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

VOLUME 12 NUMBER 4 PAGES 297– 396 November 2007 Editors International Advisory Board Ann Moore PhD, GradDipPhys, FCSP...

Author: Editors: Ann Moore and Gwen Jull

27 downloads 747 Views 3MB Size Report

This content was uploaded by our users and we assume good faith they have the permission to share this book. If you own the copyright to this book and it is wrongfully on our website, we offer a simple DMCA procedure to remove your content from our site. Start by pressing the button below!
Report copyright / DMCA form

DOWNLOAD PDF

VOLUME 12 NUMBER 4 PAGES 297– 396 November 2007

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

Gwendolen Jull PhD, MPhty, Grad Dip ManTher, FACP Department of Physiotherapy University of Queensland Brisbane QLD 4072, Australia Associate Editor’s Darren A. Rivett PhD, MAppSc, (ManipPhty) GradDipManTher, BAppSc (Phty) Discipline of Physiotherapy Faculty of Health The University of Newcastle Callaghan, NSW 2308, Australia Tim McClune D.O. Spinal Research Unit. University of Hudders¢eld 30 Queen Street Hudders¢eld HD12SP, UK Editorial Committee Masterclass Editor Karen Beeton PhD, MPhty, BSc(Hons), MCSP MACP ex o⁄cio member Associate Head of School (Professional Development) School of Health and Emergency Professions University of Hertfordshire College Lane Hat¢eld AL10 9AB, UK Case reports & Professional Issues Editor Je¡rey D. Boyling MSc, BPhty, GradDipAdvManTher, MCSP, MErgS Je¡rey Boyling Associates Broadway Chambers Hammersmith Broadway LondonW6 7AF, UK Book Review Editor Raymond Swinkels MSc, PT, MT Ulenpas 80 5655 JD Eindoven The Netherlands

Visit the journal website at http://www.intl.elsevierhealth.com/journals/math doi:10.1016/S1356-689X(07)00134-8

DOI: S1356-689X(07)00141-5

Volume Contents for Vol. 12, 2007 Vol. 12, No. 1 Editorial Dealing with heterogeneity in clinical trials R. Herbert Review Paper An evidence-based review on the validity of the Kaltenborn rule as applied to the glenohumeral joint C. Brandt, G. Sole, M.W. Krause, M. Nel Original Articles Work-related thumb pain in physiotherapists is associated with thumb alignment during performance of PA pressures A. Wajon, L. Ada, K. Refshauge Repeatability of skin displacement and pressure during ‘‘inhibitory’’ vastus lateralis muscle taping J.U. McCarthy Persson, A.C.B. Hooper, H.E. Fleming Cervicocephalic kinesthetic sensibility in young and middle-aged adults with or without a history of mild neck pain C.-C. Teng, H. Chai, D.-M. Lai, S.-F. Wang Myofascial trigger points in subjects presenting with mechanical neck pain: A blinded, controlled study C. Fernańdez-de-las-Penãs, C. Alonso-Blanco, J.C. Miangolarra Cranio-cervical flexor muscle impairment at maximal, moderate, and low loads is a feature of neck pain S. O’Leary, G. Jull, M. Kim, B. Vicenzino The clinical reasoning of pain by experienced musculoskeletal physiotherapists K. Smart, C. Doody The clinical examination of neck pain patients: The validity of a group of tests W.J. De Hertogh, P.H. Vaes, V. Vijverman, A. De Cordt, W. Duquet Palpation identification of spinous processes in the lumbar spine J.C. Harlick, S. Milosavljevic, P.D. Milburn Effectiveness of specific soft tissue mobilizations for the management of Achilles tendinosis: Single case study—Experimental design R.E. Christenson

63

Technical and Measurement Report The reliability of selected motion- and pain provocation tests for the sacroiliac joint H.S. Robinson, J.I. Brox, R. Robinson, E. Bjelland, S. Solem, T. Telje

72

Case Report A contractile dysfunction of the shoulder C. Littlewood, S. May

80

Diary of events Published only Online Letters to the Editor Book Review

1

3

12 17 22 29 34 40 50 56

84 e1–e8 e9

Vol. 12, No. 2 Editorial New year electronic resolutions! A. Moore, G. Jull

85

Masterclass Diagnosis and classification of pelvic girdle pain disorders Part 1: A mechanism based approach within a biopsychosocial framework P.B. O’Sullivan, D.J. Beales

86

Review Mulligan’s mobilization-with-movement, positional faults and pain relief: Current concepts from a critical review of literature B. Vicenzino, A. Paungmali, P. Teys

98

Original Articles The initial effects of knee joint mobilization on osteoarthritic hyperalgesia P. Moss, K. Sluka, A. Wright Associated sagittal spinal movements in performance of head pro- and retraction in healthy women: A kinematic analysis P. Rune Persson, H. Hirschfeld, L. Nilsson-Wikmar Mechanical Diagnosis and Therapy approach to assessment and treatment of derangement of the sacro-iliac joint S.J. Horton, A. Franz Initial development of a device for controlling manually applied forces G.S. Waddington, R.D. Adams Recruitment of the deep cervical flexor muscles during a postural-correction exercise performed in sitting D. Falla, S. O’Leary, A. Fagan, G. Jull Direct, quantitative clinical assessment of hand function: Usefulness and reproducibility A. Goodson, A.H. McGregor, J. Douglas, P. Taylor Neurodynamic responses in children with migraine or cervicogenic headache versus a control group. A comparative study H.J.M. von Piekartz, S. Schouten, G. Aufdemkampe Measurement of lumbar multifidus muscle contraction with rehabilitative ultrasound imaging K.B. Kiesel, T.L. Uhl, F.B. Underwood, D.W. Rodd, A.J. Nitz Attitudes to back pain amongst musculoskeletal practitioners: A comparison of professional groups and practice settings using the ABS-mp T. Pincus, N.E. Foster, S. Vogel, R. Santos, A. Breen, M. Underwood Findings of interest from immunology and psychoneuroimmunology L. Alford Case Report The use of a mechanism-based classification system to evaluate and direct management of a patient with non-specific chronic low back pain and motor control impairment—A case report W. Dankaerts, P.B. O’Sullivan, A.F. Burnett, L.M. Straker

