower segmental level and lateral flexion to the right and to the left (Pool et al., 2004). Fjellner et al. (1999) studied PIM on normal healthy subjects. Therefore, their results may not apply to patients with neck pain. Smedmark et al. (2000) studied inter-tester reliability in assessing PIM of four tests of the cervical spine: C1/C2 rotation, C3/C4 lateral flexion, C7 flexion/extension, and movement of the first rib. They reported Kappa values from .28 to .43. In addition to further investigate the reliability of testing AROM, PIM, and symptom provocation during movement, it would be helpful to determine if measures of AROM are associated with measures of disability, thus helping to establish validity for these measurements. Therefore, the objectives of this study were to: (1) determine the inter-tester reliability of PIM, AROM, and the effects of AROM on symptom provocation; (2) establish the minimal detectable change (MDC) in cervical AROM; and (3) determine the association between AROM and disability.

2. Methods This study utilized a single group repeated measures design. 2.1. Subjects This study consisted of consecutive patients referred to the University of Pittsburgh Medical Center Health System’s Spine Specialty Center with a primary complaint of neck pain. The following inclusion criteria were used: (1) age between 18 and 75 years; (2) presence of symptoms in the neck, scapula, or head areas observed on the pain diagram; (3) less than 60% score on the Neck Disability Index (NDI) (Vernon and Mior, 1991). Based on our clinical experience, scores above 60% indicate that the patient is experiencing a high level of disability in which repeating the examination procedure for reliability purposes could excessively exacerbate the patient’s symptoms. Patients were excluded if the neck pain was associated with inflammatory or congenital anomalies, presence of dizziness, or neurological signs and symptoms. This study was approved by the University of Pittsburgh Institutional Review Board, and all subjects provided informed consent prior to participate in the study. Thirty subjects with neck pain agreed to participate.

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2.2. Measure of disability The NDI was used to quantify the level of disability. The NDI is a reliable, valid and frequently used condition-specific disability scale for patients with neck pain (Vernon and Mior, 1991; Stratford et al., 1999). The disability score from the NDI was used in the assessment of the relationship between disability and AROM. 2.3. Measurements of AROM and PIM 2.3.1. Cervical AROM Extension, flexion, rotation in full flexion, left and right lateral bending, and left and right rotation were tested in the order as described. Active movements were measured in degrees using a gravity goniometer (MIE Medical Research Ltd, Leeds, UK). Measures of extension, flexion, rotation in full flexion, and lateral bending were performed with the patient seated on an examination table. Before initiating measurements, subjects were asked to ‘‘sit up and look straight ahead’’. Measurement of rotation was performed with the patient positioned in supine. Prior to the measurements, the gravity goniometer was zeroed by placement on a horizontal surface. Extension was measured by placing the gravity goniometer on the top of the patient’s head in the saggital plane. Patients were asked to bend the head backward as far as possible (Fig. 1). Flexion was measured with the gravity goniometer in the same position as for the extension measurement. The gravity goniometer was not removed from the patient’s head during extension and flexion. Patients were asked to bend the head forward as far as possible and try to touch the chest with the chin (Fig. 2). Rotation in full flexion was used to grade the atlantoaxial rotation. Patients were in full neck flexion and the gravity goniometer was positioned on the back of patient’s head in the frontal plane. Patients were asked to rotate the head to the left and right as far as possible (Fig. 3). Lateral bending was measured with the gravity goniometer in the frontal plane on the top of the patient’s head. To measure lateral bending, patients were asked to touch the left and right ear to the left and right shoulder respectively. Rotation was measured with the patient in the supine position with the head resting on a pillow. To allow pure axial rotation, the patients were permitted to lift their head of the pillow before rotation. The gravity goniometer was in the transverse plane on the top and midline of the forehead. To measure rotation, patients were asked to rotate the head to the left and after to the right as far as possible (Fig. 4).

Fig. 1. Measurement of active neck extension.

Fig. 2. Measurement of active neck flexion.

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2.3.2. Effect of movement on symptoms The effect of AROM on participant’s symptoms was recorded such as: no effect, increases symptoms, decreases symptoms, centralizes symptoms, or periph-

Fig. 3. Measurement of active neck rotation in full flexion.

eralizes symptoms. Centralization is the patient report that the neck movement has caused the symptoms to move from an area more distal or lateral in the arms or shoulder girdle to a location more central or near the midline position in the cervical spine. Alternatively, peripheralization is the patient’s report that the neck movement moved the symptoms from an area more proximal in the cervical spine to an area more distal or lateral (McKenzie, 1990; Werneke and Hart, 2001). 2.3.3. Cervical PIM PIM testing was used to qualitatively determine the amount of motion that occurred at each spinal segment. PIM for the cervical spine involves the palpation of each motion segment during passive movement of the head and neck. Measurements were performed with the patient in the supine position and in the order described. Mobility was recorded as: (1) normal; or (2) hypomobile. Pain reproduction during each movement was recorded as: (1) pain; (2) no pain. Atlanto-occipital joint—lateral glide: The examiner held the patient’s head with a neutral relationship between the occiput and atlas and performed a left lateral-glide of the occiput on atlas, followed by a right lateral-glide (Erhard, 1996; Magee, 1997). If decreased mobility was noted to one side compared to the opposite side, the test was considered positive for hypomobility. Atlanto-occipital joint—lateral displacement of axis: The examiner stabilized the axis by placing the left thumb on the left side of the spinous process of the axis. Then the examiner used the right hand to laterally bend the head to the right. The test was then repeated to the

Fig. 4. Measurement of active neck rotation in supine.


opposite side (Erhard, 1996). If decreased mobility was noted to one side compared to the opposite side, the test was considered positive for hypomobility. Tenderness over the transverse processes of atlas: The examiner gently palpated the transverse processes of the atlas and recorded the presence of symptoms on either side as positive. Atlanto-axial joint—full flexion: The examiner supported patient’s head with both hands and passively moved the patient’s neck into maximal flexion. While maintaining this position, the patient’s head was rotated first to the left and then to the right (Erhard, 1996). If the rotation to one side was decreased compared to the opposite side, the test was considered positive for hypomobility. Atlanto-axial joint—full lateral bending: The examiner passively moved the patient’s neck into end range of right lateral-bending. While maintaining this position, the patient’s head was rotated to the left. The test was then repeated to the opposite side (Erhard, 1996). If the rotation to one side was decreased compared to the opposite side, the test was considered positive for hypomobility. Mid and lower cervical: The examiner stood at the head of the examination table and used the abdomen to exert a constant pressure against the apex of the patient’s skull to stabilize the head but allow free neck movements. Each spinal level beginning at C2 was glided laterally to the left and right. The examination progressed inferiorly to C6. If decreased mobility was noted to one side compared to the opposite side, the test was considered positive for hypomobility (Erhard, 1996; Hertling and Kessler, 1996; Magee, 1997). 2.4. Procedures Patients attended one testing session lasting approximately 20 min. During the testing session, each patient remained inside an examination room. To warrant examiner’s masking, the two examiners entered the examination room independently, performed and recorded the measurements, and then left the room. The assessment results were not shared with the other examiner. To minimize the possibility that the PIM by the first examiner would cause a true change in the patient’s symptoms and restriction in motion, both examiners performed the AROM tests before the PIM. Therefore, each examiner entered the room twice. The AROM and PIM testing were always performed in the same order. The order of the examiners was varied for each new patient (i.e. examiner 1 performed the exam first for subject 1; examiner 2 performed the exam first for subject 2, and so on). Examiners were trained in manual therapy and had different levels of experience (10 and 2 years, respectively). Examiners and investiga-

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tors met once during a 2-h session before data collection to review operational definitions and practice the procedures to ensure standardization. 2.5. Sample size estimation The sample size was calculated a priori using SamplePowerTM statistical software (SPSS Inc., Chicago, Illinois) (SPSS, 1998) based on the calculation of Cohen Kappa coefficients on a dichotomous variable (i.e. hypomobile or normal). To ensure sufficient statistical power to achieve a lower bound of the 95% confidence interval for Kappa of 0.30, assuming Kappa would be equal to 0.60, we would need a sample size of 30 subjects (Cohen, 1988). 2.6. Data analysis Descriptive statistics, including frequency counts for categorical variables and means and standard deviations for continuous variables were calculated to summarize the data. Cohen’s Kappa statistic and the associated 95% confidence intervals were used to calculate inter-tester reliability of the classification of mobility and presence of pain during the PIM, and the effect of AROM on the patient’s symptoms (Cohen, 1960; Simel et al., 1991). The agreement of the effect of AROM on the patient’s symptoms was based on both examiners placing the patient in the same category of the five possible ones (e.g. both say increases symptoms; or both say centralizes symptoms). Intra-class correlation coefficient (ICC), formula 2,1, and its 95% confidence interval were calculated to determine the inter-tester reliability for measurements of cervical AROM (Shrout and Fleiss, 1979; Simel et al., 1991). Values less than 0.10 indicate virtually no agreement; 0.11–0.40 indicate slight agreement; 0.41–0.60 indicate fair agreement; values between 0.61 and 0.80 indicate moderate agreement; and values greater than 0.81 indicate substantial agreement (Shrout, 1998). The results of the reliability analyses were used to calculate the standard error of measurement (SEM) and the MDC. The SEM was calculated as sdO1r, where r is the test–retest reliability coefficient and sd is the standard deviation of the combined scores of both examiners (Stratford and Goldsmith, 1997). The MDC was calculated as 1.96 O2 SEM (Portney and Watkins, 1993). In this formula 1.96 is the standard normal score associated with a two-tailed 95% confidence interval and the O2 is included to reflect the fact that there is measurement error associated with both the first and second repeated measures when calculating test–retest reliability. The Pearson correlation coefficient was calculated to determine the association between the NDI scores and AROM.


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3. Results Demographic characteristics of the 30 subjects who participated in the study are reported in Table 1. Means and standard deviations, ICC values, the corresponding SEM and MDC values of AROM measurements are depicted in Table 2. The ICC values for measures of AROM ranged from moderate to substantial (from .78 to .91) and the respective MDC values varied from 91 to 161. Kappa values for symptom reproduction during AROM are also depicted in Table 2. Kappa values of right rotation in flexion and left lateral bending were only slight. Symptom reproduction during

Table 1 Summary statistics of participants Number ¼ 30

Neck pain patients

Gender Age

60% female 41.5 41 (12)

Median Mean (SD)

Race

87% White 7% Afro-american 3% Hispanic 3% Asian

Pain (Numeric pain scale)

Median Mean (SD)

4.5 4.7 (2.4)

NDI

Median Mean (SD)

20 24.3 (14.8)

Gender and race data is reported as a percentage of participants, whereas age, pain, and Neck Disability Index (NDI) data are reported as median, mean, and standard deviation (SD).

flexion had a substantial Kappa value (.87). The additional Kappa values of symptom reproduction were moderate (ranged from .65 to .76). Kappa values, percentage of agreement, and prevalence of positive findings for measurements of PIM are reported in Table 3. Kappa values for PIM were substantial for occipital-atlanto joint hypomobility tested with side glides (.81) and tenderness over the transverse processes of atlas (.83). Kappa values were moderate for symptom reproduction during test of atlanto–axial joint in full lateral flexion (.61) and symptom reproduction during PIM of C4 and C6 (.65 and .76, respectively). Fair Kappa values were observed during judgment of mobility in the C2 segment (.46) and symptom reproduction during PIM of C2 and C5 (.42 and .55, respectively). Other PIM tests demonstrated slight or no agreement. Increased levels of disability on the NDI were fairly associated with decreased total saggital plane AROM (flexion+extension) (r ¼ :43) and total transverse plane AROM (left rotation+right rotation) (r ¼ :40).

4. Discussion An important element of the validity of measurements, and the subsequent ability to accurately interpret these measurements, relies on the evidence of satisfactory reliability and measurement error (Hains et al., 1998). Poor reliability and high levels of measurement error reduce the usefulness of a test and limit the extent to which test results can be generalized (Hains et al., 1998). This study has shown that measures of cervical

Table 2 Means, standard deviations, ICC, SEM and MDC values for measures of AROM; and Kappa values, and percentage of agreement between raters for symptom reproduction during AROM N ¼ 30

Mean (SD)a (degrees)

ICCb (95% CI) AROM

SEMc (degrees)

MDCd (degrees)

Kappa (95% CI) symptom reproduction

Agreement

Extension Flexion Le rotation in flexion Rf rotation in flexion L lateral bending R lateral bending L rotation R rotation

48 (15) 60 (13) 39 (10)

.86 (.73: .93) .78 (.59: .89) .89 (.78: .95)

5.6 5.8 3.2

16 16 9

.65 (.54: .76) .87 (.81: .94) .69 (.59: .78)

83% 93% 83%

39 (13)

.78 (.60: .89)

5.3

15

.25 (.12: .39)

63%

39 41 68 68

.85 .87 .91 .86

4.2 3.7 4.1 4.8

12 10 11 13

.28 .75 .74 .76

63% 87% 87% 87%

a

(11) (11) (13) (14)

(.70: (.75: (.82: (.74:

.92) .94) .96) .93)

(.15: (.66: (.64: (.67:

Means and SDs are based on rater 1 whilst the SEM and MDC are based on the combined raters’ scores. Intraclass correlation coefficient. c Standard error of measurement. d Minimum detectable change. e Left. f Right. b

.41) .84) .84) .84)


327

Table 3 Kappa values, percentage of agreement between raters, and prevalence of positive tests for measurements of PIM

Occipital-atlanto joint—lateral glide Occipital-atlanto joint—lateral displacement of axis Tenderness over transverse processes of atlas Atlanto-axial joint—full flexion Atlanto-axial joint—full lateral flexion C2 C3 C4 C5 C6

Mobility Pain Mobility Pain Mobility Pain Mobility Pain Mobility Pain Mobility Pain Mobility Pain Mobility Pain Mobility Pain

Kappa (95% CI)

Agreement

Prevalence

.81 .32 .35 .35 .83 .21 .36 .30 .61 .46 .42 .25 .29 .27 .65 .18 .55 .07 .76

93% 77% 90% 83% 93% 59% 68% 64% 89% 76% 76% 62% 66% 63% 83% 63% 79% 77% 92%

27% 27% 10% 17% 30% 63% 54% 59% 63% 38% 31% 52% 45% 50% 48% 40% 41% 19% 23%

(.72: .91) (.15:. 49) (.08: .62) (.15: .55) (.74: .92) (.08: .34) (.24: .49) (.17: .43) (.5: .72) (.33: .59) (.28: .56) (.12: .38) (.16: .43) (.13: .40) (.54: .76) (.03: .33) (.43: .67) (.34: .20) (.64: .87)

Kappa is calculated for mobility (normal or hypomobile) and pain (pain or no pain).

AROM performed with a gravity goniometer are reliable and acceptable for clinical use. Reliability refers to the consistency of a measurement to yield the same results when the testing procedure is repeated on a specific population and the construct measured by the test has not changed (Guyatt et al., 1992; Shrout, 1998). Interpretation of the confidence intervals around the ICC values for cervical AROM leads to the conclusion that, even considering the worst-case scenario (lower boundaries of the 95% CI ¼ .6), the reliability of any cervical AROM measured with a gravity goniometer is still satisfactory for clinical use. Measurement error, determined in this study by calculating the MDC, provides a threshold for interpreting the measurements over time. For example, when the AROM value for extension or flexion changes more than 161, one can be reasonably confident that true change has occurred beyond that which can be attributable to measurement error. Knowledge of the MDC is essential when investigating the effect of interventions on change in cervical AROM in patients with neck pain. Our results of reliability of cervical AROM were similar to prior studies that investigated patients with neck dysfunction. Tucci et al. (1986) reported ICC values from .80 to .91 and Wainner et al. (2003)reported ICC values from .63 to .84 . Our values of measurement error were similar to the results reported by Wainner et al. (2003) (SEM from 4.61 to 7.31). No previous studies have reported the MDC. In addition to the reliability and precision of measurement, understanding the relationship between cervical AROM and measures of disability helps to

establish the validity of AROM measurement and can help clinicians interpret the meaning of this measurement (Hains et al., 1998). Therefore, we tested if the measures of AROM were associated with disability scores. Although the associations were only fair, (Portney and Watkins, 1993) explaining no more than 18% (r2 ¼ .432) of the variability in disability, the results seem to indicate that physical therapists should pay attention to changes in total saggital and transverse planes of motion when assessing patients with neck pain. Improvement in AROM in these planes will probably be relevant and may reflect in better function. These relationships make empirical sense, since adequate range of motion in the saggital and transverse planes are required in most activities of daily living such as desk or computer work, driving, housekeeping, grooming, and eating. The results of this study indicate that Kappa values for symptom reproduction during AROM can be consistently reproduced and assessed for movements in the saggital (flexion and extension) and transverse planes (rotations). However, right rotation in full flexion and left lateral bending has low reliability. Because we cannot explain why left rotation in flexion and right lateral bending had better reliability values than the same movements to the contralateral side, we advise caution regarding interpretation of the consistency of measuring symptom reproduction during rotation in flexion and lateral bending in general. During clinical practice we have noticed more discrepancy in symptom reproduction during repeated lateral bending than during movements in the saggital or transverse planes.