I

109 119 126 133 139 144 153 161 167 176

181

Technical and Measurement Report Evaluation of repeatability of pressure algometry on the neck muscles for clinical use J. Ylinen, M. Nyka¨nen, H. Kautiainen, A. Ha¨kkinen Diary of events Published only Online Diagnosis and classification of pelvic girdle pain disorders, Part 2: Illustration of the utility of a classification system via case studies Book Reviews

192 198 e1–e12 e13–e16

Vol. 12, No. 3 Editorial Physiotherapists: Closer Together, not Worlds Apart A. Moore, G. Jull Review Paper Iliotibial band friction syndrome—A systematic review R. Ellis, W. Hing, D. Reid Original Articles Changes in pelvic floor and diaphragm kinematics and respiratory patterns in subjects with sacroiliac joint pain following a motor learning intervention: A case series P.B. O’Sullivan, D.J. Beales Activation of vastus medialis oblique is not delayed in patients with osteoarthritis of the knee compared to asymptomatic participants during open kinetic chain activities J. Dixon, T.E. Howe The validity of clinical measures of patella position I. McEwan, L. Herrington, J. Thom Strain on the repaired supraspinatus tendon during manual traction and translational glide mobilization on the glenohumeral joint: A cadaveric biomechanics study T. Muraki, M. Aoki, E. Uchiyama, T. Miyasaka, G. Murakami, S. Miyamoto Changes in postural activity of the trunk muscles following spinal manipulative therapy M.L. Ferreira, P.H. Ferreira, P.W. Hodges Assessment of fine motor control in patients with occupation-related lateral epicondylitis D.K. Skinner, S.L. Curwin The diagnostic validity of the cervical flexion–rotation test in C1/2-related cervicogenic headache M. Ogince, T. Hall, K. Robinson, A.M. Blackmore Accuracy and reliability of observational motion analysis in identifying shoulder symptoms B.W. Hickey, S. Milosavljevic, M.L. Bell, P.D. Milburn The influence of specific training on trunk muscle recruitment patterns in healthy subjects during stabilization exercises V.K. Stevens, P.L. Coorevits, K.G. Bouche, N.N. Mahieu, G.G. Vanderstraeten, L.A. Danneels Case Report Improved contraction of the transversus abdominis immediately following spinal manipulation: A case study using real-time ultrasound imaging N.W. Gill, D.S. Teyhen, I.E. Lee Technical and Measurement Report Measurement of segmental cervical multifidus contraction by ultrasonography in asymptomatic adults J.-P. Lee, W.-Y.I. Tseng, Y.-W. Shau, C.-L. Wang, H.-K. Wang, S.-F. Wang Diary of events Published only Online Letter to the Editor Book Reviews

199

200

209

219 226

231 240 249 256 263 271

280

286 295 e1 e2–e8

Vol. 12, No. 4 Editorial Sharing good practice A. Moore, G. Jull Masterclass Hypermobility and the hypermobility syndrome J.V. Simmonds, R.J. Keer Systematic Review Advice for the management of low back pain: A systematic review of randomised controlled trials S. Dianne Liddle, J.H. Gracey, G. David Baxter Original Articles Construct validity of lumbar extension measures in McKenzie’s derangement syndrome H.A. Clare, R. Adams, C.G. Maher The development and use of mass media interventions for health-care messages about back pain: What do members of the public think? K.L. Barker, C.J. Minns Lowe, M. Reid Manual fixation versus locking during upper cervical segmental mobilization. Part 1: An in vitro three-dimensional arthrokinematic analysis of manual flexion–extension mobilization of the atlanto-occipital joint E. Cattrysse, J.P. Baeyens, J.P. Clarys, P. Van Roy Manual fixation versus locking during upper cervical segmental mobilization. Part 2: An in vitro three-dimensional arthrokinematic analysis of manual axial rotation and lateral bending mobilization of the atlanto-axial joint E. Cattrysse, J.P. Baeyens, J.P. Clarys, P. Van Roy Postural neck pain: An investigation of habitual sitting posture, perception of ‘good’ posture and cervicothoracic kinaesthesia S.J. Edmondston, H.Y. Chan, G. Chi Wing Ngai, M.L.R. Warren, J.M. Williams, S. Glennon, K. Netto The use of surface electromyography as a tool in differentiating temporomandibular disorders from neck disorders V.F. Ferrario, G.M. Tartaglia, F.E. Luraghi, C. Sforza

297

298

310

328

335

342

353 363

372

Technical and Measurement Reports Wireless orientation sensors: Their suitability to measure head movement for neck pain assessment J.M. Jasiewicz, J. Treleaven, P. Condie, G. Jull Clinical measurement of posterior shoulder flexibility J.D. Borstad, K.M. Mathiowetz, L.E. Minday, B. Prabhu, D.E. Christopherson, P.M. Ludewig

380

Case Report Acute neck pain: Cervical spine range of motion and position sense prior to and after joint mobilization P.J. McNair, P. Portero, C. Chiquet, G. Mawston, F. Lavaste Diary of events Volume Contents, Author Index and Keyword Index Published only Online Book Reviews

390 395 396

II

386

e1–e4

Author index A Ada, L., 12 Adams, R., 328 Adams, R.D., 133 Alford, L., 176 Alonso-Blanco, C., 29 Aoki, M., 231 Aufdemkampe, G., 153 B Baeyens, J.P., 342, 353 Barker, K.L., 335 Beales, D.J., 86, 209 Bell, M.L., 263 Bjelland, E., 72 Blackmore, A.M., 256 Borstad, J.D., 386 Bouche, K.G., 271 Brandt, C., 3 Breen, A., 167 Brox, J.I., 72 Burnett, A.F., 181 C Cattrysse, E., 342, 353 Chai, H., 22 Chan, H.Y., 363 Chi Wing Ngai, G., 363 Chiquet, C., 390 Christenson, R.E., 63 Christopherson, D.E., 386 Clare, H.A., 328 Clarys, J.P., 342, 353 Condie, P., 380 Coorevits, P.L., 271 Curwin, S.L., 249 D Dankaerts, W., 181 Danneels, L.A., 271 David Baxter, G., 310 De Cordt, A., 50 De Hertogh, W.J., 50 Dianne Liddle, S., 310 Dixon, J., 219 Doody, C., 40 Douglas, J., 144 Duquet, W., 50 E Edmondston, S.J., 363 Ellis, R., 200 F Fagan, A., 139 Falla, D., 139 Ferna¤ ndez-de-las-Pe•as, C., 29 Ferrario, V.F., 372 Ferreira, M.L., 240 Ferreira, P.H., 240 Fleming, H.E., 17 Foster, N.E., 167 Franz, A., 126

G

N

Gill, N.W., 280 Glennon, S., 363 Goodson, A., 144 Gracey, J.H., 310

Nel, M., 3 Netto, K., 363 Nilsson-Wikmar, L., 119 Nitz, A.J., 161 Nykaº nen, M., 192

H O

Haº kkinen, A., 192 Hall, T., 256 Harlick, J.C., 56 Herbert, R., 1 Herrington, L., 226 Hickey, B.W., 263 Hing, W., 200 Hirschfeld, H., 119 Hodges, P.W., 240 Hooper, A.C.B., 17 Horton, S.J., 126 Howe, T.E., 219

Ogince, M., 256 O’Leary, S., 34, 139 O’Sullivan, P.B., 86, 181, 209 P Paungmali, A., 98 Pincus, T., 167 Portero, P., 390 Prabhu, B., 386

J

R

Jasiewicz, J.M., 380 Jull, G., 34, 85, 139, 297, 380 K Kautiainen, H., 192 Keer, R.J., 298 Kiesel, K.B., 161 Kim, M., 34 Krause, M.W., 3

Refshauge, K., 12 Reid, D., 200 Reid, M., 335 Robinson, H.S., 72 Robinson, K., 256 Robinson, R., 72 Rodd, D.W., 161 Rune Persson, P., 119 S

L Lai, D.-M., 22 Lavaste, F., 390 Lee, I.E., 280 Lee, J.-P., 286 Littlewood, C., 80 Ludewig, P.M., 386 Luraghi, F.E., 372 M Maher, C.G., 328 Mahieu, N.N., 271 Mathiowetz, K.M., 386 Mawston, G., 390 May, S., 80 McCarthy Persson, J.U., 17 McEwan, I., 226 McGregor, A.H., 144 McNair, P.J., 390 Miangolarra, J.C., 29 Milburn, P.D., 56, 263 Milosavljevic, S., 56, 263 Minday, L.E., 386 Minns Lowe, C.J., 335 Miyamoto, S., 231 Miyasaka, T., 231 Moore, A., 85, 297 Moore, A.P., 199 Moss, P., 109 Murakami, G., 231 Muraki, T., 231

III

Santos, R., 167 Schouten, S., 153 Sforza, C., 372 Shau, Y.-W., 286 Simmonds, J.V., 298 Skinner, D.K., 249 Sluka, K., 109 Smart, K., 40 Sole, G., 3 Solem, S., 72 Stevens, V.K., 271 Straker, L.M., 181 T Tartaglia, G.M., 372 Taylor, P., 144 Telje, T., 72 Teng, C.-C., 22 Teyhen, D.S., 280 Teys, P., 98 Thom, J., 226 Treleaven, J., 380 Tseng, W.-Y.I., 286 U Uchiyama, E., 231 Uhl, T.L., 161 Underwood, F.B., 161 Underwood, M., 167

V Vaes, P.H., 50 Van Roy, P., 342, 353 Vanderstraeten, G.G., 271 Vicenzino, B., 34, 98 Vijverman, V., 50 Vogel, S., 167 von Piekartz, H.J.M., 153

W Waddington, G.S., 133 Wajon, A., 12 Wang, C.-L., 286 Wang, H.-K., 286 Wang, S.-F., 22, 286