During repeated lateral bending sometimes the patients report local symptoms whereas at other times the symptoms radiate to the arm or show no change at all. Therefore, it may be that the symptoms produced during movements of lateral bending and rotation in flexion truly change when the test is repeated. Our results are comparable to the ones reported by Pool et al. (2004). They recorded pain reproduction using an 11-point pain scale and calculated reliability using the ICC. The study reported ICC of .71 for provoked pain in extension, .63 for flexion, .70 for right rotation, .66 for left rotation, .65 for right lateral bending and .45 for left lateral bending. Rotation in full flexion was not investigated in that study (Pool et al., 2004). We proposed to test AROM of neck rotation in full flexion to grade atlanto-axial rotation. Although the reliability of this measurement was good, we are not sure if this test really measures atlanto-axial rotation or atlanto-axial dysfunction. We theorize that in full neck flexion, because the lower cervical spine segments are in a fully opened position, the additional movement in rotation would have to come from the upper neck, more likely the atlanto-axial joint (Hertling and Kessler, 1996; Bogduk and Mercer, 2000). We have not observed any association between this test and the traditional PIM to test the atlanto-axial joint in full flexion (Hertling and Kessler, 1996). Because this study was not intended to test diagnostic accuracy, we cannot suggest these tests are specific to the hypothesized spinal segments or dysfunctions. Our results for the PIM of the upper neck indicate that the hypomobility in the occipital-atlanto joint can be consistently reproduced and assessed during lateral glides of the occiput on the atlas (Kappa of .81, agreement of 93%) and during lateral bend of the head with a fixed axis (Kappa of .35, agreement of 90%). This later measure of PIM showed a high percentage of agreement between examiners but low Kappa coefficients. This was probably due to low prevalence of positive findings (10%) (Table 3). The low prevalence of positive findings of the lateral displacement of axis likely resulted in an artificial deflation of the Kappa statistic. The Kappa coefficient is influenced by the prevalence of the attribute (e.g. a disease or clinical sign). If the prevalence is high, chance agreement is also high and kappa is reduced accordingly (Sim and Wright, 2005). To overcome this problem and have a better distribution of positive findings, future studies should investigate upper cervical PIM using only patients with apparent upper neck complaints. In addition, in this study the patient’s pain response may have also influenced the consistency of measures of mobility during PIM of the occipital-atlanto joints. Tenderness over the transverse processes of atlas was reliable. Because the transverse processes of atlas are generally tender, we clarify that we considered positive

for tenderness when the palpation reproduced the same symptom that the patient was experiencing. Therefore, this test may be helpful to identify the source of symptoms. Regarding the atlanto-axial tests of mobility, low reliability was found in all techniques used: rotation during full neck flexion or rotation during full neck lateral flexion. The low reliability cannot be explained by the prevalence of positive findings, since around 60% of the patients had positive tests. The presence of pain during atlanto-axial joint test using the technique of rotation with the neck in full lateral flexion had a moderate reliability, with a fair lower bound of the 95% CI (.5). We believe this moderate reliability is due to the consistency of pain reproduction during the full passive lateral flexion rather than the rotation component added at the end of the movement. Regarding the reliability of PIM for mobility and pain in the mid and lower neck, we observed that judgments of hypomobility were not consistent. Since we used procedures to minimize the possibility that the PIM by the first examiner would cause a true change in the patient’s restriction in motion to the next examiner, we believe that consistency of mobility findings during these tests may not be attainable. Although true change in segmental restriction may play a role, it is a factor not easy to control. In addition, the agreement between the testers was relatively low, which supports the low Kappa values. On the other hand, symptom reproduction has shown fair to moderate reliability in the lower segments of C4–C6. Therefore, it may be that during the PIM tests, clinicians should somewhat rely on symptom reproduction of the lower neck when making treatment decisions. While we cannot do direct comparison of the reliability results for PIM between our results and other studies because the techniques used for testing were different, in general, we have found better reliability for PIM than prior studies (Fjellner et al., 1999; Smedmark et al., 2000; Pool et al., 2004). Some may argue that for the mobility classification we only used the categories hypomobility or normal. We did not classify mobility as hypermobility because in everyday practice when we perform PIM of the neck we look predominantly for hypomobility of one segment relative to the other segments. In this study, hypomobility was defined as when decreased mobility was noted to one side compared to the opposite side. Therefore, we do not discard the possibility that in some segments which were classified as having normal mobility may have shown some increased mobility. We caution the reader that some of these tests with a somewhat lower reliability coefficient may demonstrate useful validity in future investigations. To date, there is no accepted reference standard of cervical dysfunction with which to validate these tests and measures as useful diagnostic tools. However, instead of investigating the potential diagnostic accuracy of these tests, future


studies could establish the criterion validity of these tests to guide the selection of interventions and establish prognosis in patients with neck pain.

5. Conclusions Cervical spine AROM measurement demonstrated moderate to substantial inter-tester reliability and resulted in a MDC adequate for clinical use. The effect of AROM on symptom provocation also resulted in moderate to substantial reliability for tests of symptom reproduction for cervical flexion and rotation. Measures of PIM resulted in substantial and moderate reliability of assessing occipital-atlas mobility, tenderness of the transverse processes of atlas, and symptom provocation during PIM testing of the lower cervical segments. Low prevalence of positive findings likely resulted in an artificial deflation of the Kappa statistic during some PIM measures. Measures of AROM in the saggital and transverse planes were significantly associated with disability scores. Findings are relevant to plan future studies to establish the criterion validity of these tests to guide the selection of interventions and establish prognosis in patients with neck pain. Disclaimers The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the US Air Force or Department of Defense.

References Bogduk N, Mercer S. Biomechanics of the cervical spine. I: normal kinematics. Clinical Biomechanics 2000;15(9):633–48. Capuano-Pucci D, Rheault W, Aukai J, Bracke M, Day R, Pastrick M. Intratester and intertester reliability of the cervical range of motion device. Archives of Physical Medicine And Rehabilitation 1991;72(5):338–40. Childs JD, Piva SR, Whitman JM. Lower cervical spine. In: Physical Therapy for the cervical spine and temporomandibular joint. Home study course 13.3, Orthopaedic Section of the American Physical Therapy Association, La Crosse, WI. 2003. Cohen J. A coefficient of agreement for nominal scales. Educational and Psychological Measurement 1960;20:37–46. Cohen J. Statistical power analysis for the behavioral sciences. Hillsdale: Lawrence Erlbaum Associates, Inc.; 1988. Erhard RE. Manual therapy in the cervical Spineorthopedic. Physical therapy home study course. American Physical Therapy Association, Orthopaedic Section. 1996. Fjellner A, Bexander C, Faleij R, Strender LE. Interexaminer reliability in physical examination of the cervical spine. Journal of Manipulative and Physiological Therapeutics 1999;22(8):511–6. Guyatt GH, Kirshner B, Jaeschke R. Measuring health status: what are the necessary measurement properties? Journal of Clinical Epidemiology 1992;45(12):1341–5. Hains F, Waalen J, Mior S. Psychometric properties of the neck disability index. Journal of Manipulative and Physiological Therapeutics 1998;21(2):75–80.

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Hertling D, Kessler RM. Management of common musculoskeletal disorders, 3 ed. Philadelphia: Lippincott; 1996 Chapter 17, p. 540. Hole DE, Cook JM, Bolton JE. Reliability and concurrent validity of two instruments for measuring cervical range of motion: effects of age and gender. Manual Therapy 2000;1(1):36–42. Jordan K. Assessment of published reliability studies for cervical spine range-of-motion measurement tools. Journal of Manipulative and Physiological Therapeutics 2000;23(3):180–95. Kadir N, Grayson MF, Goldberg AAJ, Swain MC. A new neck goniometer. Rheumatology and Rehabilitation 1981;20:219–26. Magee DJ. Orthopedic physical assessment. Philadelphia: Saunders Co; 1997 Chapter 1, p. 9 & Chapter 3, p. 137. Maitland GD. Vertebral manipulation, 5th ed. Sydney, New South Wales, Australia: Butterworths; 1986. Mannion AF, Klein GN, Dvorak J, Lanz C. Range of global motion of the cervical spine: intraindividual reliability and the influence of measurement device. European Spine Journal 2000;9(5):379–85. McKenzie RA. Cervical and thoracic spine: mechanical diagnosis and therapy. Minneapolis: Orthopaedic Physical Therapy Products; 1990. Nilsson N. Measuring passive cervical motion: a study of reliability. Journal of Manipulative and Physiological Therapeutics 1995; 18:293–7. O’Driscoll SL, Tomenson J. The cervical spine. Clinics in Rheumatic Diseases 1982;8:617–30. Petersen CM, Johnson RD, Schuit D. Reliability of cervical range of motion using the OSI CA 6000 spine motion analyser on asymptomatic and symptomatic subjects. Manual Therapy 2000; 5(2):82–8. Pool JJ, Hoving JL, de Vet HC, van Mameren H, Bouter LM. The interexaminer reproducibility of physical examination of the cervical spine. Journal of Manipulative and Physiological Therapeutics 2004;27:84–90. Portney LG, Watkins MP. Foundations of clinical research: applications to practice. Stamford: Appleton & Lange; 1993 [Chapter 5, p. 58, and Chapter 26, p. 523–24]. Rheault W, Albright B, Byers C, Franta M, Johnson A, Skowronek M. Intertester reliability of the cervical range of motion device. Journal of Orthopaedic & Sports PhysicalTherapy 1992;15:147–50. Shrout PE. Measurement reliability and agreement in psychiatry. Statistical Methods in Medical Research 1998;7(3):301–17. Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychological Bulletin 1979;86:420–8. Sim J, Wright CC. The kappa statistic in reliability studies: use, Interpretation, and sample size requirements. Physical Therapy 2005;85:257–68. Simel DL, Samsa GP, Matchar DB. Likelihood ratios with confidence: sample size estimation for diagnostic test studies. Journal of Clinical Epidemiology 1991;44(8):763–70. Smedmark V, Wallin M, Arvidsson I. Inter-examiner reliability in assessing passive intervertebral motion of the cervical spine. Manual Therapy 2000;5(2):97–101. Solinger AB, Chen J, Lantz CA. Standardized initial head position in cervical range-of-motion assessment: reliability and error analysis. Journal of Manipulative and Physiological Therapeutics 2000; 23(1):20–6. SPSS for Windows 10.0, 1998. SPSS Inc, Chicago. Stratford PW, Goldsmith CH. Use of standard error as a reliability index of interest: an applied example using elbow flexor strength data. Physical Therapy 1997;77(7):745–50. Stratford PW, Riddle DL, Binkley FM, Spadoni G, Westaway MD, Padfield B. Using the neck disability Index to make decisions concerning individual patients. Physiotherapy Canada 1999;51:107–12. Tucci SM, Hicks JE, Gross EG, Campbell W, Danoff J. Cervical motion assessment: a new, simple and accurate method. Archives of Physical Medicine and Rehabilitation 1986;67:225–30.



Vernon H, Mior S. The neck disability index: a study of reliability and validity. Journal of Manipulative and Physiological Therapeutics 1991;14:409–15. Viikari-Juntura E. Interexaminer reliability of observations in physical examinations of the neck. Physical Therapy 1987;67:1526–32. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine 2003;28(1):52–62. Werneke M, Hart DL. Centralization phenomenon as a prognostic factor for chronic low back pain and disability. Spine 2001;26(7):758–64. Youdas JW, Carey JR, Garrett TR. Reliability of measurements of cervical spine range of motion—comparison of three methods. Physical Therapy 1991;71(2):98–104.

Further reading Christensen HW, Nilsson N. The reliability of measuring active and passive cervical range of motion: an observer-blinded and randomized repeated-measures design. Journal of Manipulative and Physiological Therapeutics 1998;21(5):341–7. Jette DU, Jette AM. Physical therapy and health outcomes in patients with spinal impairments. Physical Therapy 1996;76(9): 930–41. Jordan K, Dziedzic K, Jones PW, Ong BN, Dawes PT. The reliability of the three-dimensional FASTRAK measurement system in measuring cervical spine and shoulder range of motion in healthy subjects. Rheumatology (Oxford) 2000;39(4): 382–8.

ARTICLE IN PRESS


Technical and measurement report

Interexaminer reliability of lumbar segmental mobility tests Fredrik Johansson Department of Physiotherapy, Vardcentralen Staffanstorp, Sweden Received 14 July 2003; received in revised form 5 May 2005; accepted 2 June 2005

Abstract The purpose of this study was to investigate the interexaminer reliability of segmental mobility tests for the lumbar flexion and extension movement. Available reliability studies are rare and investigate total segmental mobility through several tests, making the understanding of the effect of each test more difficult. There is also a risk of creating a test situation that has less resemblance to the work situation of physiotherapists if two physiotherapists who have trained and coordinated their manual techniques together in advance are studied. Three physiotherapists with step 2 of the Swedish orthopaedic manual therapy education (OMT) performed one segmental mobility test for lumbar flexion and one for lumbar extension on twenty subjects. They were not permitted to obtain additional information, apart from a standing inspection without movements. The physiotherapists had not worked together, nor did they have a chance to coordinate their manual techniques prior to the examinations. The results showed no interexaminer reliability and suggest that future research is essential if a conclusion about lumbar intersegmental mobility tests is to be reached. r 2005 Elsevier Ltd. All rights reserved. Keywords: Manual therapy; Lumbar mobility; Low back mobility; Interexaminer reliability

1. Introduction The case history and the physical examination are of crucial importance in treating patients with LBP (Harms-Ringdahl et al., 1999). Spinal mobility is often regarded as important in the functional evaluation of LBP patients, and estimation of joint mobility is often included in the examination (Korpi et al., 1988; Dillard et al., 1991; Russell et al., 1993; Ensink et al., 1996). Efforts have been made to quantify the size of intervertebral movements and to establish values of normal range of motion for the lumbar spine. There is, however, no consensus in this area due to considerable variations in lumbar range of motion in healthy individuals (Korpi et al., 1988; Hayes et al., 1989; Boden and Wiesel, 1990; Steffen et al., 1997). Research on pathological lumbar movements has focused on measuring instability, and many studies have defined various values for translatoric and angular Fax: +46 46 259 659.

E-mail address: [email protected]. 1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.06.014

instability (Korpi et al., 1988; Panjabi et al., 1988; Boden and Wiesel, 1990; Dvora´k et al., 1991; Nachemson, 1991; Panjabi, 1992). One of the difficulties in reaching consensus in this matter arises from the large number of categories of variations which might affect spinal movements. Such variations are gender, age, time of day, present or previous LBP, lifestyle, bodily constitution, posture and the different methods that have been used in the scientific study of spinal movements and instability (Battie´ et al., 1987; Korpi et al., 1988; Russell et al., 1992, 1993; McGregor et al., 1995; Ensink et al., 1996). Physiotherapists, medical doctors with education in orthopaedic manual medicine and chiropractors often perform manual examination of segmental mobility and of range and quality of motion (Panzer, 1992; Troyanovich and Harrison, 1998). The manual mobility tests are part of what is known as manual therapy, orthopaedic manual medicine or orthopaedic manual therapy (OMT). OMT education for physiotherapists in Sweden is divided into three steps. Step one consists of three 5-day courses, step two of 280 h of study, usually


F. Johansson / Manual Therapy 11 (2006) 331–336

running over 2 years and step three is a further period of deeper study, the three steps adding up to a qualification in OMT. Available reviews in the area of lumbar motion palpation consist of articles more than 8 years old and many of these studies deal with a lateral deviation test, practiced above all by chiropractors, with the patient in a sitting position (Panzer, 1992; Riddle, 1992; Keating, 1989; Hestbaek and Leboeuf-Yde, 2000). Because of the differences in mobility tests and in the movements examined, comparison of these studies is difficult. Out of five earlier studies of interexaminer reliability of lumbar, manual mobility tests with the patient in a lateral position, two reported high and acceptable interexaminer reliability (Kaltenborn and Lindahl, 1969; Gonnella et al., 1982; Jull and Bullock, 1987; Strender et al., 1997; Lundberg and Gerdle, 1999). In the study by Strender et al. two experienced physiotherapists tested two segments (L4–S1) for tenderness and mobility in accordance with the OMT technique and found a high percentage of agreement and kappa values of 0.54 and 0.75 (moderate and good). The result consisted of several mobility tests that the therapist summed up in one rating of the total mobility of each segment. The same methodology was used by Lundberg and Gerdle on eight segmental levels (Th10–S1) but they also studied the interexaminer reliability for the separate movements. Good reliability was found in levels Th11–Th12 in all movements, L1–L2 extension, L4–L5 extension and gliding and L5–S1 extension, rotation left and rotation right. Good reliability was found for total segmental mobility on levels Th11–Th12, L1–L3 and L4–S1. Although two other studies also reported a high percentage of agreement, they did not use the kappa coefficient (K) to calculate reliability (Kaltenborn and Lindahl, 1969; Jull and Bullock, 1987). Hence, the only two previous interexaminer reliability studies found with the patients in a lateral position indicate that it is possible to reach good reliability for assessments based on multiple mobility tests (Strender et al., 1997; Lundberg and Gerdle, 1999). Using this method unfortunately also means, however, that not every specific test will be investigated, which is what the present study aims to do with two of the lumbar mobility tests. As opposed to earlier studies, the present study also investigates the reliability of the tests when the physiotherapists have not been working together, or have in other ways had no chance to standardize their techniques in advance. The study will thus gain a closer approach to reality than a created test-situation with clinicians coordinating their methods of examining lumbar mobility in advance. The aim of the present study was to investigate the interexaminer reliability of segmental mobility tests for the lumbar flexion and extension movements, and by doing so hopefully to contribute to research that assists therapists to choose

the examination methods that are most likely to have the desired outcome.

2. Methods 2.1. Subjects and physiotherapists Three physiotherapists participated in the study (Pt1, Pt2 and Pt3) (Table 1). To take part the physiotherapists had to fulfil the following criteria: to have completed OMT education step 2, be currently practising the intersegmental mobility tests and to have no history of working at the same clinic as the other physiotherapists in the study. Each of the twenty subjects was examined by the physiotherapists. Subjects with ongoing LBP or a recent history of LBP applied from a health club in Lund and students without LBP from the University of Lund (Table 2). Body mass index for the group showed four subjects classified as being overweight and 16 subjects as normal-weight. Fourteen subjects had experienced LBP during the last twelve months, four of them during the week preceding the intervention. 2.2. Procedures Upon volunteering, the subjects received both written and verbal information on the study. To avoid burdening the physiotherapists with an excessive work load, the subjects were divided into three approximately equal groups and examined on three separate occasions. On each occasion every physiotherapist examined all the subjects present. Five to fifteen minutes before the examinations started the subjects participated in a warm-up programme for the back. Rotational, lateral flexion, flexion and extension movements of the lumbar spine were performed.

Table 1 Years as a registered physiotherapist (RPT) and years as a registered physiotherapist after the OMT-education step 2 Variables

Pt1

Pt2

Pt3

Years as a RPT Years as a RPT after the OMT education step 2

17 2

14 2

20 1

Table 2 Weight and height of subjects (n ¼ 20) Variables

Mean

Median

Range

Weight (kg) Height (cm)

68.5 171

70 169.5

55–85 156–191

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In order to be able to place the subject lying on the side with the back in a normal curvature the physiotherapist was allowed to inspect the subject in an upright standing position. The segmental mobility testing of each subject took no longer than 15 min and was performed in separate rooms. It included no other conversation between the physiotherapist and the subject than was necessary for conducting the examination and physiotherapists were unaware of the low back pain status. The time interval between the ratings was less than 15 min, and the order between the three physiotherapists was varied at random. Immediately after the examination each physiotherapist gave the completed evaluation form to the conductor and supervisor of the examination. Intersegmental mobility of flexion and extension were tested in the five lumbar segments using the tests taught to Swedish physiotherapists and students by the OMT section of the Swedish Registered Physiotherapist Union (LSR). The subject lay on the side with hips and knees slightly flexed and the examiner stood opposite the subject. Segmental mobility was estimated by palpating the spinous process of the target vertebra and the adjacent spinous processes while moving the subject’s legs to produce a passive flexion and extension movement in the area of examination (Maitland, 1964; Cyriax, 1985; Kaltenborn, 1989; Kaltenborn, 1993). On the basis of these passive movements the examiners graded segmental mobility in flexion and extension, respectively. A five-point scale was used: 2 ¼ extreme hypomobility, 1 ¼ hypomobility, 0 ¼ normal mobility, +1 ¼ hypermobility and +2 ¼ extreme hypermobility (Lundberg and Gerdle, 1999). No other tests were performed. 2.3. Statistics The degree of agreement between the three physiotherapists was calculated using the kappa coefficient (K) and the weighted kappa coefficient (Kw), the quadratic weighting method (Altman, 1996). The kappa values express the amount by which the agreement exceeds that which would be expected by chance. The weighted kappa indicates the degree to which the findings deviate from each other, weighting the disagreement according to the magnitude of the discrepancy. Weighted kappa is usually higher than unweighted kappa because disagreements are more likely to be in only one category than in several (Altman, 1996). To clarify the effect of weighted kappa and to allow comparison with previous studies, the unweighted kappa value is presented beside the weighted kappa value in the tables of results. The kappa and the weighted kappa coefficients have a maximum of 1.00 when agreement is perfect, a value of 0 indicating no agreement better than chance, and a

333

negative value indicating poorer than chance agreement. The kappa and weighted kappa values were interpreted as follows: o0.20 ¼ poor, 0.21–0.40 ¼ fair, 0.41–0.60 ¼ moderate, 0.61–0.80 ¼ good and 0.81–1.00 ¼ very good (Domholdt, 2000; Altman, 1996).

3. Results The degree of agreement (weighted kappa) between the physiotherapists was below 0.20 in 24 of the 30 comparisons and 0.21–0.40 in four comparisons (Tables 3 and 4). The weighted kappa coefficient was found to be ‘‘moderate’’ in segments L2–L3 and L5–S1 for physiotherapists 2 and 3 in the extension test. When the five-point scale was transformed into a three-point scale of mobility (1, 0 and +1), where all extreme hypo- and hypermobility ratings (2 and +2) were considered as hypo- and hypermobility (1 and +1), the weighted kappa coefficient did not differ notably. Sixty-seven per cent of all the subjects’ first ratings that were evaluated as hypomobile (1 or 2) were evaluated in the third test as more mobile. Seventy-seven per cent of the first ratings evaluated as hypermobile (+1 or +2) were evaluated in the third rating as less mobile. Hence, when the first and the third assessments Table 3 The segmental mobility tests on vertebral levels L1–S1 Flexion

L1–L2 L2–L3 L3–L4 L4–L5 L5–S1

Pt1–Pt2

Pt2–Pt3

Pt1–Pt3

K

Kw

K

Kw

K

Kw

0.17 0.17 0.18 0.08 0.05

0.22 0.27 0.12 0.02 0.07

0.07 0.11 0.17 0.06 0.01

0.07 0.08 0.28 0.16 0.03

0.17 0.17 0.16 0.21 0.10

0.06 0.14 0.09 0.17 0.15

The kappa values (K) and the weighted kappa values (Kw) are presented for the rating of the segmental flexion mobility.

Table 4 The segmental mobility tests on vertebral levels L1–S1 Extension

L1–L2 L2–L3 L3–L4 L4–L5 L5–S1

Pt1–Pt2

Pt2–Pt3

Pt1–Pt3

K

Kw

K

Kw

K

Kw

0.12 0.16 0.18 0.14 0.25

0.19 0.12 0.06 0.13 0.09

0.24 0.51 0.28 0 0.53

0.27 0.54 0.19 0.12 0.56

0.07 0.01 0.27 0.06 0.03

0.06 0.01 0.18 0.06 0.17

The kappa values (K) and the weighted kappa values (Kw) are presented for the rating of the segmental extension mobility.


334

Table 5 The sum of points from the first, second and third ratings

1st ratings 2nd ratings 3rd ratings

Sum of plus points

Sum of minus points

+42 +44 +42

56 56 55

Table 6 Number of times the physiotherapists rated the mobility on each level on the five-point scale (n ¼ 598)

Pt1 Pt2 Pt3

Extreme hypo (2)

Hypo (1)

Normal (0)

Hyper (+1)

Extreme hyper (+2)

12 4 2

31 50 50

117 108 112

27 34 35

11 4 1

are compared, the evaluated mobility had not changed more frequently towards increased mobility than it had towards decreased mobility. Table 5 displays an equal distribution of hypermobility scores (+) and hypomobility scores () after adding the scores in the first, second and third ratings. The ratings of increased or decreased mobility were surprisingly frequent. Forty-four per cent of all ratings noted some kind of deviation from normal mobility. Table 6 displays the extent to which the physiotherapists used the grades of the five-point scale. Only on one level in one test subject did one physiotherapist (Pt1) state that it was not possible to assess mobility, which explains why the total number of assessments is 598 and not 600.

4. Discussion Clinical evaluation of intersegmental mobility is controversial. The individual skills, education and experience of the examiner are crucial for the outcome of the study of intersegmental mobility testing. Teachers of OMT stress that the individual skills of palpation, even after education, differ between students. Evaluating manual mobility tests is just as much an evaluation of the physiotherapist performing the test. In spite of the physiotherapists’ level of education and experience of OMT in the present study, they did not succeed in producing reliable results in their mobility evaluations. In the study by Strender et al. the physiotherapists had been working together for several years and had therefore reached a standardization of techniques (Strender et al., 1997). In the study by Lundberg and Gerdle the physiotherapists performing the examination

were given sufficient time to coordinate definitions and evaluations before the interventions started (Lundberg and Gerdle, 1999). A created situation like this, the authors acknowledge, is unrealistic from a clinical point of view. The results nevertheless indicate that the tests are useful and reliable. But the reaching of agreement between different examiners after standardization of definitions and evaluation methods does not prove that the test has good interreliability under normal circumstances. It may indicate that the test can show good interreliability given that the physiotherapists during their education have sufficient time to compare their findings with a ‘‘gold standard’’ (the teacher’s standard). In the study of interreliability, definitions that influence validity might be altered when compromises are made so as to standardize the motion palpation of the participating physiotherapists. In the present study the physiotherapists had not been working together, nor had they any possibility of standardizing their techniques before intervention. This problem arises from the fact that validity studies of high quality in manual mobility testing are very rare (Leboeuf-Yde et al., 2002; Hestbaek and Leboeuf-Yde, 2000). The knowledge of what spinal structures are being affected during manual segmental mobility testing would of course influence the use of this method. The lack of such knowledge creates insecurity about what exactly is being estimated. Nevertheless, the results from reliability studies are of interest to manual therapists. Good reliability proves that something is being evaluated, and if the therapists continue to use the test and continually compare its result with the case history of the patient, other test findings and the treatment results, they will finally know if it is helpful or not. It is also reasonable to conclude that the combination of several passive tests results in a higher degree of reliability for the rating of a total segmental mobility than one test for the rating of one particular segmental movement does. This might also be one reason why there was higher reliability in the studies of Strender et al. and Lunberg and Gerdle than in the present study. It is not clear which of the two aspects of vertebral movement is of greater interest to practitioners of manual medicine: to make an effort in rating each separate direction of segmental mobility or to estimate the total segmental mobility. To reduce the risk of subjects starting the examinations with decreased lumbar mobility due to variations in the activities preceding the examinations, all the subjects performed a common exercise programme not more than 15 min before the examinations started. It could still be argued that a degree of mobilization occurred in a hypomobile segment during the test procedure. One can, however, exclude a generally increased spinal mobility between the first and third examination as having caused the low interreliability.


About as many first ratings changed from being hypomobile to hypermobile in the third rating as the other way around. The good interreliability achieved in the two studies referred to above also indicates that no change of segmental mobility during the examinations took place in those studies (Strender et al., 1997; Lundberg and Gerdle, 1999). In the present study measures were also taken to ensure that the physiotherapists were evaluating the same vertebral levels. For rating intersegmental mobility there is no scale that is considered standard. In previous studies scales grading from three to thirteen grades of lumbar movement have been used (Kaltenborn and Lindahl, 1969; Gonnella et al., 1982; Jull and Bullock, 1987; Strender et al., 1997; Lundberg and Gerdle, 1999). In the present study, like Kaltenborn, we used a five-grade scale with two grades on either side of normal mobility (Kaltenborn, 1989; Lundberg and Gerdle, 1999). The transformation of the scale into a three-grade one (the 2 ratings becoming 1 and the +2 ratings becoming +1), however, only produced an insignificant increase of agreement. This shows that the divergent ratings in particular were not made on either side of normal mobility (‘‘0’’). When asked after the examinations, all three physiotherapists stated that their ratings of () and (+) 1 represented such a significant decrease and increase of mobility that it would have motivated treatment if other tests in clinical situations had supported these findings. There is only a small deviation between Pt2 and Pt3 in the use of the grading alternatives. Except for the moderate reliability between Pt2- and Pt3 on the extension tests L2–L3 and L5–S1, this was no indication of better agreement. The fact that weighted kappa, overall, was not significantly higher than unweighted shows that the ratings often diverged by more than one degree. Table 6 also shows that the rating alternatives were used extensively; the kappa was not poor as a result of poor spreading amongst the ratings. The majority of the subjects had experienced LBP during the previous year but only four were in pain during the examinations or had been during the preceding 7 days. The subjects were healthier overall than the patients the physiotherapist normally meets in the clinic. This raises the question whether or not the concordance would have been higher if all subjects had suffered from LBP and perhaps had more palpable deviations from normal mobility. This is not likely since a greater proportion of the ratings would then have shown normal than was the case. Teachers of OMT claim that it is normal for the lumbar back to retain painless mobility deviations when examined. None of these mobility tests are useful in the clinic if they lack interexaminer reliability. The same patient might then be diagnosed by one physiotherapist as having hypermobility problems and by another as

335

having hypomobility problems, which would result in different treatment strategies. In clinical work, though, one could argue, many tests, not just one, are used to guide the physiotherapist in the right direction. This is indeed so and makes the segmental mobility tests less decisive, and the intersegmental mobility tests are often used to verify what the examiner already suspects. Reducing the significance of a test, however, does not make it more useful if it produces false information. For a test to be useful, also in cooperation with other tests, it must present a validity and reliability of its own. This outcome challenges the claims that therapists are able to grade lumbar intersegmental movements. The difference in results and methods between this study and the other two Swedish studies referred to above indicates that physiotherapists do not learn exactly how to evaluate findings of lumbar intersegmental movements during their training (Strender et al., 1997; Lundberg and Gerdle, 1999). If this is the case, there are two possible reasons: one is that it takes more or better education and/or more practice to learn the mobility tests of flexion and extension and the other possible reason is that these tests do in fact lack reliability and fail to produce relevant information about segmental mobility. Extensive further research on interreliability in this field is, however, needed before any kind of conclusion can be drawn. Such studies should continue to include practitioners of manual medicine who share the same education and, a similar amount of experience, and who have not standardized their techniques by working together.

Acknowledgements This paper resulted from work for the requirements for the degree of Master of Physiotherapy at Lund University.

References Altman DG. Practical statistics for medical research. London: Chapman & Hall; 1996. p. 403–7. Battie´ MC, Bigos SJ, Sheehy A, Worthley MD. Spinal flexibility and individual factors that influence it. Physical Therapy 1987;67:653–8. Boden SD, Wiesel SW. Lumbosacral segmental motion in normal individuals; have we been measuring instability properly? Spine 1990;15(6):571–5. Cyriax J. Textbook of orthopaedic medicine. London: Baillie`re Tindall; 1985. p. 107. Dillard J, Trafimow J, Andersson BJ, Cronin K. Motion of the Lumbar Spine; reliability of two measurement techniques. Spine 1991;16(3):321–4. Domholdt E. Physical therapy research. 2nd ed. Philadelphia: WB Saunders Company; 2000. p. 365–6.


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Dvora´k J, Panjabi MM, Chang DG, Theiler R, Grob D. Functional radiographic diagnosis of the lumbar spine. Spine 1991;16(5): 562–71. Ensink F-BM, Sauer PMM, Frese K, Seeger D, Hildebrandt J. Lumbar range of motion: influence of time of day and individual factors on measurements. Spine 1996;21(11):1339–43. Gonnella C, Paris SV, Kutner M. Reliability in evaluating passive intervertebral motion. Physical Therapy 1982;62:436–44. Harms-Ringdahl K, Holmstro¨m E, Lindstro¨m I, Jonsson T. Evidensbaserad sjukgymnastisk behandling, patienter med la¨ndryggsbesva¨r, no. 102 okt Nordisk Bokindustri, Farsta. 1999. p. 12. Hayes MA, Howard TC, Gruel CL, Kopta JA. Roentgenographic evaluation of lumbar spine flexion-extension in asymptomatic individuals. Spine 1989;14(3):327–31. Hestbaek L, Leboeuf-Yde C. Are chiropractic tests for the lumbopelvic spine reliable and valid? A systematic critical literature review. Journal of Manipulative and Physiological Therapeutics 2000;23:258–75. Jull G, Bullock M. A motion profile of the lumbar spine in an ageing population assessed by manual examination. Physiotherapy Practice 1987;3:70–81. Kaltenborn F, Lindahl O. Reproducerbarheten vid ro¨relseunderso¨kning av enskilda kotor. La¨kartidningen 1969;66(10):962–5. Kaltenborn FM. Manuell mobilisering av ryggraden. Oslo: Olaf Norlis Bokhandel; 1989. Kaltenborn FM. The spine. 2nd ed. Oslo: Olaf Norlis Bokhandel; 1993. p. 134. Keating JC. Inter-examiner reliability of motion palpation of the lumbar spine: a review of quantitative literature. The American Journal of Chiropractic Medicine 1989;2(3):107–10. Korpi J, Poussa M, Helio¨vaara M. Radiographic mobility of the lumbar spine and its relation to clinical back motion. Scandinavica Journal of Rehabilitation Medicine 1988;20:71–6. Leboeuf-Yde C, von Dijk J, Franz C, Hustad SA, Olsen D, Phil T, Robech R, Skov Vendrup S, Bendix T, Kyvik KO. Motion palpation findings and self-reported low back pain in a population-

based study sample. Journal of Manipulative and Physiological Therapeutics 2002;25(2):80–7. Lundberg G, Gerdle B. The relationship between spinal sagittal configuration, joint mobility, general low back mobility and segmental mobility in female homecare personnel. Scandinavica Journal of Rehabilitation Medicine 1999;31:197–206. Maitland GD. Vertebral manipulation. London: Butterworths; 1964. p. 15–6. McGregor AH, McCarthy ID, Hughes SP. Motion characteristics of the lumbar spine in the normal population. Spine 1995;20(22):2421–8. Nachemson AL. Instability of the lumbar spine. Neurosurgery Clinics of North America 1991;2(4):785–9. Panjabi MM, Thibodeau LL, Crisco JJ, White AA. What constitutes spinal instability? Clinical Neurosurgery 1988;34:313–39. Panjabi MM. The stabilizing system of the spine. Part 1. Function, dysfunction adaptation and enhancement. Journal of Spinal Disorders 1992;5:383–9. Panzer DM. The reliability of lumbar motion palpation. Journal of Manipulative and Physiological Therapeutics 1992;15(8):518–24. Riddle LD. Measurement of accessory motion: critical issues and related concepts. Phys Ther 1992;72:865–74. Russell P, Weld A, Pearcy MJ, Hogg R, Unsworth A. Variation in lumbar spine mobility measured over a 24-hour period. British Journal of Rheumatology 1992;31:329–32. Russell P, Pearcy MJ, Unsworth A. Measurement of the range and coupled movements observed in the lumbar spine. British Journal of Rheumatology 1993;32:490–7. Steffen T, Rubin RK, Baramki HG, Antoniou J, Marchesi D, Aebi M. A new technique for measuring lumbar segmental motion in vivo. Spine 1997;22(2):156–66. Strender LE, Sjo¨blom A, Sundell K, Ludwig R, Taube A. Interexaminer reliability in physical examination of patients with low back pain. Spine 1997;7:814–9. Troyanovich SJ, Harrison DD. Motion palpation: it’s time to accept the evidence. Journal of Manipulative and Physiological Therapeutics 1998;21(8):568–71.

ARTICLE IN PRESS


Professional issue

To treat or not to treat postpartum pelvic girdle pain with stabilizing exercises? Britt Stugea,, Inger Holma,b, Nina Vøllestada a

Section for Health Science, University of Oslo, P.O. Box 1153, Blindern, N-0316 Oslo, Norway b Physical Department, Rikshospitalet University Hospital, Oslo, Norway Received 3 June 2004; received in revised form 2 June 2005; accepted 26 July 2005

Abstract Women with pelvic girdle pain (PGP) often consult physical therapists for help and are treated with different therapies without firm evidence for the effectiveness. Two randomized controlled trials have investigated the effect of stabilizing exercises for PGP. The most recent study demonstrated significant positive results in favour of exercises (Stuge et al. The efficacy of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy. A randomized controlled trial. Spine 2004a;29(10):351–9), the other did not (Mens et al. Diagonal trunk muscle exercises in peripartum pelvic pain: a randomized clinical trial. Phys. Ther. 2000;80(12):1164–73). Consequently, the two studies provide contradictory advice for treatment of PGP. The question is thus, whether stabilizing exercises should be recommended as treatment for PGP. Both the studies are of high methodological quality and are comparable with regard to subjects studied. However, there are several differences in the interventions and these are explored and discussed for better understanding of the conflicting results. Exercises that focused on only global muscles showed no effect. However, these exercises were not individualized and they were instructed by videotape. In the more recent study, exercises that initially focused on local muscles, and then gradually added global muscles showed a significant, positive effect. Exercises in that study were supervised, corrected, individualized concerning choice of exercises, order and dosage, and pain was avoided. This comparison indicates that effective treatment of postpartum PGP may be achieved when exercises for the entire spinal musculature are included, individually guided and adapted to each individual. r 2005 Elsevier Ltd. All rights reserved. Keywords: Postpartum pelvic girdle pain; Stabilizing exercises; Evidence-based practice

1. To treat or not to treat postpartum pelvic girdle pain with exercises? Women with pelvic girdle pain (PGP) often consult physical therapists for help. They are provided with various forms of treatment; however, these different therapies have been without firm evidence of their effectiveness (Mens et al., 1996). A systematic review revealed that few clinical trials have evaluated the effectiveness of physical therapy for pregnancy-related low back pain (LBP) and PGP (Stuge et al., 2003). Corresponding author. Tel.: +47 22 85 84 18; fax: +47 22 85 84 11.