IV

Warren, M.L.R., 363 Williams, J.M., 363 Wright, A., 109 Y Ylinen, J., 192

Subjet index A Accuracy 56, 263 Achilles tendinosis 63 Advice 310 Age 22 Algometer 192 Arthritis 144 Assessment 226, 298 Attitudes 167 Axial rotation 353 B Back pain 167 Biomechanics 119 Biopsychosocial 176 Blinded controlled study 29 Brighton Criteria 298 C C1/2 segment 256 Cervical 119 Cervical multifidus 286 Cervical pain 192 Cervical spine 390 Cervicogenic 153 Cervico-thoracic 363 Children 153 Chiropractors 167 Classification 86 Clinical palpation 56 Clinical reasoning 40 Clinical tests 72 Cochin scale 144 Conservative treatment 200 Coupled motion 342, 353 Cranio-cervical flexor muscles 34 D Diagnosis 50 Diaphragm 209 Disability 144 Dynamometer 133 Dynamometry 34 E Electromyography 139, 161, 219, 372 Evidence-based 3 Exercise 126, 139 F Fine-wire EMG 240 Flexion–extension 342 Force variation 133 Fresh cadaver 231 G Glenohumeral 3 Grip 144 H Hand function 144 Head movement 380 Head pain 372 Head posture 119 Headache 153

Healing 176 Hypermobility 298 Hypermobility Syndrome 298 I Iliotibial band 200 Iliotibial band friction syndrome 200 In vitro 342, 353 Inertial sensors 380 K Kaltenborn 3 Kinaesthesia 363 Kinematic analysis 342, 353 Knee 109, 219

Patella 226 Pelvic floor 209 Pelvic girdle pain 72, 86 ‘‘physical therapy (specialty)’’ 12 Physical therapy techniques 12 Physiotherapists 40, 167 Physiotherapy 176 Pinch 144 Positional faults 98 Posterior capsule 386 Posture 139, 363 Pressure 17 Pressure pain threshold 109 Prevention 271 Psychoneuroimmunology 176 Q

L Lateral bending 353 Lateral epicondylitis 249 Low back pain 209, 310, 328 Lumbar extension measures 328 Lumbar spine 56 Lumbar stabilization training 271 M

Quadriceps 219 R Randomised controlled trials 310 Range of motion 144, 390 Range of motion measurement 386 Rehabilitation 161 Reliability 72, 226, 263, 286 Repeatability 17 Repetitive strain 249 Respiration 209 Rotator cuff tear 231

Management 298 Manipulation 12 Manual examination 256 Manual forces 133 Manual mobilization 342, 353 S Manual therapy 390 Mass media 335 Sacroiliac joint 72, 86, 126, 209 McKenzie 126 Sensitivity 50, 256 McKenzie derangement classification 328 Shoulder 263 Mechanical neck pain 29 Shoulder impingement 386 Mechanism(s) 98 Single case study 63 Migraine 153 Skin displacement 17 Mobilization 109 Specific soft tissue mobilizations 63 Mobilization-with-movement 98 Specificity 50, 256 Motor control 86, 209, 240, 249 Spinal 12 Movement 263 Spinal manipulative therapy 240 Movement analysis 119 Stabilization exercise 271 Muscle hyperalgesia 192 Strain 231 Musculoskeletal manipulation 153 Supraspinatus tendon 231 Musculoskeletal manipulations 12 Surface electromyography 271 Myofascial pain 29 Systematic review 200 Myofascial trigger points 29 T N Taping 17 Neck pain 34, 50, 139, 372, 380, 390 Temporomandibular disorders 372 Neck proprioception 22 Tendonitis 249 Neck repositioning test 22 Thumb 12 Nervous system 153 Translational glide 3 Neuroplasticity 249 Transversus abdominis 240 Nociception 192 U Non-specific low back pain 335 O Osteoarthritis 109, 219 Osteopaths 167 Outcome measures 310

Ultrasonography 161, 286 Upper-cervical 342, 353 User’s views 335 V Validity 56, 226, 286

P Pain 12, 40, 98, 363 Pain mechanisms 86 Pain threshold 192

W Whiplash 380

V

ARTICLE IN PRESS

Manual Therapy 12 (2007) 297 www.elsevier.com/locate/math

Editorial

Sharing good practice Welcome to this, the last Manual Therapy Journal issue of 2007. We celebrate the increase in Manual Therapy Journal’s impact factor to 1.931 and the fact that the journal has maintained its position of 3rd in the rehabilitation journal rankings on the ISI Journal Citation Index. The page extent of Manual Therapy Journal has increased significantly this year to enable us to publish more original articles and we now publish Book Reviews and Letters to the Editors only online. We have experienced a year-on-year increase in Original Article submissions since the journal entered Index Medicus which reflects an increase in our popularity as a publication outlet for musculoskeletal research and also an increase in research activities internationally in musculoskeletal therapy. Rapid publication of manuscripts on line has also hastened the dissipation of this knowledge in an efficient way. Pleasingly, we have noted an increase in manuscript submissions from nations not previously represented in the journal’s publications over the last 2 years. This is an excellent trend as it demonstrates the will of musculoskeletal researchers to share findings with the musculoskeletal global community. It is important to further facilitate ways of sharing information between musculoskeletal researchers and clinicians to further drive and enhance the quality of research and practice. Collaboration is vital in today’s research and clinical environment. Yet more global collaborations could occur through

1356-689X/$ - see front matter r 2007 Published by Elsevier Ltd. doi:10.1016/j.math.2007.08.001

international/national research networks similar to the National Physiotherapy Research Network established over the last 2 years in the United Kingdom. Conducting multi-site research activities in common thematic areas is potentially a powerful way to enhance knowledge and practice which can be widely extrapolated. Additionally, clinicians collect a wealth of data in their daily clinical practice. Perhaps collecting and sharing this data, with the development of an international standardised data collection tool, could be a way forward to harness this information and explore international trends. Sharing research experiences, research methodologies, research approaches, research findings and new initiatives during international and national conference events is already well established in the musculoskeletal field. As seasonal festivities approach across the world, perhaps this is a good time for us all to consider how we can best collaborate and share practice and research findings locally, nationally and internationally. Let us make 2008 the year of sharing in musculoskeletal physiotherapy with IFOMT 2008 one of the major foci for this to happen. Seasons Greetings to all readers across the world.