E-mail address: [email protected] (B. Stuge). 1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.07.004

Because of heterogeneity and the varying quality of the studies, no strong evidence exists concerning the effect of treatment for PGP. Postpartum PGP represents a significant challenge to therapists, yet only 2 randomized controlled trials have investigated the effect of exercises in the treatment of postpartum PGP (Mens et al., 2000; Stuge et al., 2004a). Mens et al. (2000) investigated the effect of diagonal trunk muscle exercises (n ¼ 16) compared with training of the longitudinal trunk muscle system (n ¼ 14) and no exercises (n ¼ 14). The subjects performed the exercises at home, instructed by videotape. Comparison between the groups at the end of 8 weeks’ intervention, revealed no significant differences. In a more recent clinical



study, we compared the effect of stabilizing exercises (n ¼ 40) with no specific exercises (n ¼ 41) (Stuge et al., 2004a). Both groups had on average 11 treatments during the intervention period of 20 weeks. The results demonstrated that women with an individualized treatment approach focusing on specific stabilizing exercises experienced significantly lower pain intensity, lower disability and higher quality of life than did women with individualized physical therapy without specific stabilizing exercises. These results were found after 20 weeks, and the effect was maintained 1 and 2 years postpartum (Stuge et al., 2004a, b). The inclusion criteria—age, parity, duration of complaints, time since delivery, baseline pain intensity and the posterior pelvic pain provocation test scores— were similar in the two studies, making the studies comparable (Mens et al., 2000; Stuge et al., 2004a). Both studies were of high methodological quality as assessed by internal validity (Clarke & Oxman, 1999). However, the results of the two studies provide contradictory evidence regarding advice for treatment of PGP. The question is thus whether stabilizing exercises should be recommended as treatment for PGP. When attempting to answer this question, it is necessary to understand the differences between the two studies. One obvious possibility for the different results may be that the rather low number of subjects in the study by Mens et al. (2000) is too small to detect significant differences between the groups. However, differences regarding the interventions employed in the two studies may also contribute to the inconsistent results. The aim of this paper is thus to explore and discuss elements of the two intervention strategies and their theoretical rationale. By this we hope to provide a better foundation for understanding the conflicting results, and also to highlight important principles for treatment for PGP.

Fig. 1. An illustration of muscles with implication for lumbopelvic stability and control. Short arrows indicate deep local muscles (the transverse abdominals, the multifidus, diaphragm and the pelvic floor muscles). Long arrows indicate the posterior oblique muscle sling with latissimus dorsi, gluteus maximus and the intervening thoracolumbar fascia. Reproduced by kind permission of C. DeRosa.

(form closure, force closure, motor control, emotions and awareness). Bergmark (1989) described two functional muscle systems linked to spinal stabilization as the deep local and the larger torque-producing global muscle systems. During recent years, there has been increased focus on the local muscle system, including musculus transversus abdominis (TrA), obliquus internus, multifidus, pelvic floor and the diaphragm. TrA is said to play an important role in stabilizing the lumbar column and the pelvis (Hodges & Richardson, 1996; Richardson et al., 1999, 2002). Functional stabilization of the pelvic girdle was expected to require both local and global muscles appropriately timed and co-ordinated through efficient motor control. Muscles regarded as being significant in the stability of the lumbopelvic region are illustrated in Fig. 1.

1.1. Theoretical models for the treatment programs 1.2. The exercise interventions It has been suggested that PGP is related to insufficient stability of the lumbopelvic region. The exercises in the study by Mens et al. (2000) were based on a theoretical model of sacroiliac (SIJ) function, the self-locking mechanism. According to that model, stability is obtained by a combination of form and force closure (Vleeming et al., 1997). It is thought that SIJ shear may be prevented by friction (form closure), and dynamically influenced by muscle force and the integrity of facial structures and ligament tension (force closure). The treatment program in our study (Stuge et al., 2004a, b) was founded on the theories of an integrated model for lumbopelvic function and stability (Lee & Vleeming, 2000). This model is an expansion of the selflocking model and is comprised of four components

Mens et al. (2000) believed that training of the diagonal trunk muscle systems (gluteus maximus and the contralateral latissimus dorsi, and the oblique abdominals) would increase stability and benefit women with PGP, partly by increasing muscle force and endurance. The subjects received a 30-min videotape in which explanations were given about the possible cause of PGP, prognosis, ergonomic advice, and information on how to use a pelvic belt and instructions on how to train the diagonal trunk muscle system by two different exercises. Light exercises to improve muscular awareness were to be performed 3 times a day and heavy exercises 3 times a week. The subjects were to gradually increase the number of repetitions per series, guided by their pain and fatigue.


Our treatment program (Stuge et al., 2004a) focused on stabilizing exercises for specific activation of the local and the global muscle system, with attention on motor control to coordinate muscle recruitment. An individual treatment plan was made based on the clinical findings. The focus in the initial stage of the treatment program was to train specific contractions of the deep muscle system, independently from the superficial muscles. This focus was combined with information, ergonomic advice, body awareness training, relaxation of global muscles, and mobilization, depending on the clinical findings. When asymmetric motion of the SIJs was noticed, joint mobilization was executed to optimize form closure, either performed by the therapist with simple techniques of oscillation between ilium and sacrum or by self-mobilizing using a muscle energy technique (DonTigny, 1997). When low force contractions of the transversely oriented abdominal muscles were achieved, exercises for the global muscles were gradually added to the program. The importance of activating the local muscles before adding the global muscles was stressed during all exercises and daily activities. The difference between

339

stability and rigidity (inflexibility, stiffness) was emphasized to the patients. Rigidity was considered unfavourable. Specific exercises for each patient were taken out of a fixed menu of exercises (examples given in Fig. 2). The goal was to execute 3 sets of 10 repetitions of each exercise 3 days a week. The number of exercises and repetitions was determined by the quality of the execution of the exercise. The exercises should not trigger a trembling of the lumbosacral region or provoke pain, either during the exercise program or at any time afterwards. However, the patients were encouraged to feel the difference between pain and muscle soreness, the latter was considered positive. Women with PGP often experience pain while bearing weight, which is unavoidable when caring for newborns. Hence, the sling exercise apparatus TerapiMaster (Ljunggren et al., 1997) was chosen to carry out most of the exercises. By using the TerapiMaster it is easy to down- and up-grade the exercises to an individual level of load. It was expected that the systematic increase of lever arms together with a training diary would be motivational in achieving adherence to the exercise program. To allow the exercise program to be performed

Fig. 2. Examples of exercises used in the treatment program.



mainly at home, the subjects borrowed the sling exercise equipment during the intervention period.

2. Discussion 2.1. Exercises for local and global muscles In contrast to the study by Mens et al. (2000), the focus in the initial stage of our treatment program (Stuge et al., 2004a) was to specifically train contractions of the deep muscle system, independently of the superficial muscles. Deep local muscles are thought to provide the fine-tuning of the intersegmental motion as a component of the complex interdependent activity of the trunk muscles to stabilize the lumbopelvic region (Hodges & Moseley, 2003). The TrA and the pelvic floor muscles are found to stiffen and hence possibly stabilize the female SIJ (Richardson et al., 2002; Pool-Goudzwaard et al., 2004). The deep muscles provide control of intersegmental motion that is not specific to the direction of force, whereas the superficial muscles control the orientation of the spine (Moseley et al., 2002). Because probably all trunk muscles are required for lumbopelvic control and functional stability of the spine, global muscles were gradually added to the exercise program (Hodges & Moseley, 2003). A significant increase in SIJ stiffness has been demonstrated by contracting global muscles such as erector spinae, biceps femoris, gluteus maximus and latissimus dorsi (van Wingerden et al., 2004). Functional stability depends on the relative activation of all trunk muscles and the relative contribution of a given muscle to spine stability has been shown to depend significantly on loading magnitude and direction (Cholewicki and VanVliet, 2002; Kavcic et al., 2004). No consensus, however, exists on effects of altered muscle recruitment patterns (Cholewicki et al., 2003; Hodges & Moseley, 2003; van Dieen et al., 2003). Nonetheless, interventions, such as those used in our study (Stuge et al., 2004a), focusing on reorganisation of the control of the deep and superficial trunk muscles through motor learning strategies have shown reduced pain and disability, and reduced recurrence of pain in LBP patients (O’Sullivan et al., 1997; Hides et al., 2001). To activate the local muscle system may thus be a necessary first stage of rehabilitation, before more generalized exercising (Hides et al., 1996; Jull et al., 1998). This may have been a missing element in conventional exercise programs, as it was in the study by Mens et al. (2000). 2.2. Performance of exercises Avoiding pain provocation and maintaining lumbopelvic control was considered important when choosing

and carrying out the exercises in our study (Stuge et al., 2004a). Clinical experience indicates that exercises which specifically activate the hamstrings often provoke pain: such exercises were therefore not included in our program. In subjects with pain related to the SIJ region, a delayed onset of activity of obliques internus, multifidus and gluteus maximus has been demonstrated by means of electromyography (Hungerford et al., 2003). Delayed activation of gluteus maximus may alter compression of the SIJ (Barker et al., 2004), with a subsequent failure of the mechanism required for optimal load transfer through the pelvis. As reported by Hungerford et al. (2003), biceps femoris activation occurred earlier on the symptomatic side. It was speculated that the early onset of the biceps femoris activation occurred to assist hip extension because of delayed onset of gluteus maximus activity, or to augment force closure across the SIJ via connections of biceps femoris to the sacrotuberous ligament (Hungerford et al., 2003). Early biceps femoris activation may have occurred in a hip extension exercise used in the study by Mens et al. (2000), and may be one reason why pain was provoked in 25% of the exercise group. The authors of that study suggest that training of hip extension may worsen PGP. However, hip extension should be trained with a dominance of gluteus maximus activity to avoid pain and possibly increase stability of the lumbopelvic region. In our study (Stuge et al., 2004a) co-contraction exercises were mainly directed to the local muscles. Hyperactivity of global muscles was unwanted. Compensatory activity of the global muscle system is reported to occur in the presence of local muscle system dysfunctions (Hodges, 2003). This is claimed to be the neural control system’s attempt to maintain the stability demands of the spine in the presence of local muscle dysfunction (Richardson et al., 1999). A compensatory pattern with hyperactive muscles giving too much compression or muscle imbalance may cause pain and reduce mobility in the SIJ. It is likely that exercises may provoke pain if a compensatory pattern is sustained during training. According to Hodges and Moseley (2003) a strategy with increased stiffening of the spine by activation of the large superficial muscles may compromise optimal lumbopelvic function with excessive compressive loading to spinal structures. In people with low back pain, electromyography studies show sustained activity of the erector spinae at the end range of spinal flexion (Shirado et al., 1995). If these observations are applicable for PGP patients, hyperactivity of the extensor muscles is possible because of pain or fear of pain (Hodges & Moseley, 2003). In the study by Stuge et al. (2004a), therefore, intermittent relaxation of the extensor muscles was considered to be just as important as optimal contraction of these muscles to avoid ‘‘splinting’’ the lumbosacral region. It is possible that


the participants in the study by Mens et al. (2000) constantly contracted the back extensor muscles during the leg and arm extension exercise and thereby provoked pain. It is also possible that a lack of specific activation of local muscles while exercising reduced lumbopelvic control and provoked pain in that study. Quite often, patients experience a flare-up of pain during exercising (Moseley, 2003). This may be because of an unfavourable performance of the exercises, or because of too high a dosage. According to Moseley (2003) increasing the exercise load too fast is a common reason for failure in the management of exercise programs. To balance progression with avoidance of flare-ups we used an exercise diary to document the progression. The importance of a systematic approach to identification and progression of level of physical exercises and daily activities should not be underestimated and it has probably influenced the results of our study (Stuge et al., 2004a). Also, supervision of exercises is critically important in improving quality of exercise performance. A strong correlation between the quality of exercise performance and decrease in pain has been found (Friedrich et al., 1996). Supervision and regular follow-up enable the therapist to adjust a program according to the patients’ progress and might contribute to the maintenance of exercise benefits (Liddle et al., 2004). Our supervised exercise program is in strong contrast to exercises guided by a videotape, as used in the study by Mens et al. (2000). A videotape provides no possibility to guide a patient in choice, dosage or optimal performance of exercising, or to adapt a treatment program to each individual. 2.3. Joint mobilization Heterogeneity of problems among PGP patients highlights the need for an individual problem solving approach, based on an individual examination. Clinical experience and recent research reports have demonstrated an association between asymmetric laxity of the SIJs and PGP postpartum (Buyruk et al., 1999; Damen et al., 2002). Adjusting asymmetrical motion of the SIJs prior to exercising with joint mobilization may influence optimal form closure and enhance the possibility to exercise without pain, and such adjustment was thus performed in our study (Stuge et al., 2004a). Mobilization however, was not performed in the study by Mens et al. (2000), although it might have been indicated.

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be taken into account that nociception, neuropathy, and psychological or environmental factors may singly, or in combination, contribute to the experience of pain. The patient in pain must always be seen in the context of these interacting factors (Loeser & Cousins, 1990; Siddall & Cousins, 1997). Emotions and awareness of the patients’ pain problem were therefore focused upon in our treatment program (Stuge et al., 2004a). The patients underlined the importance of gaining insight to their situation through talking to the therapist and the care given. Information and advice were also given in the study by Mens et al. (2000); however, it was given by a videotape in a standardized manner. Thus, the possibility for the patients to benefit from a patient– therapist relationship was hindered. It is possible that both pain and fear of pain may lead to changes in motor control (Hodges and Moseley, 2003). The avoidance of provoking pain and encouraging the women to get the feeling of control of their body probably also reduced possible fear of physical activity. 2.5. Compliance Compliance is essential for proper interpretation of the effect of an exercise intervention. To exercise 3 times a week, which is considered optimal (Kraemer et al., 2002), can be hard to achieve for women with a newborn child. Clinical experience shows that for these patients it is a challenge to get continuity in an outpatient exercise program. In our study (Stuge et al., 2004a) the subjects reported to have accomplished on average 80% (CI 74, 86) of exercising 3 times a week for 15–20 weeks. This compliance was surprisingly high (Sluijs et al., 1993; Ostgaard et al., 1997; Mens et al., 2000; Middleton, 2004). The women in our study (Stuge et al., 2004a) reported that reasons for the high compliance were the possibility of exercising at home and the guidance by the therapist. Also, the fact that exercising did not provoke pain probably influenced compliance. In the study by Mens et al. (2000) 25% in the exercise group stopped exercising because of pain provoked by the exercises, which is known to contribute to low compliance (Linton et al., 1996). Additionally, in our study (Stuge et al., 2004a), the experience of continual improvement made visible by the exercise diary probably contributed to the high compliance. It was also emphasized that the patients should understand why, not just what to do, to facilitate empowerment and commitment to change (Lively, 2002; Liddle et al., 2004).

2.4. Emotions/awareness Musculoskeletal pain can occur following damage to the bony, muscular, and ligamentous structures (Siddall & Cousins, 1997). However, the perception of pain is a complex phenomenon that involves sensory, emotional, and behavioural factors. In pain management it should

3. Conclusion Despite conflicting evidence we recommend treating postpartum PGP with stabilizing exercises. However, exercises for enhancing lumbopelvic control and



stability should involve the entire spinal musculature. Focusing on only global muscles, and without individual guidance, seems insufficient. The individualized and supervised treatment program focusing on the local system with gradual addition of exercises for the global system showed better results, and a high compliance. Further studies are needed to examine the importance of the different aspects of the interventions, such as choice, order and dosage of exercises, supervision and compliance.

Acknowledgements The study is supported by the Norwegian Foundation for Health and Rehabilitation and the Norwegian Women’s Public Health Association.

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Hodges PW, Richardson CA. Inefficient muscular stabilization of the lumbar spine associated with low back pain. A motor control evaluation of transversus abdominis. Spine 1996;21(22):2640–50. Hungerford B, Gilleard W, Hodges P. Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain. Spine 2003;28(14):1593–600. Jull GA, Scott Q, Richardson C, Henry S, Hides J, Hodges P. New concepts for the control of pain in the lumbopelvic region. In: Vleeming A, et al., editors. Conference Proceedings. Vienna, Austria: Third interdisciplinary world congress on low back and pelvic pain; 1998. p. 128–31. Kavcic N, Grenier S, McGill SM. Determining the stabilizing role of individual torso muscles during rehabilitation exercises. Spine 2004;29(11):1254–65. Kraemer WJ, Adams K, Cafarelli E, et al. Progression models in resistance training for healthy adults. Med Sci Sports Exerc 2002; 34(2):364–80. Lee D, Vleeming A. Current concepts on pelvic pain, Perth, Australia. Conference proceedings of the seventh scientific conference of the international federation of orthopaedic manipulative therapists, 2000. p. 118–23. Liddle SD, Baxter GD, Gracey JH. Exercise and chronic low back pain: what works? Pain 2004;107:176–90. Linton S, Hellsing A, Bergstom G. Exercise for workers with musculoskeletal pain: does enhancing compliance decrease pain? J Occup Health 1996;6,:177–89. Lively MW. Sports medicine approach to low back pain. Southern Med J 2002;95(6):642–6. Ljunggren AE, Weber H, Kogstad O, Thom E, Kirkesola G. Effect of exercise on sick leave due to low back pain. Spine 1997;22(14): 1610–6. Loeser JD, Cousins MJ. Contemporary pain management. Med J Australia 1990;153:208–16. Mens JM, Snijders CJ, Stam HJ. Diagonal trunk muscle exercises in peripartum pelvic pain: a randomized clinical trial. Phys Ther 2000;80(12):1164–73. Mens JM, Vleeming A, Stoeckart R, Stam HJ, Snijders CJ. Understanding peripartum pelvic pain. Implications of a patient survey. Spine 1996;21(11):1363–9. Middleton A. Chronic low back pain: patient compliance with physiotherapy advice and exercise, perceived barriers and motivation. Phys Ther Rev 2004;9:153–60. Moseley GL. A pain neuromatrix approach to patients with chronic pain. Manual Ther 2003;8(3):130–40. Moseley GL, Hodges PW, Gandevia SC. Deep and superficial fibers of the lumbar multifidus muscle are differentially active during voluntary arm movements. Spine 2002;27(2):E29–E-36. O’Sullivan PB, Phyty GD, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine 1997;22(24):2959–67. Ostgaard HC, Zetherstrom G, Roos-Hansson E. Back pain in relation to pregnancy: a 6-year follow-up. Spine 1997;22(24):2945–50. Pool-Goudzwaard A, van Dijke GH, van Gurp M, Mulder P, Snijders C, Stoeckart R. Contribution of pelvic floor muscles to stiffness of the pelvic ring. Clin Biomech 2004;19(6):564–71. Richardson CA, Jull GA, Hodges PW, Hides JA. Therapeutic exercise for spinal segmental stabilization in low back pain, First published ed. London, UK: Churchill Livingstone; 1999. Richardson CA, Snijders CJ, Hides JA, Damen L, Pas MS, Storm J. The relation between the transversus abdominis muscles, sacroiliac joint mechanics, and low back pain. Spine 2002;27(4):399–405. Shirado O, Ito T, Kaneda K, Strax TE. Flexion-relaxation phenomenon in the back muscles—a comparative-study between healthysubjects and patients with chronic low-back-pain. Am J Phys Med Rehab 1995;74(2):139–44.

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ARTICLE IN PRESS


Case report

Is spinal mobilization safe in severe secondary osteoporosis?—a case report$ Meena M. Srana,b,c,d,, Karim M. Khana,b,c,e a

Osteoporosis Program, BC Women’s Health Centre, Vancouver, Canada Division of Orthopaedic Engineering Research, Faculty of Medicine, University of British Columbia, Vancouver, Canada c Bone Health Research Group, Faculty of Medicine, University of British Columbia, Vancouver, Canada d Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada e Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, Canada

b

Received 3 July 2004; received in revised form 3 April 2005; accepted 17 August 2005

1. Background Glucocorticoid therapy, for diseases including rheumatoid arthritis, respiratory and immune system disorders, is the most common cause of secondary osteoporosis (Ramsey-Goldman, 2002). The incidence of glucocorticoid-induced osteoporosis (GIO) has been estimated at 50% in patients treated for greater than 6 months (Sambrook, 2000), with fractures occurring in 25–33% of patients using glucocorticoids long term (Adinoff and Hollister, 1983; Michel et al., 1991, 1993). Systemic glucocorticoid therapy for more than 2–3 months and doses of prednisone exceeding 2.5 mg/day have also been associated with an increased risk of fracture (Adachi et al., 2000; Van Staa et al., 2000), and bone loss is most rapid during the first year of glucocorticoid use. Glucocorticoids inhibit gastrointestinal absorption and increase renal excretion of calcium. This results in a compensatory increase in secretion of parathyroid hormone (PTH), which increases the number of sites undergoing bone remodelling. Glucocorticoids inhibit the secretion of gonadal hormones, which further affect $ Ethical Approval: This report was approved by the University of British Columbia and Children’s & Women’s Health Centre Clinical Research Review Boards. Corresponding author. BC Women’s Hospital and Health Centre, F2-Women’s Health Centre, 4500 Oak St. Vancouver, BC, Canada V6H 3N1. Tel.: +1 604 875 2341; fax: +1 604 875 3136. E-mail address: [email protected] (M.M. Sran).


bone resorption, reducing recruitment of osteoblasts and causing osteocytes to inhibit osteoblastic bone formation. An increase in the number of sites undergoing bone remodelling in addition to a decrease in bone formation at each site results in rapid bone loss (Sambrook, 2002). The effect of glucocorticoid therapy is more pronounced in trabecular bone, resulting in rapid bone loss and fractures most commonly in the vertebrae, ribs, and the ends of long bones. Given the high population prevalence of back pain (Kelsey and White, 1980; Volinn, 1997), it is not surprising that many individuals with osteoporosis also have back pain (Leidig et al., 1990; Patel et al., 1991; Malmros et al., 1998). Manual examination by a physiotherapist is accurate in detecting the segmental level responsible for pain when compared with a spinal block (Jull et al., 1988; Phillips and Twomey, 2000) and is correlated with disability (Lundberg and Gerdle, 2000). Further, physiotherapy including spinal mobilization has been shown to be effective in reducing spinal pain (Farrell and Twomey, 1982; Goodsell et al., 2000; Sterling et al., 2001; Hoving et al., 2002; Jull et al., 2002; Niemisto et al., 2003) and more effective than physiotherapy excluding spinal mobilization (Hoving et al., 2002). There is evidence suggesting spinal mobilization techniques can stimulate sympathetic nervous system activity (McGuiness et al., 1997; Vicenzino et al., 1998; Sterling et al., 2001), and promote motor activity (Sterling et al., 2001; Jull et al., 2002). While spinal manipulation (high velocity thrust

ARTICLE IN PRESS M.M. Sran, K.M. Khan / Manual Therapy 11 (2006) 344–351

technique) is contraindicated in individuals with spinal osteoporosis (Tobis and Hoehler, 1986; Grieve, 1988; Maitland et al., 2001; Ernst, 2003), there is also concern that spinal mobilization (low velocity techniques) could cause a fracture in this population (Sran, 2003; Sran and Khan 2004; Sran et al., 2004). Our previous work suggests that some physiotherapists use manual therapy with clients who have osteoporosis (Sran and Khan, 2004). Despite this, and the high prevalence of osteoporosis, there is little published data on the safety of spinal mobilization for individuals with osteoporosis (Sran, 2003; Sran et al., 2004) and no published data on its effectiveness in this population. Thus reports on the safety and efficacy of spinal mobilization for back pain in this population are urgently needed (Sran, 2003; Sran and Khan, 2004). For these reasons, the authors report on an individual with glucocorticoid-induced osteoporosis, numerous vertebral compression fractures and back pain with the aim of investigating change in pain, function and quality of life from baseline to 1 and 3 months after beginning physiotherapy intervention which included spinal mobilization. Of particular interest was whether or not spinal mobilization caused further injury clinically or radiologically.

2. Case description This report was approved by the University of British Columbia and Children’s & Women’s Health Centre Clinical Research Review Boards, which required the subject’s consent. 2.1. History The patient, a 53-year-old woman, had had previous physiotherapy (3 years prior). At that time she complained of thoracic and lumbar back pain, loss of height (134 inches) and impaired function with activities of daily living and physical activity. The relevant past history was that she had been diagnosed with chronic myeloid leukaemia (CML), 5 years prior to her physiotherapy presentation. CML treatment included chemotherapy, radiation therapy and subsequent bone marrow transplantation with an unrelated donor. As part of this treatment she was prescribed the glucocorticoid prednisolone for 6 years. The initial dose was 25 mg/day, reducing to 7.5 mg/day over 5.5 years. This therapy was then reduced in a tapered fashion over 3 months. 2.1.1. Non-traumatic fractures One month after beginning high dose prednisolone treatment, she recalled the sudden onset of back pain

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associated with an episode of severe vomiting. X-rays revealed multiple spinal compression fractures. 2.1.2. Past physiotherapy Three years previously the client had been referred to a physiotherapist for pain control. The referral stated that she had ‘‘prominent midthoracic back pain with radiation laterally’’. The client was scheduled for an exercise class approximately 6 weeks after examination by a physiotherapist. One month later the client attended an education session on osteoporosis. Subjective comments (according to chart review) included fatigue and ongoing mid-thoracic pain aggravated by standing and relieved by rest. The patient also reported low back pain. The physiotherapist reported reduced back pain approximately 5 months after initial assessment, and commented that this may have been related to the client taking prednisolone. Physiotherapy treatment (six sessions over 6 months) included manual hamstring stretching, active hamstring and calf stretches, TENS to the thoracic and lumbar spine, rhomboid and lower trapezius exercises, scapular mobilizations in side lying, shoulder and thoracic mobility exercises, strength exercises with resistance tubing for shoulder retractors, shoulder extensors, and shoulder abductors. The therapist attempted to followup with the client 6 months later. The client was discharged as a telephone conversation revealed that she was planning to attend a group exercise session and was having ongoing problems due to graft versus host disease. 2.1.3. Medications Other relevant history included the use of hormone replacement therapy for 6 years, Alendronate (a bisphosphonate which affects bone resorption and is indicated as a treatment for GIO) for three and a half years (not tolerated well), and Raloxifene [a selective oestrogen-receptor modulator that also inhibits bone resorption (Jordan et al., 2001; O’Regan and Gradishar, 2001)] for the previous year and on an ongoing basis. 2.1.4. Bone mineral density The individual underwent a dual energy X-ray absorptiometry (DXA) scan of her lumbar spine to determine bone mineral density (g/cm2) in this region. On the initial scan she had a t-score of 0.8 (L2–4), which is at the lower end of normal bone mineral density based on World Health Organization (WHO) criteria. One year later, a right total hip DXA scan reported a t score of 1.0 (L2–4), on the borderline of normal and osteopenia. Despite falling into the normal range for bone mineral density based on DXA results, she was diagnosed with osteoporosis, as per WHO criteria, because of her history of non-traumatic spinal


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compression fractures [which are known to inflate bone mineral density measures (Ryan et al., 1992)].

She stated that it was hard to sit up straight due to feeling weak and tired in the mid-back. 3.2. Physical examination findings

3. Methods The patient presented to the physiotherapist based on the recommendation of a physician in the Osteoporosis Program at the BC Women’s Health Centre. 3.1. Subjective examination The client reported thoracic backache and pain with movement or positions involving forward bending or leaning. The client also reported pain in the upper trapezius region bilaterally and occasional mild lower back pain (Fig. 1). The client reported that massage therapy gave her relief for a few minutes after treatment. The client was not currently engaged in a regular exercise regime. She had recently tried a group exercise class in the community for individuals with osteoporosis but stopped because she was not sure that a generic class was ideal given her history, and because she ‘‘doesn’t like exercise’’. She reported being active with her housework but avoiding vacuuming. The client reported height loss of 134 inches and that she had become more sedentary due to the illness and back pain. Her ability to undertake physical activity was affected by her fragility fractures (and concern about risk of future fractures), pain and weight gain associated with taking prednisolone.

3.2.1. Posture The client sat and stood with excessive mid-thoracic flexion. Her head was forward and her shoulders ‘rounded’. Arm swing was reduced during gait. 3.2.2. Active range of motion (ROM) Active ROM revealed slight restriction of cervical rotation bilaterally, slight restriction and discomfort (at the cervicothoracic junction) with cervical flexion, and restricted mid-thoracic motion in all directions, but severe restriction in right rotation and also in extension. The client had reduced shoulder elevation through flexion (limited by discomfort in the mid-back at 1401). 3.2.3. Passive ROM Passive intervertebral movement testing revealed moderate hypomobility in extension at T1–2 and T4–5 and severe hypomobility at T5–6, T7–8 and T9–10. Flexion was slightly limited at T4–5 and T7–8. Passive accessory movement testing with a caudad biased central posteroanterior (PA) mobilization revealed moderate hypomobility of T7, severe hypomobility at T2, T3, T6 and T8, and moderate hypomobility on cephalad biased central PA at T7 and T8. The client reported more pain with the T7 and T8 cephalad biased

Fig. 1. Pain Diagram. zzz ¼ deep ache, *** ¼ ache, +++ ¼ mild discomfort, I/M ¼ intermittent.


central PA, but all accessory movement tests were uncomfortable. Unilateral PA motion on the right was moderately restricted at T4, T5, T8, T11 and severely restricted at T2, T6 and T7. Unilateral PA motion on the left was severely restricted at T4, T6 and T11 and moderately restricted at T5 and T8. Transverse oscillatory pressure against the lateral aspect of the spinous process (Magarey, 1994) on the right side was severely restricted at T7–T9. 3.2.4. Motor control and general fitness The client was generally de-conditioned. In addition, the client had very poor control and endurance of the lower trapezius, deep neck flexors and transversus abdominis. She used an apical breathing pattern. 3.3. Interpretation of physical findings 3.3.1. Hypothesis Her mid-thoracic pain was related to the severe restriction of thoracic extension in the mid-thoracic joints that had resulted from numerous vertebral compression fractures. The reduced shoulder elevation was related to the reduced thoracic extension. The slight restriction of cervical rotation and flexion was related, in part, to restricted upper thoracic joint motion. The lack of control and endurance in her lower trapezius, deep cervical flexors and transversus abdominis muscles contributed to her poor posture, pain and feelings of weakness and tiredness when attempting to sit or stand up ‘straight’ or perform housework. Her general feelings of fatigue were related to her chronic pain and overall de-conditioned state. 3.4. Outcome measures and data analysis 3.4.1. Vertebral fractures A board-certified musculoskeletal radiologist with extensive experience in interpreting films in patients with osteoporosis evaluated pre- and post-treatment plain radiographs. 3.4.2. Back pain and function 3.4.2.1. McGill Pain Questionnaire (MPQ). The descriptor lists of the MPQ were read to the client with the explicit instruction that she choose only those words which describe her feelings and sensations of her worst back pain over the past 24 h. The MPQ data was examined by three indices consisting of the number of words chosen (NWC), the Pain Rating Index (PRI) and present pain intensity (PPI). The PRI is based on the rank values of the words. The word in each subclass implying the least pain is given a value of 1, the next word is given a value of 2 and so forth. PPI (pain at the time of testing) was scored on a scale of 0–5 where 0 ¼ no

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pain and 5 ¼ excruciating pain (Melzack and Torgerson, 1971). 3.4.2.2. Oswestry Disability Index (ODI). The ODI is a validated outcome measure used in the management of spinal disorders (Fairbank and Pynsent, 2000). Scores range from 0% to 100% with a higher score reflecting a greater degree of disability. This questionnaire was scored as reported previously (Fairbank and Pynsent, 2000). 3.4.3. Function and quality of life 3.4.3.1. Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO). QUALEFFO is a self-administered instrument designed to measure quality of life among adults with vertebral osteoporosis. It includes 41 items and the response to each item was scored from 1 to 5, except questions 23–28 (scored 1–3 or 1–4). The scale was reversed for questions 33–35, 37, 39, 40, to reflect a healthier score (1) to a less healthy sures (appears as improved function but may be seasonal). The same three measurement instruments were administered at baseline, 1 month and 3 months. 3.5. Pre-treatment measures—baseline data 3.5.1. Vertebral fractures Pre-treatment radiography revealed mild compression fractures (20% anterior height loss) at T5, T7, T9 and T10, a T11 crush fracture, 30% anterior height loss at T12, and 20% at L1, L2, L4 and L5 (Fig. 2). 3.5.2. Back pain 3.5.2.1. MPQ. When asked about her back pain over the past 24 h (at baseline), the NWC was 9, PRI was 18 and PPI was 2. 3.5.3. Back pain and function 3.5.3.1. ODI. Before treatment the client’s score was 18.0%. 3.5.4. Function and quality of life 3.5.4.1. QUALEFFO. Before treatment the client’s score was 56.0%.

4. Intervention Based on the subjective and physical examination findings and the interpretation of these findings, physiotherapy management included: postural training, specific exercise therapy, spinal mobilization, and the early stages of an exercise program for bone health. The client received a total of ten physiotherapy sessions over the 3-month intervention period—five sessions before


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the 1-month evaluation and five sessions between the 1- and 3-month evaluations. Postural training included exercises focused on scapular, head and neck position. Specific exercise therapy included training of her breathing pattern (less apical), transversus abdominis (Richardson et al., 1999), lower trapezius (Cools et al., 2003) and deep cervical flexors (Sterling et al., 2001; Jull et al., 2002). Spinal joint mobilization techniques were used in the thoracic and cervicothoracic regions. Predominantly grade III mobilization was used in the thoracic region and mostly grade IV in the cervicothoracic region. Specifically, unilateral PA mobilization was applied at T2, T6, T7 and T8. Transverse oscillatory pressure (right lateral aspect of the spinous process) was applied at T7–T9. The physiotherapist also prescribed a home exercise program which included stretching of the hip flexor, calf, gluteal, and hamstring muscle groups, and strengthening of the quads, gluteal, calf, triceps and upper body. Upper body exercises included functional drills using resistance tubing.

5. Results 5.1. Vertebral fractures—post-treatment radiography The radiologist reported no change in the appearance of the vertebrae on examination of radiographs taken 4 months after the start of physiotherapy. There was no clinical or radiological evidence of adverse effects after physiotherapy treatment including spinal mobilization. 5.2. Pain, function and quality of life A summary of changes from baseline (at the 1- and 3-month follow-ups) is presented in Table 1. 5.2.1. Pain The client experienced less pain following physiotherapy management including manual spinal joint mobilization, specific exercise therapy and postural re-education. Specifically, the patient reported a reduction in the number of hours of pain per day and number of days of pain per week after 3 months of treatment. In addition, at baseline she was getting less than 6 h of sleep per night yet 1 month after beginning treatment pain no longer prevented her from sleeping well. Her night pain remained reduced at the

Fig. 2. Plain radiographs of thoracic (A) and lumbar spine (B) showing mild compression fractures (20% anterior height loss) at T5, T7, T9, and T10, a T11 crush fracture, 30% anterior height loss at T12, and 20% at L1, L2, L4 and L5.