Editors Ann Moore, Gwen dolen Jull

ARTICLE IN PRESS

Manual Therapy 12 (2007) 298–309 www.elsevier.com/locate/math

Masterclass

Hypermobility and the hypermobility syndrome Jane V. Simmondsa,,1, Rosemary J. Keerb,2 a

University of Hertfordshire, School of Health and Emergency Professions, College Lane Campus, Hatfield, Hertfordshire, AL10 9AB, UK b Central London Physiotherapy Clinic, Harley Street, London, UK Received 5 March 2007; received in revised form 6 March 2007; accepted 12 May 2007

Abstract Hypermobile joints by definition display a range of movement that is considered excessive, taking into consideration the age, gender and ethnic background of the individual. Joint hypermobility, when associated with symptoms is termed the joint hypermobility syndrome or hypermobility syndrome (JHS). JHS is an under recognised and poorly managed multi-systemic, hereditary connective tissue disorder, often resulting in a great deal of pain and suffering. The condition is more prevalent in females, with symptoms frequently commencing in childhood and continuing on into adult life. This paper provides an overview of JHS and suggested clinical guidelines for both the identification and management of the condition, based on research evidence and clinical experience. The Brighton Criteria and a simple 5-point questionnaire developed by Hakim and Grahame, are both valid tools that can be used clinically and for research to identify the condition. Management of JHS frequently includes; education and lifestyle advice, behaviour modification, manual therapy, taping and bracing, electrotherapy, exercise prescription, functional rehabilitation and collaborative working with a range of medical, health and fitness professionals. Progress is often slow and hampered by physical and emotional setbacks. However with a carefully considered management strategy, amelioration of symptoms and independent functional fitness can be achieved. r 2007 Elsevier Ltd. All rights reserved. Keywords: Hypermobility; Hypermobility Syndrome; Brighton Criteria; Assessment; Management

1. Introduction Joint hypermobility is defined as a condition in which most of an individual’s synovial joints move beyond the normal limits taking into consideration the age, gender and ethnic background of the individual (Grahame, 2003a). Hypermobility may be inherited (Child, 1986; Beighton et al., 1989a), or acquired through years of training and stretching, as seen in ballet dancers and gymnasts (Grahame, 2003a). Furthermore, hypermobility may also develop as a result of changes in connective Corresponding author. Tel.: +44 1707 28 6108.

E-mail address: [email protected] (J.V. Simmonds). Clinical specialist in Hypermobility Syndrome, Hospital of St John and St Elizabeth, London, UK. 2 Physiotherapy advisor to the Hypermobility Syndrome Patient Association. 1

1356-689X/$ - see front matter r 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2007.05.001

tissue in a number of other diseases (Beighton et al., 1989b). Where once it was common for health and exercise professionals to view hypermobility as ‘the upper end of a Gaussian distribution of the normal joint range of movement’; we now understand that, in fact, it represents a departure from normality (Grahame, 1999). Hypermobility may pose no problems, but in some individuals it predisposes to a wide variety of soft tissue injuries and internal joint derangements, arthritis, arthralgias or myalgias, which lead sufferers to seek medical attention (Grahame, 1990; Cherpel and Marks, 1999; Dolan et al., 2003). Joint hypermobility, when associated with symptoms is termed the joint hypermobility syndrome or hypermobility syndrome (JHS), (Grahame, 2003a). JHS is one of the well-defined polygenic heritable connective tissue disorders (Zweers et al., 2004) which presents with a recognisable

ARTICLE IN PRESS J.V. Simmonds, R.J. Keer / Manual Therapy 12 (2007) 298–309

299

Marfan’s Syndrome

Ehlers–Danlos Syndrome

Marfanoid Habitus

Stretchy skin

Joint Hypermobility Syndrome

Osteopenia

Osteogenesis Imperfecta

Fig. 2. Inter-relationship between the heritable connective tissue disorders. Adapted from Grahame (2003b).

Fig. 1. ‘‘Saint Cyriaque’’ Matthias Grunewald (1460–1528): demonstrates hyperextension of the metacarpal phalangeal and interphalangeal joints.

phenotype, described and discussed in more detail later in this paper. Hypermobility is not new in the arts and medical humanities. Hippocrates in the 4th century BC is said to have speculated that the Scythians were defeated in India because the hyperlaxity of their shoulder and elbow joints prevented them from drawing a bow or hurling a javelin effectively (Beighton et al., 1989c; Larsson et al., 1993a). Notably, artists Matthias Grunewald (1460–1528) observed hypermobility in ‘‘Saint Cyriaque’’ in the Heller Retable (Fig. 1), and later, Peter Rubens observed hyperextension of the metacarpal joints, flat footedness and hyperlordosis in ‘‘The Three Graces’’ (1638–1640), Prado, Madrid (Dequecker, 2001). The musical successes of Paganini were attributed to his extreme hand mobility in the 18th century (Larsson et al., 1993b; Cherpel and Marks, 1999). However, by the end of the 19th century, rather than being characterised as an oddity, impediment or asset, joint hypermobility was recognised as having considerable clinical significance (Grahame, 1971). Into the 20th century, clinical observation and research led to the specific recognition of the JHS by Kirk et al., 1967, who described the occurrence of ‘musculo-skeletal symptoms in the presence of generalised joint laxity in otherwise normal subjects’.

Now in the 21st century, we know much more about JHS. Far from individuals being ‘otherwise normal or healthy subjects’, the condition is beginning to be taken more seriously. JHS has now been classified as a hereditary connective tissue disorder (HCTD) sharing the less severe features with its’ more serious counterparts; Marfan’s Syndrome, Ehlers–Danlos Syndrome and Osteogenesis Imperfecta, as illustrated by Grahame (2003a) (Fig. 2). JHS is the commonest of all the HCDTs and one that is seen most frequently in clinical practice (Grahame, 2003a). Many authorities consider JHS to be synonymous with Ehlers–Danlos hypermobility type, formerly known as Ehlers–Danlos type III (Grahame, 2001). Despite the substantial volume of published literature JHS continues to be under-recognised, poorly understood and inadequately managed by the medical and physiotherapy professions (Gurley-Greene, 2001; Keer, 2003). This paper aims to provide the reader with an overview of JHS including the epidemiology, pathogenesis, presentation and suggests guidelines for assessment and management. 1.1. Epidemiology and demographics The reported prevalence and incidence of hypermobility and JHS varies in the literature reviewed. This is largely due to the use of varying screening and diagnostic criteria. We know that gender, ethnicity and age are important factors, with hypermobility being more prevalent in females and those of African or Asian descent when compared with their Caucasian counterparts (Cherpel and Marks, 1999; Russek, 1999). We also know that it decreases with age (Bridges, 1992; Larsson et al., 1993a; Russek, 1999). The prevalence of hypermobility in children has been estimated to be 10– 25% (Biro et al., 1983; U¨mit et al., 2005) with a higher incidence in girls than boys (Larsson et al., 1987; Qvindesland and Jonsson, 1999). The prevalence of

ARTICLE IN PRESS 300

J.V. Simmonds, R.J. Keer / Manual Therapy 12 (2007) 298–309

hypermobility in adults also varies, from 5% in the USA (Jessee et al., 1980) to between 25% and 38% in Iraq (Al-Rawi et al., 1985) and 43% being recorded in the Noruba tribe in Nigeria (Birrell et al., 1994). Hakim and Grahame (personal communication, 2004) investigated referral data from a West London Rheumatology clinic over a six-month period in 2003, showing JHS to be more prevalent amongst nonCaucasian females in this discrete population. Within the female, non-Caucasian group, the JHS phenotype was present in 58% of the sample and in the same male cohort, 29% of individuals exhibited the JHS phenotype. Similarly, in a cross-sectional, matched, controlled study of female patients aged between 18 and 50 years in multicultural Oman, 55% of female patients attending the rehabilitation outpatient department exhibited the JHS phenotype (Clarke and Simmonds, 2007). 1.2. Pathogenesis The JHS is a genetically inherited disorder, presenting with an autosomal dominant pattern, thought to affect the encoding of the connective tissue proteins collagen (Grahame, 2003b). It has been proposed that individuals with JHS display an abnormal ratio of type III to type I collagen (Child, 1986). Type I collagen has a high tensile strength and is the most common collagen in the body, abundant in tendon, joint capsule, skin, demineralised bone and nerve receptors. Type II collagen is found in cartilage, and designed to withstand compressive stress, whereas type III collagen is much more extensible and disorganised, occurring in organs such as the gut, skin and blood vessels (Beighton et al., 1989d) which may explain the inherent laxity or ‘reduced tissue stiffness’ (Russek, 1999). Mutations in genes encoding collagen type V have also recently been implicated (Malfait et al., 2005), with type V collagen under normal control interacting with type I collagen during fibrillogenesis and having a role in regulation of fibril diameter. An alteration in this process may potentially lead to thinner, fine and more disorganised collagen fibres. Skin fibroblast biopsy analysis, has allowed researchers to further investigate the microscopic structural discrepancies that may define HCTDs. Malfait et al. (2005) hypothesise that it is the interference with the processing of the N-propeptide of either a-chain (a1 or a2) of type I collagen that is responsible for Ehlers– Danlos-like symptoms of skin laxity, joint subluxation and dislocation. The nervous system is affected in individuals with JHS. Lack of efficacy of local anaesthetics when injected or topically applied, has been reported by ArendtNielsen et al. (1990). The mechanism for this is unknown. Studies have also shown that individuals with JHS are less accurate than individuals without the

condition at reproducing proximal interphalangeal joint angles (Mallik et al., 1994). Research also shows that position sense at the knee is decreased, particularly the ability to locate end-range extension (Hall et al., 1995). Laxity and fragility of connective tissue coupled with a decreased proprioceptive acuity and altered neuromuscular reflexes are the possible causes of the predisposition of individuals with JHS to damage and injury (Johansson et al., 2000; Stillman et al., 2002). 1.3. Clinical presentation Hypermobility does not necessarily result in problems and may sometimes be considered an asset (Grahame, 2003a). However, for those less fortunate, hypermobility and tissue laxity can be the cause of a variety of debilitating symptoms. Symptoms frequently commence in childhood with the potential to continue into adult life (Grahame, 2001). One study (Kirk et al., 1967) reported three quarters of hypermobile adolescents developing symptoms by the age of 15 and Lewkonia and Ansell (1983) and Murray and Woo (2001) recognise JHS as one of the most frequent causes of musculo-skeletal symptoms in children and adolescents, particularly girls, aged between 13 and 19 years of age. The predominant presenting complaint is pain, which is often widespread and longstanding, with patients reporting pain ranging from 15 days to 45 years (El-Shahaly and El-Sherif, 1991). In addition there are many other symptoms reported by patients associated with the joints, such as, stiffness, ‘feeling like a 90 year old’, clicking, clunking, popping, subluxations, dislocations, instability, feeling that joints are ‘vulnerable’ as well as symptoms affecting other tissues such as paraesthesiae, tiredness, faintness, feeling unwell and suffering flu-like symptoms (Keer, 2003). Fig. 3 illustrates a typical patient pain chart. Complaints are sometimes difficult to match with the way the patient looks or moves (Russek, 2000) as individuals frequently look well and move well. This infrequently leads to the patient being misunderstood and at worst the patient is made to feel like a hypochondriac and may be labelled as having psychological problems (Child, 1986). Extra articular manifestations of the syndrome may include skin fragility and laxity (Grahame, 1999, 2003a), autonomic disturbances (Gazit et al., 2003; Hakim and Grahame, 2004), ocular ptosis, varicose veins (Mishra et al., 1996), bruising (Bridges, 1992; Kaplinsky et al., 1998), urogenital prolapses (Al-Rawi and Al-Rawi, 1982; El-Shahaly and El-Sherif, 1991), Raynaud’s phenomenon (El-Garf et al., 1998), development motor co-ordination delay (DCD) (Kirby and Sugden, 2007), alterations in neuromuscular reflex action (Johansson et al., 2000; Stillman et al., 2002), neuropathies, tarsal