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Table 1 Changes in back pain, function and quality of life from baseline to 1 and 3 months Variable

Outcome measure

Baseline

1 month

3 months

Pain

MPQ

PRI ¼ 9 PPI ¼ 2 NWC ¼ 9 Back pain 4–6 days/wk 3–5 h back pain in the daytime Night pain 2 /wk Score ¼ 18% Pain affecting sleep despite taking meds Score ¼ 56% A little difficulty with bathing

PRI ¼ 3 PPI ¼ 2 NWC ¼ 3 Back pain everyday+ 6–10 h back pain in the daytime+ Night pain less than once/wk* Score ¼ 28%+ Pain not affecting sleep*

PRI ¼ 6* PPI ¼ 3+ NWC ¼ 6 Back pain 2–3 days/wk* 1–2 h back pain in the daytime* Night pain less than once/wk* Score ¼ 20% Pain not affecting sleep*

Score ¼ 51%* A little difficulty with bathing

Score ¼ 51%* Moderate difficulty with bathing+

Washing dishes with a little difficulty Great difficulty lifting and carrying a 20 lb object Participated in social activities less than once a month Overall fair

Washing dishes with a little difficulty Great difficulty lifting and carrying 20 lb object Participated in social activities 1–2 /month* Overall satisfactory*

Moderate difficulty washing dishes+ A little difficulty lifting and carrying 20 lb object* Participated in social activities 1–2 /wk or more* Overall fair

Tired in the morning Feels downhearted 3–5 days/wk Feels full of energy 1–2 days/wk Gets upset over little things quite often Often easy to make contact with people

Not tired in the morning* Feels downhearted once in a while* Feels full of energy 1–2 days/wk Gets upset over little things quite often Always easy to make contact with people*

Not tired in the morning* Feels downhearted once in a while* Almost never feels full of energy+ Sometimes gets upset over little things* Always easy to make contact with people*

QUALEFFO

Function

Oswestry

Quality of life

QUALEFFO Activities of daily living

Mobility General health perception Mental health

MPQ ¼ McGill Pain Questionnaire, Oswestry ¼ Oswestry Disability Index (ODI), QUALEFFO ¼ Quality of Life Questionnaire of the European Foundation for Osteoporosis, PPI ¼ Present Pain Intensity, PRI ¼ Pain Rating Index, NWC ¼ Number of Words Chosen, wk ¼ week, * ¼ improved as compared to baseline,+ ¼ worse compared to baseline.

3-month follow-up (Table 1). Her PPI score on the MPQ showed little change between baseline and followups, but her PRI improved and fewer words were chosen (NWC) (Table 1). 5.2.2. Function The patient’s outcome with regards to function was variable. She reported an increase in difficulty with bathing and washing dishes at 3-month follow-up yet could lift a heavy object of 20 lb (and carry it at least 10 yards) with less difficulty at 3 months than at baseline. Scores for the ODI are presented in Table 1. 5.2.3. Quality of life Her quality of life appeared to improve over the intervention period. Her QUALEFFO score showed consistent reduction (improved quality of life) from baseline (56.0%) to 1- and 3-month follow-ups (53.0% and 51.0%, respectively)—a 5% improvement in a short (3-month) intervention period. She participated in social activities more often and showed strong improvement on all but one mental health question (Table 1).

5.3. Physical examination findings at 1 and 3 months 5.3.1. One month Passive intervertebral movement testing revealed moderate hypomobility at T5–6 and T7–8 in extension and slight restriction at T4–5 and moderate restriction at T9-10 in flexion. Passive accessory movement testing revealed moderate hypomobility of central PA motion at T4 and T6 (caudad bias) and T8 (cephalad bias). Unilateral PA motion was moderately restricted on the left at T4 and T6, and slightly restricted at T8. The client could perform lower trapezius exercises in both prone and sitting, and the quality and endurance had improved (10 s hold, repeat 10 times, each side). 5.3.2. Three months Findings were similar to 1-month except for the following. Movement of T5–6 in extension and T9–10 in flexion improved. Unilateral PA motion was slightly restricted at T4 on the left. The client could perform transversus abdominis exercises in crook lying, without using an apical breathing pattern, for six repetitions with 8 s hold per repetition. Shoulder elevation through


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flexion improved to 1601, still limited by mid-back discomfort.

6. Discussion The authors present novel data on physiotherapy management of back pain in an individual with GIO and numerous vertebral compression fractures. The radiography results indicate that physiotherapy treatment including spinal mobilization caused no bony injury. As this is a single case report, conclusions must remain limited. All three outcome measures used in this study are valid and reliable (Klepac et al., 1981; Deyo et al., 1998; Lips et al., 1999; Badia et al., 2001; Fritz and Irrgang, 2001; Murrell et al., 2001; Sran et al., 2002), contributing to the strength of our investigation. The patient’s ODI scores increased by 5 points (10%) at the 1-month follow-up then decreased at the 3-month follow-up (4 points; 8%) (Table 1). This could be related to the tapering of prednisolone, which began shortly before the 1-month follow-up. One can also argue that this change is not clinically relevant or does not reflect real change. ‘‘Minimum detectable change’’ (MDC) is the amount of change required to be 90% confident that an observed change in scores reflects real change (Stratford et al., 1996). MDC reported for the ODI varies from four (Meade et al., 1990) to 17 points (Davidson and Keating, 2002), thus the one point difference from baseline to 3 months in our study may not reflect a ‘real’ change. Further, the literature suggests that the largest changes in ODI scores are seen in patients with primary back pain (Fairbank and Pynsent, 2000). This client’s history is indicative of secondary back pain, related to CML, secondary osteoporosis and numerous vertebral compression fractures. This may explain the small changes in ODI scores seen in this case. As the ODI does not distinguish between impairment arising from different vertebral regions, it is theoretically possible that changes in lumbar spine pathology would influence the overall ODI. However, the treating author’s (MS) clinical impression was that the patient’s lumbar spine symptoms were minimal and stable during this period. Although the 5% improvement we report on the QUALEFFO in this study may be considered of borderline clinical significance, some previous work from our group suggests that this instrument is not highly sensitive to change in an older adult population. In a study of 70-year-old women with osteoporosis, intervention participants who made marked improvement in physiological measures (Carter et al., 2001) and in qualitative measures (Khan, unpublished data), did not change from baseline in their QUALEFFO score.

However, we used the QUALEFFO because it is a valid and reliable disease-specific questionnaire developed for patients with back pain due to vertebral compression fractures (Lips et al., 1999; Badia et al., 2001). Further studies may be needed to investigate the responsiveness of this tool. This case documents safe use of spinal mobilization to treat back pain in an individual with previous vertebral fractures. Given the understandable concern about spinal mobilization in women with osteoporotic fractures, this case reports that the carefully applied procedure can be safe. The results of an in vitro laboratory study from our group suggest that the forces generated in some spinal mobilization techniques may be lower than the load required for vertebrae to fail (fracture) in this population (Sran et al., 2004). However, a larger in vivo trial is required before we can make general statements about the safety and effectiveness of spinal mobilization in populations with osteoporosis. References Adachi JD, Olszynski WP, Hanley DA, Hodsman AB, Kendler DL, Siminoski KG, et al. Management of corticosteroid-induced osteoporosis. Seminars in Arthritis and Rheumatism 2000;29(4):228–51. Adinoff AD, Hollister JR. Steroid-induced fractures and bone loss in patients with asthma. New England Journal of Medicine 1983;309(5):265–8. Badia X, Diez-Perez A, Alvarez-Sanz C, Diaz-Lopez B, Diaz-Curiel M, Guillen F, et al. Measuring quality of life in women with vertebral fractures due to osteoporosis: a comparison of the OQLQ and QUALEFFO. Quality of Life Research 2001;10(4):307–17. Carter ND, Khan KM, Petit MA, Heinonen A, Waterman C, Donaldson MG, et al. Results of a 10 week community based strength and balance training programme to reduce fall risk factors: a randomised controlled trial in 65–75 year old women with osteoporosis. British Journal of Sports Medicine 2001;35(5):348–51. Cools AM, Witvrouw EE, Declercq GA, Danneels LA, Cambier DC. Scapular muscle recruitment patterns: trapezius muscle latency with and without impingement symptoms. American Journal of Sports Medicine 2003;31(4):542–9. Davidson M, Keating JL. A comparison of five low back disability questionnaires: reliability and responsiveness. Physical Therapy 2002;82(1):8–24. Deyo RA, Battie M, Beurskens AJ, Bombardier C, Croft P, Koes B, et al. Outcome measures for low back pain research. A proposal for standardized use. Spine 1998;23(18):2003–13. Ernst E. Chiropractic spinal manipulation for (osteoporotic) back pain. British Journal of Sports Medicine 2003;37:195–6. Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine 2000;25(22):2940–52. Farrell JP, Twomey LT. Acute low back pain. Comparison of two conservative treatment approaches. The Medical Journal of Australia 1982;1(4):160–4. Fritz JM, Irrgang JJ. A comparison of a modified Oswestry Low Back Pain Disability Questionnaire and the Quebec Back Pain Disability Scale. Physical Therapy 2001;81(2):776–88. Goodsell M, Lee M, Latimer J. Short-term effects of lumbar posteroanterior mobilization in individuals with low-back pain.

ARTICLE IN PRESS M.M. Sran, K.M. Khan / Manual Therapy 11 (2006) 344–351 Journal of Manipulative and Physiological Therapeutics 2000; 23(5):332–42. Grieve G. Common Vertebral Joint Problems, second ed. New York: Churchill Livingstone; 1988. Hoving JL, Koes BW, de Vet HC, van der Windt DA, Assendelft WJ, van Mameren H, et al. Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain. A randomized, controlled trial. Annals of Internal Medicine 2002;136(10):713–22. Jordan VC, Gapstur S, Morrow M. Selective estrogen receptor modulation and reduction in risk of breast cancer, osteoporosis, and coronary heart disease. Journal of the National Cancer Institute 2001;93(19):1449–57. Jull G, Bogduk N, Marsland A. The accuracy of manual diagnosis for cervical zygapophyseal joint pain syndromes. The Medical Journal of Australia 1988;148(5):233–6. Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002;27(17):1835–43. Kelsey JL, White III AA. Epidemiology and impact of low-back pain. Spine 1980;5(2):133–42. Klepac RK, Dowling J, Hauge G. Sensitivity of the McGill Pain Questionnaire to intensity and quality of laboratory pain. Pain 1981;10(2):199–207. Leidig G, Minne HW, Sauer P, Wuster C, Wuster J, Lojen M, et al. A study of complaints and their relation to vertebral destruction in patients with osteoporosis. Bone and Mineral 1990;8(3):217–29. Lips P, Cooper C, Agnusdei D, Caulin F, Egger P, Johnell O, et al. Quality of life in patients with vertebral fractures: validation of the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO). Working Party for Quality of Life of the European Foundation for Osteoporosis. Osteoporosis International 1999;10(2):150–60. Lundberg G, Gerdle B. Correlations between joint and spinal mobility, spinal sagittal configuration, segmental mobility, segmental pain, symptoms and disabilities in female homecare personnel. Scandinavian Journal of Rehabilitation Medicine 2000;32:124–33. Magarey ME. Examination of the cervical and thoracic spine. In: Grant R, editor. Physical Therapy of the Cervical and Thoracic Spine. second ed. New York: Churchill Livingstone; 1994. Maitland GD, Banks K, English K, Hengeveld E. Maitland’s Vertebral Manipulation, sixth ed. Boston: Butterworth Heinemann; 2001. Malmros B, Mortensen L, Jensen MB, Charles P. Positive effects of physiotherapy on chronic pain and performance in osteoporosis. Osteoporosis International 1998;8:215–21. McGuiness J, Vicenzino B, Wright A. Influence of a cervical mobilization technique on respiratory and cardiovascular function. Manual Therapy 1997;2(4):216–20. Meade TW, Dyer S, Browne W, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. British Medical Journal 1990; 300:1431–7. Melzack R, Torgerson WS. On the language of pain. Anesthesiology 1971;34(1):50–9. Michel BA, Bloch DA, Fries JF. Predictors of fractures in early rheumatoid arthritis. Journal of Rheumatology 1991;18(6):804–8. Michel BA, Bloch DA, Wolfe F, Fries JF. Fractures in rheumatoid arthritis: an evaluation of associated risk factors. Journal of Rheumatology 1993;20(10):1666–9. Murrell P, Todd CJ, Martin A, Walton J, Lips P, Reeve J. Postal administration compared with nurse-supported administration of the QUALEFFO-41 in a population sample: comparison of results

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and assessment of psychometric properties. Osteoporosis International 2001;12(8):672–9. Niemisto L, Lahtinen-Suopanki T, Rissanen P, Lindgren KA, Sarna S, Hurri H. A randomized trial of combined manipulation, stabilizing exercises, and physician consultation compared to physician consultation alone for chronic low back pain. Spine 2003;28(19): 2185–91. O’Regan RM, Gradishar WJ. Selective estrogen-receptor modulators in 2001. Oncology (Huntingt) 2001;15(9) 1177–1185, 1189–1190. Patel U, Skingle S, Campbell GA, Crisp AJ, Boyle IT. Clinical profile of acute vertebral compression fractures in osteoporosis. British Journal of Rheumatology 1991;30(6):418–21. Phillips DR, Twomey LT. A comparison of manual diagnosis with a diagnosis established by a uni-level lumbar spinal block procedure. Manual Therapy 2000;1(2):82–7. Ramsey-Goldman R. Missed opportunities in physician management of glucocorticoid-induced osteoporosis? Arthritis and Rheumatism 2002;46(12):3115–20. Richardson C, Jull G, Hodges P, Hides J. Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain. New York: Churchill Livingstone; 1999. Ryan PJ, Evans P, Blake GM, Fogeman I. The effect of vertebral collapse on spinal bone mineral density measurements in osteoporosis. Bone and Mineral 1992;18(3):267–72. Sambrook PN. Corticosteroid osteoporosis: practical implications of recent trials. Journal of Bone and Mineral Research 2000;15(9): 1645–9. Sambrook PN. Glucocorticoid osteoporosis. Current Pharmaceutical Design 2002;8(21):1877–83. Sran MM. Chiropractic spinal manipulation for (osteoporotic) back pain; commentary. British Journal of Sports Medicine 2003;37: 195–6. Sran MM, Khan KM. Physiotherapy and osteoporosis: practice behaviors and clinicians’ perceptions—a survey. Manual Therapy 2004;10(1):21–7. Sran M, Souvlis T, Vicenzino B, Wright A. Characterisation of chronic lateral epicondylalgia using the McGill pain questionnaire, visual analog scales, and quantitative sensory tests. The Pain Clinic 2002;13(3):251–9. Sran MM, Khan KM, Zhu Q, McKay HA, Oxland TR. Failure characteristics of the thoracic spine with a posteroanterior load: investigating the safety of spinal mobilization. Spine 2004;29(21): 2382–8. Sterling M, Jull G, Wright A. Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity. Manual Therapy 2001;6(2):72–81. Stratford PW, Binkley J, Solomon P, Finch E, Gill C, Moreland J. Defining the minimum level of detectable change for the Roland–Morris questionnaire. Physical Therapy 1996;76(4): 359–65. Tobis JS, Hoehler F. Musculoskeletal Manipulation: Evaluation of the Scientific Evidence. Springfield, IL: Charles C. Thomas Publisher; 1986. Van Staa TP, Leufkens HG, Abenhaim L, Zhang B, Cooper C. Use of oral corticosteroids and risk of fractures. Journal of Bone and Mineral Research 2000;15(6):993–1000. Vicenzino B, Collins D, Benson H, Wright A. An investigation of the interrelationship between manipulative therapy-induced hypoalgesia and sympathoexcitation. Journal of Manipulative and Physiological Therapeutics 1998;21(7):448–53. Volinn E. The epidemiology of low back pain in the rest of the world. A review of surveys in low- and middle-income countries. Spine 1997;22(15):1747–54.

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Erratum

Erratum to ‘‘Sternocleidomastoid muscle imbalance in a patient with recurrent headache’’ [Manual Therapy 11(1), 78–82] Michael T. Cibulka Jefferson County Rehabilitation & Sports Clinic, 1330 YMCA Drive, Suite 1200, Festus, MO 63028, USA

In the second column on page 80 of the above paper, the sentence ‘The patient was then instructed to lift the left ear toward her chest (sternum) in the same way Kendall describes the SCM muscle tests (Kendall et al., 1993)’, should have read as below. ‘The patient was then instructed to lift the right ear toward her chest (sternum) in the same way Kendall describes the SCM muscle tests (Kendall et al., 1993)’.

DOI of original article: 10.1016/j.math.2005.01.006

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E-mail address: [email protected]. 1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.03.005

Manual Therapy (2006) 11(4), 353

Diary of events

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

The Society for Back pain Research Annual General Meeting 2006 2–3 November 2006 Gisborough Hall, Guisborough, North Yorkshire The Theme of the meeting will be ‘Fitness for Work’ Guest Speakers: Prof Mansel Aylward, Dr Leena Niemisto, Dr kaija Paustjarvi and Prof Gordon Waddell Full details are availabel at www.sbpr.info Abstracts should be submitted to [email protected] Deadline for abstract submission is 4 August 2006

If you wish to advertise a course/conference, please contact: Karen Beeton, Associate Head of School (Professional Development), School of Health and Emergency Professions, University of Hertfordshire, College Lane, Hatfield, Herts AL10 9AB, UK. There is no charge for this service.