301

Fig. 3. Typical JHS body chart presentation.

and carpal tunnel syndrome (Francis et al., 1987; March et al., 1988), fibromyalgia (Acasuso-Diaz and CollantesEstevez, 1998), low bone density (Mishra et al., 1996, Gulbahar et al., 2006), anxiety and panic states (Bulbena et al., 1993) and depression (Grahame, 2000). 2. Patient assessment Recognising generalised hypermobility as a contributory factor to musculo-skeletal complaints is often difficult, frequently overlooked, or not considered. This occurs for a variety of reasons; lack of knowledge or experience, focusing exclusively on the problem area rather than looking at the patient as a whole and failing to recognise that a ‘normal’ range of movement may not be ‘normal’ for the hypermobile patient. Additionally, it may also be difficult to identify JHS as a contributory factor to a patient’s complaints of pain and dysfunction in older patients, and in those who have stiffened significantly in response to aging, disuse and pain, as they may have lost their previous flexibility. The following discussion of characteristics may assist the therapist to recognise and diagnose JHS when examining a patient. 2.1. Subjective examination The onset of symptoms is frequently associated with trauma, pregnancy, childbirth, unresolved previous joint

problem (s), or de-conditioning related to a sedentary lifestyle. Problems in childhood can be a useful clue to the presence of hypermobility with many hypermobile individuals reporting joint pains, particularly in the back and knees in childhood and there is often a history of growing pains or benign paroxysmal nocturnal leg pain (Maillard and Murray, 2003). A history of participation in activities such as ballet and gymnastics where inherent flexibility is considered an asset may be an indication of hypermobility. Past history of soft tissue injuries, joint pain, fractures, dislocation and subluxations, particularly if they occur with minimal provocation and have been slow to resolve, may be a good indicator of hypermobility and may also provide valuable information about tissue healing rate, which has been reported as slower in hypermobile individuals (Russek, 2000). As JHS is an inherited disorder, exploring the family history may also assist with its recognition. Several authors (Biro et al., 1983, Finsterbush and Pogrund, 1982) have reported that between 27% and 65% of their patients had relatives with a history of joint hypermobility. Even if it is not known that relatives were hypermobile, other complaints such as arthritis, multiple joint problems and dislocations may provide further clues and point to a possible case of inherited hypermobility. Exploratory questions about other areas of the body and body systems may reveal a host of other problems


302

Box 1 5 point hypermobility questionnaire (Hakim and Grahame 2003). o Can you now [or could you ever] place your hands flat on the floor without bending your knees? o Can you now [or could you ever] bend your thumb to touch your forearm? o As a child, did you amuse your friends by contorting your body into strange shapes or could you do the splits? o As a child or teenager, did your kneecap or shoulder dislocate on more than one occasion? o Do you consider yourself ‘‘double-jointed’’? Answering yes to 2 or more of these questions suggests hypermobility with sensitivity of 85% and specificity 90%.

for the individual with JHS. Patients are often reluctant to reveal this information, as they may not consider these issues to be related to their presenting musculoskeletal complaint(s). These systemic signs and symptoms may include urogenital problems (prolapse, incontinence), vascular problems (bruising, varicose veins, low blood pressure), neural problems (clumsiness, unsteadiness, paraesthesiae, neuropathies). Furthermore, poor response to local anaesthetics has also been associated with JHS (Arendt-Nielsen et al., 1990) and may result in significant distress for individuals when not recognised or believed, for example, by a dentist when carrying out dental work or an obstetrician during childbirth. Finally, the inclusion of a simple five-part questionnaire devised by Hakim and Grahame (2003) can easily be incorporated into the assessment of most patients. The questionnaire has been shown to have good sensitivity and specificity and correctly identified hypermobility in 84% of a group of subjects. The questionnaire is outlined in Box 1. 2.2. Objective examination 2.2.1. Observation Observing sitting position during the subjective part of the examination may give a clue to the presence of hypermobility. Individuals with JHS frequently fidget and adopt end of range postures such as entwining their legs, sitting rotated and twisting in the seat, or side sitting (Oliver, 2000). When sitting unsupported, hypermobile individuals frequently slouch, and rest in posterior pelvic tilt position. We speculate that these postures are an attempt to find some stability through tightening of the ligaments. Observation of the hands while talking can be a very helpful indicator of the syndrome as often individuals with JHS show hyperextension at the metacarpal-phalangeal and/or interphalangeal joints. It is important to observe the whole body and in the majority of cases, this will mean undressing to underwear