10th International Conference in Mechanical Diagnosis and Therapy — The Evidence Mounts 23–25 March 2007 Queenstown, New Zealand Honorary Chairman: Robin McKenzie Presented by: The McKenzie Institute International For more information visit: www.mckenziemdt.org

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DOI: S1356-689X(06)00159-7

Volume Contents for Vol. 11, 2006 Vol. 11, No. 1 Editorial New years resolutions and personal and professional development 2006 A. Moore, G. Jull Masterclass The interpretation of experience and its relationship to body movement: A clinical reasoning perspective I. Edwards, M. Jones, S. Hillier Original Articles Subjective and objective descriptors of clinical lumbar spine instability: A Delphi study C. Cook, J.-M. Brismeé, P.S. Sizer Jr Flexor carpi radialis motoneuron pool in subjects with chronic carpal tunnel syndrome are more excitable than matched control subjects S. Jaberzadeh, S. Scutter The inter-examiner reliability of a classification method for non-specific chronic low back pain patients with motor control impairment W. Dankaerts, P.B. O’Sullivan, L.M. Straker, A.F. Burnett, J.S. Skouen The lumbar multifidus muscle and patterns of pain J. Cornwall, A. John Harris, S.R. Mercer Monitoring the change: Current trends in outcome measure usage in physiotherapy D. Abrams, M. Davidson, J. Harrick, P. Harcourt, M. Zylinski, J. Clancy The response of the transverse abdominis and internal oblique muscles to different postures A.-M. Ainscough-Potts, M.C. Morrissey, D. Critchley Test–retest reliability of cervicocephalic kinesthetic sensibility in three cardinal planes H.-Y. Lee, C.-C. Teng, H.-M. Chai, S.-F. Wang Diagnostic value of five clinical tests in patellofemoral pain syndrome J. Nijs, C. Van Geel, C. Van der auwera, B. Van de Velde Case Report Sternocleidomastoid muscle imbalance in a patient with recurrent headache M.T. Cibulka Letters to the Editor MACP Report Book Reviews List of Reviewers 2005 Diary of events Published only online Book Reviews

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28 40 46 54 61 69

78 84 85 87 88 90 e1–e2

Vol. 11, No. 2 Editorial The systematic review of systematic reviews has arrived! A. Moore, G. Jull Review Paper Methodological quality and outcomes of studies addressing manual cervical spine examinations: A review D. Hollerwo¨ger Original Articles The relationship of cervical joint position error to balance and eye movement disturbances in persistent whiplash J. Treleaven, G. Jull, N. LowChoy Effects of a manual therapy technique in experimental lateral epicondylalgia H. Slater, L. Arendt-Nielsen, A. Wright, T. Graven-Nielsen Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache G. Zito, G. Jull, I. Story Mulligan bent leg raise technique—a preliminary randomized trial of immediate effects after a single intervention T. Hall, S. Hardt, A. Scha¨fer, L. Wallin Electromyographic assessment of the activity of the masticatory using the agonist contract–antagonist relax technique (AC) and contract–relax technique (CR) S. Armijo, D.J. Magee Reliability and validity of shoulder tightness measurement in patients with stiff shoulders J.-j. Lin, J.-L. Yang Short Communication Vertebral artery dominance and hand preference: Is there a correlation? B. Cagnie, M. Petrovic, D. Voet, E. Barbaix, D. Cambier Case Report Osteochondritis dessicans: A complex case of anterior knee pain J. Davin, J. Selfe Book Reviews Letter to the Editor

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157 162 164

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355 Keynote Addresses Classification of lumbopelvic pain disorders—Why is it essential for management P. O’Sullivan Workshop: Clinical implications for clinicians treating patients with non-specific arm pain, whiplash and carpal tunnel syndrome J. Greening Tissue pathophysiology, neuroplasticity and motor behavioural changes in painful repetitive motion injuries A.E. Barr Measuring and managing pain and performance M.J. Simmonds Balancing the ‘bio’ with the psychosocial in whiplash associated disorders M. Sterling Original Articles The relationship between patella position and length of the iliotibial band as assessed using Ober’s test L. Herrington, N. Rivett, S. Munro Chronic musculoskeletal pain in chronic fatigue syndrome: Recent developments and therapeutic implications J. Nijs, M. Meeus, K. De Meirleir Musculoskeletal adaptations to resistance training in old age N.D. Reeves, M.V. Narici, C.N. Maganaris Sensorimotor contribution to shoulder stability: Effect of injury and rehabilitation J.B. Myers, C.A. Wassinger, S.M. Lephart Lumbar spine reposition sense: The effect of a ‘slouched’ posture K.J. Dolan, A. Green Motor control and the management of musculoskeletal dysfunction P.M. van Vliet, N.R. Heneghan A preliminary investigation into the relationship between cervical snags and sympathetic nervous system activity in the upper limbs of an asymptomatic population A. Moulson, T. Watson Myofascial trigger points in the suboccipital muscles in episodic tension-type headache C. Fernańdez-de-las-Penãs, C. Alonso-Blanco, M. Luz Cuadrado, J.A. Pareja Pathological muscle activation patterns in patients with massive rotator cuff tears, with and without subacromial anaesthetics F. Steenbrink, J.H. de Groot, H.E.J. Veeger, C.G.M. Meskers, M.A.J. van de Sande, P.M. Rozing Announcement 2nd International conference on Movement Dysfunction Elsevier Sponsored Awards—Best Oral and Best Poster Presentation M.S. Somerville, A. Russell, P.W. Hodges and M. Gorelick, M. Brown, H. Groeller Published only online Eccentric biceps Poster

169 171 173 175 180

182 187 192 197 202 208

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Vol. 11, No. 4 Editorial Adverse events and the vertebral artery: Can they be averted? D.A. Rivett

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Masterclass Cervical arterial dysfunction assessement and manual therapy R. Kerry, A.J. Taylor

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Review Paper The lumbar multifidus: Does the evidence support clinical beliefs? D.A. MacDonald, G. Lorimer Moseley, P.W. Hodges

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Original Articles The relationship beween posture and back muscle endurance in industrial workers with flexion-related low back pain P.B. O’Sullivan, T. Mitchell, P. Bulich, R. Waller, J. Holte Exercise therapy for low back pain: A small-scale exploratory survey of current physiotherapy practice in the Republic of Ireland acute hospital setting K. Byrne, C. Doody, D.A. Hurley Slump stretching in the management of non-radicular low back pain: A pilot clinical trial J.A. Cleland, J.D. Childs, J.A. Palmer, S. Eberhart Abdominal and pelvic floor muscle function in women with and without long lasting pelvic girdle pain B. Stuge, S. Mørkved, H. Haug Dahl, N. Vøllestad Comparison of the effectiveness of a behavioural graded activity program and manual therapy in patients with sub-acute neck pain: Design of a randomized clinical trial J.J.M. Pool, R.W.J.G. Ostelo, A.J. Ko¨ke, L.M. Bouter, H.C.W. de Vet Predictors for the immediate responders to cervical manipulation in patients with neck pain Y.-L. Tseng, W.T.J. Wang, W.-Y. Chen, T.-J. Hou, T.-C. Chen, F.-K. Lieu A perspective for considering the risks and benefits of spinal manipulation in patients with low back pain J.D. Childs, T.W. Flynn, J.M. Fritz Technical and Measurement Reports Inter-tester reliability of passive intervertebral and active movements of the cervical spine S.R. Piva, R.E. Erhard, J.D. Childs, D.A. Browder Interexaminer reliability of lumbar segmental mobility tests F. Johansson

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272 279 287

297 306 316

321 331

Professional Issue To treat or not to treat postpartum pelvic girdle pain with stabilizing exercises? B. Stuge, I. Holm, N. Vøllestad

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Case Report Is spinal mobilization safe in severe secondary osteoporosis?—a case report M.M. Sran, K.M. Khan

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Erratum to ‘‘Sternocleidomastoid muscle imbalance in a patient with recurrent headache’’ [Manual Therapy 11(1), 78–82] M.T. Cibulka

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Volume Contents, Author Index and Keyword index

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Author index A Abrams, D., 46 Ainscough-Potts, A.-M., 54 Alonso-Blanco, C., 225 Arendt-Nielsen, L., 107 Armijo, S., 136 B Barbaix, E., 153 Barr, A.E., 173 Bouter, L.M., 297 BrismeŁ e, J.-M., 11 Browder, D.A., 321 Bulich, P., 264 Burnett, A.F., 28 Byrne, K., 272 C Cagnie, B., 153 Cambier, D., 153 Chai, H.-M., 61 Chaitow, L., 83 Chen, T.-C., 306 Chen, W.-Y., 306 Childs, J.D., 279, 316, 321 Cibulka, M.T., 78, 352 Clancy, J., 46 Cleland, J.A., 279 Cook, C., 11 Cornwall, J., 40 Critchley, D., 54 D Dankaerts, W., 28 Davidson, M., 46 Davin, J., 157 de Groot, J.H., 231 De Meirleir, K., 187 de Vet, H.C.W., 297 Dolan, K.J., 202 Doody, C., 272 E Eberhart, S., 279 Edwards, I., 2 Erhard, R.E., 321 F Ferna¤ ndez-de-las-Pe•as, C., 225 Flynn, T.W., 316 Fritz, J.M., 316 G Graven-Nielsen, T., 107 Green, A., 202 Greening, J., 171 H Hall, T., 130 Hammond, J., 164 Harcourt, P., 46 Hardt, S., 130

Harrick, J., 46 Haug Dahl, H., 287 Heneghan, N.R., 208 Herrington, L., 182 Hillier, S., 2 Hodges, P.W., 254 Hollerw˛ger, D., 93 Holm, I., 337 Holte, J., 264 Hou, T.-J., 306 Hurley, D.A., 272 J

Peter, O., 169 Petrovic, M., 153 Piva, S.R., 321 Pool, J., 87 Pool, J.J.M., 297 R Reeves, N.D., 192 Rivett, D.A., 241 Rivett, N., 182 Rozing, P.M., 231 S

Jaberzadeh, S., 22 Johansson, F., 331 John Harris, A., 40 Jones, M., 2 Jull, G., 1, 91, 99, 118, 167 K Kerry, R., 243 Khan, K.M., 344 K˛ke, A.J., 297 L Lee, H.-Y., 61 Lephart, S.M., 197 Lieu, F.-K., 306 Lin, J.-j., 146 Lorimer Moseley, G., 254 LowChoy, N., 99 Luz Cuadrado, M., 225 M MacDonald, D.A., 254 Maganaris, C.N., 192 Magee, D.J., 136 Maigne, J.-Y., 165 McCarthy, C., 85 Meeus, M., 187 Mercer, S.R., 40 Meskers, C.G.M., 231 Mitchell, T., 264 Moore, A., 1, 91 Moore, A.P., 167 Mrkved, S., 287 Morrissey, M.C., 54 Moulson, A., 214 Munro, S., 182 Myers, J.B., 197 N Narici, M.V., 192 Nijs, J., 69, 187

Schaº fer, A., 130 Scutter, S., 22 Selfe, J., 157 Simmonds, M.J., 175 Sizer Jr, P.S., 11 Skouen, J.S., 28 Slater, H., 107 Sran, M.M., 344 Standen, C., 162 Steenbrink, F., 231 Sterling, M., 180 Story, I., 118 Straker, L.M., 28 Stuge, B., 287, 337 T Taylor, A.J., 243 Teng, C.-C., 61 Testa, M., 84 Treleaven, J., 99 Tseng, Y.-L., 306 V van de Sande, M.A.J., 231 Van de Velde, B., 69 van den Dolder, P.A., 163 Van der auwera, C., 69 Van Geel, C., 69 van Vliet, P.M., 208 Veeger, H.E.J., 231 Voet, D., 153 Vllestad, N., 287, 337 W Waller, R., 264 Wallin, L., 130 Wang, S.-F., 61 Wang, W.T.J., 306 Wassinger, C.A., 197 Watson, T., 214 Wright, A., 107

O O’Sullivan, P.B., 28, 264 Ostelo, R.W.J.G., 297

Y Yang, J.-L., 146 Z

P

Zito, G., 118 Zylinski, M., 46

Palmer, J.A., 279 Pareja, J.A., 225

356

Keyword index A Abdominal muscles 54 Activity levels 264 Agreement 28 Arterial dissection 243 Assessment 175 B Back muscle endurance 264 Balance 99 C Carpal tunnel syndrome 22, 171, 173 Cervical manipulation 306 Cervical movement 118 Cervical spine 93 Cervicogenic headache 118 Chronic low back pain 28 Chronic pain 2 Classification 28 Clinical instability 11 Clinical prediction rule 306 Clinical reasoning 2, 243 Compensation 46 Consistency 321 Construct validity 146 Coordination 231 D Deep abdominals 287 Delphi 11 Diagnosis 69 Dizziness 99

J Joint stability 197 K Kinaesthesia 61 L Lateral epicondylalgia 107 Low back mobility 331 Low back pain 130, 254, 264, 272, 279 Lumbar mobility 331 Lumbar multifidus 254 Lumbar spine 11, 202 M Manipulation 107 Manual assessment 93 Manual therapy 130, 214, 316, 331 Masticatory muscles 136 Measurement 321 Migraine 118 Mobilization 107 Motor behaviour 173 Motor control 208 Motor control impairment 28 Movement 2, 107 Mulligan 130 Multifidus 40 Muscle 192, 231 Muscle function 118 Musculoskeletal dysfunction 208 Myofascial trigger points 225 N

E Electromyography 231 Electromyography (EMG) 136 Evidence-based practice 337 Exercise 192 Exercise therapy 254, 272 Experimental muscle pain 107 Eye movement 99 H Haemodynamics 243 Head repositioning 61 Headache 78 H-reflex 22 Hypersensitivity 22 I Inflammation 173 Interexaminer reliability 331 Internal carotid artery 243 Interpreted experience 2 ITB 182

Neck pain 306, 321 Nerve mechanosensitivity 171 Nerve movement 171 Neurodynamics 279 Neuromuscular control 197 Non-specific arm pain 171 O Ober’s test 182 Old age 192 Outcome measures 46 Outcome predictor 306 P Pain 175, 231 Pain maps 40 Patella position 182 Patellofemoral 69 Patellofemoral pain syndrome 69 Pelvic floor 287 Physical performance 175 Physical therapy 11, 78, 316

357

Physiotherapy 272 Postpartum pelvic girdle pain 287, 337 Postural control 99 Posture 54, 202, 264 Principal action 231 Proprioception 61, 99, 197, 202 Proprioceptive neuromuscular facilitation techniques (PNF) 136 Q Questionnaires 46 R Referred pain 40, 225 Rehabilitation 208, 254 Relative risk 316 Reliability 28, 61, 93, 146 Repeated measures study 321 Repetitive motion injury 173 Reposition sense 202 Review 93, 254 Rotator cuff 231

Stiff shoulder 146 Straight leg raise 130 Suboccipital muscles 225 Survey 272 Sustained natural apophyseal glides (SNAGs) 214 Sympathoexcitation 214 T Teaching 2 Tear 231 Tendon 192 Tennis elbow 107 Tension-type headache 225 U UK BEAM 316 Ultrasound 287 Ultrasound imaging 171 Ultrasound scanning 54 Upper cervical spine 78 V

S Shoulder 231 Shoulder tightness 146 Slump stretching 279 Slump test 279 Stabilizing exercises 337

Validity 69 Vertebrobasilar insufficiency 243 W Whiplash 99, 171

358

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

Book review H. Biedermann, Manual Therapy in Children, Churchill Livingstone, New York, NY, ISBN 0443100187, 2004 (£29.99). The 332 pages of text are grouped into 5 main sections, 27 chapters and contain 250 illustrations. Section One (Basics) consists of a summary of the theoretical background for example embryology of the cervical spine and of the nervous system and senso- and neuromotor development of the first 5 years. Section Two (Clinical insights) looks at issues which may affect the neuromotor development of the child and presents approaches to the management of, e.g. birth intervention-trauma and asymmetry. Section 3 includes guidance for the examination and treatment of the neuromusculoskeletal system divided into different joint- and spinal regions. Method, interpretation and documentation of functional, radiology of the spine in young children are described in Section 4. The book concludes with various clinical patterns seen in young and older children that are based on the previously discussed biomechanical, neurological and functional disorders.

doi:10.1016/j.math.2005.06.003

This dominantly clinical book reflects the work of an editor/author with a long clinical expertise in this field. The chapters refer to current literature and most statements are based on the current scientific evidence. Interesting in this book is the overlap of knowledge and a common goal that is shared between different professions such as (neuro-) pediatricians, psychologists, orthodontists and manual therapists. Therefore this book reflects new ideas, thoughts and a multidisciplinary approach to this young patient population which is a new subject for most manual therapists. Up to this date hard evidence for the efficacy of treatment methods is lacking in this field but the book draws on enough clinically relevant and practical resources for manual therapists working with children. Furthermore it adds biomedical and clinical knowledge which could help to explain difficult clinical patterns in patients suffering from long-term head-, neck- and facial pain who are seen by manual therapist in their daily practice.

Harry J.M. von Piekartz Health Care Centre, Rijssen, Netherlands

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Book review R. Keer, R. Grahame, Hypermobility Syndrome: Recognition and Management for Physiotherapists, first ed., Butterworth-Heinemann, Stoneham, MA, ISBN 0750653906, 2003 (176pp., £29.99). This book is written to help physiotherapists (and manual therapists in my opinion) to recognize and treat patients with a hypermobility syndrome (hypermobility of multiple joints+complaints). Chapter 1 deals with recognition, epidemiology and complaints related to generalized joint hypermobility. Chapter 2 describes hypermobility and heritable connective tissue disorders such as the Marfan syndrome and the Ehlers Danlos Syndrome. Chapter 3 describes the overall management of the hypermobility syndrome. In Chapters 4, 5, and 6 the hypermobility syndrome is described for children, adolescents and adults, respectively. In these chapters clinical conditions related to the syndrome, musculoskeletal problems, presentation of complaints and physiotherapeutic assessment are described. Additionally the management of the syndrome is described in Chapters 4, 5 and 7 for children, adolescents and adults,

doi:10.1016/j.math.2005.06.004

respectively. In Chapter 8 the principles of rehabilitation, sports and performance of patients with joint hypermobility syndrome are described. Work-related musculoskeletal disorders and joint hypermobility are described in Chapter 9. In the last two chapters joint hypermobility in relation to chronic pain is discussed and joint hypermobility is reviewed from the patient’s perspective. The authors realize that the evidence for the effectiveness of physiotherapy management is scarce. If the evidence is not available they share their extensive clinical experience with the readers. The book provides an excellent overview of joint hypermobility and the hypermobility syndrome relevant for the physiotherapist and manual therapist.

Pieter Ubele Dijkstra Department of Rehabilitation and Department of Oral and Maxillofacial Surgery, University Hospital Groningen, The Netherlands

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Book review Elizabeth Holey, Eileen Cook, Evidence Based Therapeutic Massage: A Practical Guide for Therapists, second ed., Churchill Livingstone, New York, ISBN 0-44307230-2, 2003 (343pp., £ 29.99). Massage, in one form or another seems to be one of the most common interventions provided by physiotherapists. Despite its widespread use, massage is often perceived to be more of an art than a science. This text attempts to bridge that gap by bringing together the available evidence about massage and combine this with a guide about its practical and clinical applications. The book is divided into three broad areas. The first section lays the historical and theoretical groundwork of massage and has quite a detailed section on the anatomy of the skin, connective tissue, muscle and fluid dynamics including blood circulation and lymphatic systems. There is also a detailed chapter on the therapeutic and reflex effects of massage on the body’s various tissues and systems and the evidence base for this. The authors

doi:10.1016/j.math.2005.06.006

are thorough in dealing with the research into massage but are realistic that this research still leaves quite large gaps in our knowledge. Contraindications and precautions to massage are also covered well in this section. The second and third sections of this book go through the practical applications of massage and the different techniques that can be used with different regions, problems and with different patient groups. Wherever possible the findings from relevant studies are included. This book is well written and would appeal to therapists treating a wide range of patients, including those with sporting injuries, orthopaedic and rheumatological conditions as well as palliative and aged care patients. I have no hesitation in recommending this text as it provides both the undergraduate and postgraduate reader a solid foundation of the background, evidence and clinical application of massage.

Paul Andrew van den Dolder Auburn Hospital, Sydney, Australia

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Book review L. Chaitow, Palpation and Assessment Skills, second ed., Churchill Livingstone, New York, ISBN 0443072183, 2003 (£39,993, 48pp.). This 2-coloured book contains a mixture of more than hundred different palpation methods from many therapeutic backgrounds like manual therapy, osteopathy, chiropractic and acupuncture. Skills of joint, muscles and even Chinese pulse palpation are clearly described ending with exercises at the end of each chapter. A special CD Rom with video sequences of techniques accompanies the text. The techniques on the CD Rom compliment the text and are clearly performed by the author. This book not only shows palpation to be a powerful instruments in manual diagnosis and treatment, but also discusses recent research data of poor results in palpation accuracy. Interesting is the palpa-

doi:10.1016/j.math.2005.06.007

tion-reliability debate from experts, working in different professions, whereby there emerges a sense that palpation is a costly instrument for every practitioner/ therapist. References are updated to 2001. It is a pity that not all chapters have been reviewed. For example Chapter 7, which describes the assessment of the nervous system, still has a lot of terminology of the late 1980s. Also, in my opinion, a chapter on palpation skills linked in with pain management is missing. In summary, this is a clear and comprehensive workbook review for practitioners/therapists who want to refine and explore further their palpation skills.

Harry J.M. von Piekartz Health Care Center, Wierden, Netherlands

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Book review J Smith (Ed.), Structural Bodywork, first ed., Elsevier, Amsterdam, ISBN 0-44310-018-7, 2005 (£29.99, 368pp.). This book has been very interesting to read. It is not the type I would naturally read, but I have found it very thought provoking. The author attempts to describe and explore the whole notion and practice of structural bodywork (soft-tissue assessment and treatment). It is written gently and with great insight. The first section describes historical developments of structural bodywork, with particular attention to Rolfing. The second section explores concepts and the basic science of the body’s soft-tissues. The third section provides a practical guide/training for treatment techniques—photographic and very clear. I suspect that an in-depth and detailed study of fascia and connective tissue is not fully developed within osteopathic/chiropractic/physiotherapy undergraduate courses; so, this book would be great for students and young graduates

doi:10.1016/j.math.2005.08.001

wishing to develop and explore soft-tissue techniques for clinic. After initial enthusiasm though, and it is often the case for books on ‘therapy’, on closer scrutiny, the referencing is far from scientific, usually from books, rarely from peer-review publication. What can seem radical and revolutionary, drifts into ‘wouldn’t it be great if!! This seems to be the same with structural bodywork. The therapy is very passive, but contemporary research of musculoskeletal dysfunction/treatment, suggests that active management achieves the best results, possibly combined with cognitive and behavioural intervention, a more holistic approach. So, I am left wondering if the confidence that the author demonstrates in this form of therapy is justified? You ought to read and make up your own mind though. Tim McClune Spinal Research Unit, University of Huddersfield, UK

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Book review S. Lawrence Nordoff, Motor Vehicle Collision Injuries: Biomechanics, Diagnosis and Management, Jones and Bartlett Publishers, Boston, MA, ISBN 0763733350, 2005 (638pp.). This second edition is an impressive and very extensive book. It is wide-ranging, and with a sufficient scientific body of knowledge to justify publication for a broad public of readers over many disciplines. The book consists of 22 Chapters, which could be split up in several groups: Chapter 1 is a general introduction titled ‘Motor vehicle collision facts in America’, followed by 6 Chapters with regard to examination in all relevant aspects: history and physical examination strategies, diagnosis of common crash injuries, radiological evaluation of spinal trauma following motor vehicle crashes, and neurodiagnosis for injuries from automobile accidents (Chapters 2–6). Chapter 7 deals with the basic concepts of soft tissue healing and factors influencing recovery, followed by 5 Chapters with regard to the management of motor vehicle crash injuries and sequel: really all conceivable approaches are discussed and hold against the light of the clinical relevance and the scientific evidence. This also includes emerging trends in traumatic spine injury care, time off work, return to work, and disability after

doi:10.1016/j.math.2005.08.005

automobile crashes, and the initial and long-term symptoms following traffic accidents. The next 6 Chapters (Chapter 14–19) concern the epidemiological considerations, biomechanics and injuries of different kind of crashes: frontal collisions, side crashes, rear-end collisions, and the human factors that could influence injury and recovery. Finally, Chapters 20–22 deal with ‘going to court’, evidence for chiropractic treatment, and tips in writing reports for medical doctors, insurance companies and others. Besides the author, 15 co-authors have contributed their real-world expertise in this field. A strong aspect of this book is that it does not only focus on whiplash injuries, but on all kind of motor vehicle crashes and its consequences. With close to 1600 references cited, this second edition has become one of the most thoroughly referenced texts available, demonstrating good scientific background, but at the same time a high relevance for clinical practice. A useful reference book for every discipline dealing with victims of motor vehicle crashes.

Raymond Swinkels Health Care Centre Coevering, Geldrop, The Netherlands

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Book review J.D. Boyling, G.A. Jull, Grieve’s Modern Manual Therapy: The Vertebral Column, Churchill Livingstone, New York, ISBN 0443071551, 2004 (643pp). Reviewing a text such as Modern Manual Therapy (3rd edition) is a somewhat daunting prospect. It is a diverse and detailed volume which charts the progress of spinal manual therapy into the 21st century. In the decade since the previous edition was published, the body of biomedical and clinical research relevant to manual therapy, and the related methods of practice have grown and developed rapidly. Modern Manual Therapy presents a state of the art review of these issues in a highly readable and well-referenced text. The ‘Foundation Sciences’ section contains a series of chapters which review the anatomy and biomechanics of the various spinal regions with a strong clinical focus. Four chapters in this section are dedicated to motor control and the impact of spinal pain on the motor system. These chapters bring together key elements of motor control theory with contemporary research findings, which define the impairments of motor control commonly associated with spinal pain disorders. The comprehensive chapter on pain neurophysiology spans the peripheral nociceptor to the forebrain. This highlights the potential responses of the nervous system to injury, and provides some new insights into the possible avenues for pain modulation. The ‘Clinical Sciences’ section includes chapters on specific pathologies such as osteoporosis, vertebral artery insufficiency, neuropathic pain and cervical vertigo. Common patterns of clinical presentation relevant to manual therapy practice such as cervicogenic headache, whiplash injuries and lumbar spine clinical instability are also included in this section. This is an interesting section of the text which is something of a transition between the biomedical sciences presented in the earlier chapters, and the clinical practice chapters in

doi:10.1016/j.math.2005.08.006

the following section. This highlights the emergence of manual therapy as a discipline which continues to develop on a foundation of clinical science, and the substantial overlap between biological and clinical research. The ‘Practices of Manual Therapy’ section begins with chapters which present the neurophysiological and biomechanical effects of manual therapy procedures, followed by two chapters which review the clinical reasoning process in relation to the diagnosis and management of spinal pain. An excellent series of chapters in this section provide an overview of clinical management for various spinal pain disorders, all written by respected leaders in their area of clinical expertise. The chapters on vascular pathology provide good balance in this section, and are a reminder of the importance of a considered diagnostic process in patient management. The final section will appeal to manual therapists seeking a better understanding of issues related to evidence-based practice. This is a new direction for Modern Manual Therapy, and a welcome and timely addition. The role of evidence-based practice in manual therapy, outcome measurement, clinical trial methodology and treatment guidelines are all specifically addressed by authors with significant experience in conducting clinical trials or systematic reviews. As a manual therapy teacher and practitioner I highly recommend this text to manual therapists entering the relevant professions, as well as those seeking to update their knowledge. It is comprehensive, well referenced and extensively illustrated and is an excellent resource for contemporary manual therapy practice.

Stephen Edmondston School of Physiotherapy, Curtin University of Technology, Perth, Australia

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Book review Steven J. Linton, Understanding Pain for Better Clinical Practice: a Psychological Perspective, Elsevier, Amsterdam, ISBN 0444515917, 2005 (180pp., £59.95). This book is a comprehensive and practical guide for every care giver working with patients in pain. It elucidates working mechanisms of psychological factors influencing thoughts, feelings and behaviours of people in pain. Understanding these influencing psychological processes better might enhance our understanding, communication, and treatment of persons with a pain problem. This book contains two sections with eight and six chapters, respectively. Furthermore, an appendix was added in which a manual has been described for an early cognitive-behavioural group-treatment. The first part concerns the psychology of pain perception and behaviour. Different aspects of the psychology of pain, beliefs we have about pain, cognitions, emotions, etc. are explained. In the last chapter of this section a psychological model is presented, building on the previous chapters, integrating all influencing psychological factors in one framework. The second part refers to the implications of these ‘normal’ psychological reactions for clinical practice. A special interest is given to the prevention of pain becoming chronic, which is the reason why the author

doi:10.1016/j.math.2005.08.007

puts special emphasis on screening patients at risk of developing a chronic pain problem, effective patient communication, and early interventions. It is also the reason the author starts the clinical section of the book describing the first visit of a patient with his healthcare provider. The author views this first visit essential in enhancing self-care and educating the patient. Throughout the book, a case study is presented illustrating the described psychological processes and consecutively the application of the techniques at issue in clinical practice. This book provides a compact overview of the latest scientific knowledge available concerning the psychology of pain. It is relevant for both clinicians and students. It reports on psychological factors that influence the perception of pain from the beginning of a pain problem. A better knowledge of these factors might increase the healthcare provider’s awareness of possible pitfalls in the treatment of patients with pain, and together with the more clinical focus addressed in part 2 it might enhance early interventions, in this way possibly preventing long lasting pain from being established. Ilse Swinkels-Meewisse Department of Medical, Clinical and Experimental Psychology, University of Maastricht, The Netherlands

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Book review E. Lederman, The Science and Practice of Manual Therapy, Churchill Livingstone, ISBN 0443074321, 2005 (317pp.). This book is presented as a second edition of the first work of Eyal Lederman that was published in 1997 as ‘Fundamentals of manual therapy: physiology, neurology, and psychology’. This updated edition represents a comprehensive, scientifically based and profound work on the fundamentals for manual therapy on the tissue dimensions, the neurological dimensions and the psychophysiological processes involved. These three dimensions also represent the construct of the book. Section one reflects on aspects of the effects of manual therapy on the tissues, tissue repair, and tissue adaptation. The second section consists of fourteen chapters discussing topics such as the effect of manual therapy on proprioception, neuromuscular ‘re-abilitation’, psychomotor and behavioral conditions and muscle tone. The author succeeds in maintaining the reader’s attention by sometimes looking at things in a not so classical way. For instance, in chapter 9 on the motor system, some classical principles are presented in a new/renewed look at co-activation motor-patterns in relation to stability and movement. The figures and

doi:10.1016/j.math.2006.05.002

tables in this as well as in the following sections are very expressive and meaningful in underlining the content. In the third section manual therapy is considered in its psychological/psychophysiological dimension including reflections on the psychosomatic field and the therapeutic potential of touch. Each section is completed with an extensive reference list including several recent publications. As references are used several times throughout each section it is inherent in the numerical classification system that the retrieval of the references becomes laborious. The referral in the title to ‘the practice of manual therapy’ applies mainly to the clinical implications of the fundamental scientific topics discussed in each section. The reader should not expect a book on techniques or exercises. However the content of the book applies to all therapeutic techniques where the hands are used as instruments, and not only to manual therapy in the strict sense of manual articular techniques. Therefore the book can be of major interest for physiotherapists as well as manual therapists, chiropractors and osteopaths, students as well as lecturers. Erik Cattrysse Vrije Universiteit Brussel, Brussels, Belgium E-mail address: [email protected]

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Book review Rosemary A. Payne (Ed.), Relaxation Techniques, third ed., Elsevier, Churchill Livingstone, ISBN 044307447X, 2005 (288pp.). This book on relaxation techniques can be regarded as an overview of most (if not all) of the relevant relaxation approaches used in the treatment of stressrelated problems. As such, it is a standard work for all health professionals, students and lay-people who wish to increase their understanding of the causes and impact of these kind of problems. In its extent, this work provides more than a simple introduction to the concepts of relaxation. Besides extensive theoretical information on most techniques, it also provides information on practical applications. After an introductory section, the two main groups of relaxation techniques are covered in sections two and three. In these sections, somatic methods of relaxation (progressive relaxation, passive muscular relaxation, behavioral relaxation training, the Mitchel method, the Alexander technique, physical exercise, breathing, etc.) and cognitive approaches (self-awareness, autogenic training, cognitive behavioral approaches, etc.) are

doi:10.1016/j.math.2006.05.003

introduced and discussed. Each chapter on a technique includes an introduction and rationale, and a description of the procedure, including the information and formulations therapists should use for their trainees. Interestingly, the author includes a brief paragraph on pitfalls in each chapter. This third edition adds some rewritten and extra chapters to both previous editions. It includes now a chapter on research results relating to specific techniques and on relaxation therapy in general. Though such an inclusion is worthwhile, the reader should be aware that a non-systematic analysis of the literature does not represent evidence of effectiveness. Health professionals, who already possess an earlier version, will appreciate the additional aspects of this third version. For those not familiar with the previous editions, it may prove to be a worthy addition to their library.

Erik Cattrysse Vrije Universiteit Brussel, Brussels, Belgium E-mail address: [email protected].

Manual Therapy Journal - Volume 11, Issue 4, Pages 241-358 (November 2006)

Manual Therapy Journal - Volume 12, Issue 4, Pages 297-396 (November 2007)

Manual Therapy Journal - Volume 10, Issue 4, Pages 239-304 (November 2005)

Manual Therapy Journal - Volume 8, Issue 4, Pages 193-270 (November 2003)

Manual Therapy Journal - Volume 9, Issue 4, Pages 183-246 (November 2004)

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

Manual Therapy Journal - Volume 11, Issue 3, Pages 167-240 (August 2006)

Manual Therapy Journal - Volume 11, Issue 2, Pages 91-166 (May 2006)

Manual Therapy Journal - Volume 13, Issue 4, Pages 277-372 (August 2008)

Manual Therapy Journal - Volume 14, Issue 4, Pages 353-460 (August 2009)

Spektrum der Wissenschaft November 2006 issue 11

Manual Therapy Journal - Volume 14, Issue 2, Pages 117-240 (April 2009)

Manual Therapy Journal - Volume 13, Issue 2, Pages 91-180 (April 2008)

Manual Therapy Journal - Volume 14, Issue 5, Pages 461-584 (October 2009)

Manual Therapy Journal - Volume 8, Issue 2, Pages 63-128 (May 2003)

Manual Therapy Journal - Volume 8, Issue 1, Pages 1-62 (February 2003)

Manual Therapy Journal - Volume 8, Issue 3, Pages 129-192 (August 2003)

Manual Therapy Journal - Volume 13, Issue 1, Pages 1-90 (February 2008)

Manual Therapy Journal - Volume 12, Issue 3, Pages 199-296 (August 2007)

Manual Therapy Journal - Volume 10, Issue 1, Pages 1-92 (February 2005)

Manual Therapy Journal- Volume 13, Issue 6, Pages 475-564 (December 2008)

Manual Therapy Journal - Volume 12, Issue 1, Pages 1-84 (February 2007)

Manual Therapy Journal - Volume 12, Issue 2, Pages 85-198 (May 2007)

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

Manual Therapy Journal - Volume 10, Issue 2, Pages 93-174 (May 2005)

Manual Therapy Journal - Volume 14, Issue 1, Pages 1-116 (February 2009)

Manual Therapy Journal - Volume 9, Issue 2, Pages 59-120 (May 2004)

Manual Therapy Journal - Volume 14, Issue 6, Pages 585-716 (December 2009)

Manual Therapy Journal - Volume 13, Issue 3, Pages 181-276 (June 2008)

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

Manual Therapy Journal - Volume 14, Issue 3, Pages 241-352 (June 2009)

Manual Therapy Journal - Volume 11, Issue 4, Pages 241-358 (November 2006)

Manual Therapy Journal - Volume 12, Issue 4, Pages 297-396 (November 2007)

Manual Therapy Journal - Volume 10, Issue 4, Pages 239-304 (November 2005)

Manual Therapy Journal - Volume 8, Issue 4, Pages 193-270 (November 2003)

Manual Therapy Journal - Volume 9, Issue 4, Pages 183-246 (November 2004)

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

Manual Therapy Journal - Volume 11, Issue 3, Pages 167-240 (August 2006)

Manual Therapy Journal - Volume 11, Issue 2, Pages 91-166 (May 2006)

Manual Therapy Journal - Volume 13, Issue 4, Pages 277-372 (August 2008)

Manual Therapy Journal - Volume 14, Issue 4, Pages 353-460 (August 2009)

Spektrum der Wissenschaft November 2006 issue 11

Manual Therapy Journal - Volume 14, Issue 2, Pages 117-240 (April 2009)

Manual Therapy Journal - Volume 13, Issue 2, Pages 91-180 (April 2008)

Manual Therapy Journal - Volume 14, Issue 5, Pages 461-584 (October 2009)

Manual Therapy Journal - Volume 8, Issue 2, Pages 63-128 (May 2003)

Manual Therapy Journal - Volume 8, Issue 1, Pages 1-62 (February 2003)

Manual Therapy Journal - Volume 8, Issue 3, Pages 129-192 (August 2003)

Manual Therapy Journal - Volume 13, Issue 1, Pages 1-90 (February 2008)

Manual Therapy Journal - Volume 12, Issue 3, Pages 199-296 (August 2007)

Manual Therapy Journal - Volume 10, Issue 1, Pages 1-92 (February 2005)

Manual Therapy Journal- Volume 13, Issue 6, Pages 475-564 (December 2008)

Manual Therapy Journal - Volume 12, Issue 1, Pages 1-84 (February 2007)

Manual Therapy Journal - Volume 12, Issue 2, Pages 85-198 (May 2007)

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

Manual Therapy Journal - Volume 10, Issue 2, Pages 93-174 (May 2005)

Manual Therapy Journal - Volume 14, Issue 1, Pages 1-116 (February 2009)

Manual Therapy Journal - Volume 9, Issue 2, Pages 59-120 (May 2004)

Manual Therapy Journal - Volume 14, Issue 6, Pages 585-716 (December 2009)

Manual Therapy Journal - Volume 13, Issue 3, Pages 181-276 (June 2008)

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

Manual Therapy Journal - Volume 14, Issue 3, Pages 241-352 (June 2009)

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