Fig. 4. Papyraceous (paper) scarring.

and observing the individual from all directions. Papyraceous scarring as can be seen in Fig. 4, is a documented feature of JHS (Grahame, 2003b) and therefore inspection of surgical and injury scars should be observed and noted. An interesting clinical observation is that muscle definition often appears poor with low resting tone even when the individual has been training and is reasonably fit. Both static postures, including standing and sitting and dynamic activities such as walking, stair climbing, sit to stand, standing on one leg and squatting should be carefully observed. Hypermobile individuals are frequently observed to adopt end of range postures. A typical standing posture shows flat feet, knees and hips hyperextended and lumbar spine in a sway posture with increased compensatory curve higher up the spine. Hip hitch, drop and adduction ‘hip hanging’ is also frequently observed when standing on one leg. 2.2.2. Measuring hypermobility The Beighton score (Beighton et al., 1973) is an easy to administer 9-point scale where points are given for


303

Box 2 Brighton criteria—diagnostic criteria for hypermobility syndrome (Grahame et al., 2000) Major criteria 1. A Beighton score of 4/9 or greater (either currently or historically) 2. Arthralgia for longer than 3 months in four or more joints. Minor criteria 1. A Beighton score of 1,2, or 3/9 (0,1,2,or 3 if aged 50+). 2. Arthralgia (for 3 months or longer) in one to 3 joints or back pain for (for 3 months or longer), spondylosis, sponylolysis/spondylolisthesis. 3. Dislocation/subluxation in more than one joint, or in one joint on more than one occasion. 4. Soft tissue rheumatism: three or more lesions (e.g. epicondylitis, tenosynovitis, bursitis). 5. Marfanoid habitus (tall, slim, span/height ration41.03 upper: lower segment ration less than 0.89, arachnodactyly (positive steinberg/wrist signs). 6. Abnormal skin striae, hyperextensibility, thin skin, papyraceous scarring. 7. Eye signs: drooping eyelids or myopia or antimongoloid slant. 8. Varicose veins or hernia or uterine/rectal proplapse. BJHS is diagnosed in the presence of two major criteria or one major and two minor criteria, or four minor criteria. Two minor criteria will suffice where there is an unequivocally affected first-degree relative. BJHS is excluded by the presence of Marfan or Ehlers—Danlos syndromes other than the EDS hypermobility type (formerly EDS III). nb: Criteria Major 1 and Minor 1 are mutually exclusive, as are Major 2 and Minor 2.

the performance of five manoeuvres. It is generally considered that hypermobility is present if 4 out of 9 points are scored. The scale was not designed for clinical use and has been criticised because it only samples a few joints and gives no indication of the degree of hypermobility. Other scales, such as the Comtompasis score (Grahame, 2003a) and the 10-point Hospital del Mar (Barcelona) criteria (Bulbena et al., 1992) have also been used to identify hypermobility, mostly in the context of research, as they are often too timeconsuming to perform in the clinical setting. The Beighton score has been incorporated into a more comprehensive and validated set of criteria used to identify JHS called the Brighton Criteria (Grahame, 2000), Box 2. This set of criteria takes account of not only the presence of joint hypermobility, either currently or historically, but also links this to symptoms and other characteristics of connective tissue laxity. This is an important advance as patients seek help from medical practitioners usually not for hypermobility but rather for the effects of hypermobility. As with other scales, it was initially designed for use in research, but is proving to be a useful clinical diagnostic tool (Grahame, 2003b). Active movement testing may reveal ‘normal’ range of movement despite the patient complaining of symptoms such as pain and stiffness. Therapists are generally trained to identify and associate restricted or reduced movement as indicative of a problem. Full range movement is often interpreted, as meaning there is not

a problem. However, the question that therapists needs to ask is, is this ‘normal’ range of movement being performed by the patient ‘normal’ for them? A simple question to ask with regard to lumbar flexion is, ‘‘could you ever place your hands flat on the floor without bending your knees?’’ Observation of hypermobility or excessive movement in other joints, not associated with the problem area, may be helpful in confirming the diagnosis of hypermobility and JHS. It is particularly important to analyse quality and patterns of the movement, rather than quantity of movement in this group of individuals, as information gained through this observation will often provide an indication of the direction treatment should take. The concept of compensatory relative flexibility (Sahrmann, 2002) is an important consideration, and occurs as a result of muscle imbalances, joint stiffness, poor motor control and altered recruitment patterns. A good example of this is, spinal extension, where frequently the majority of movement occurs in the mid lumbar spine with relatively little or no movement in the thoracic spine. The lumbar spine is one of the most mobile sections of the vertebral column and in the hypermobile individual often moves excessively. If this movement pattern is repeatedly re-enforced through activities of daily living, it may lead to pain arising from overuse in the lumbar spine motion segments. In addition to demonstrating an excessive range of movement in some joints, as described earlier,


304

Fig. 5. Testing skin laxity on the dorsum of the hand.

proprioceptive deficits are also frequently observed. In the clinical environment, balance testing is generally used as an indication of lower limb proprioception. Double and one legged Romberg tests, with arms by the side and eyes closed and where the clinician observes the tendency to sway or fall to the side can easily be incorporated into the assessment to give a subjective indication of proprioception (Harrelson and Leaver-Dunn, 1998). More objective and reliable tests of sway may be performed and measured using calibrated standing platforms (Cachupe et al., 2001). Joint and soft tissue palpation, a valuable and important part of the clinical examination, must be performed with care because of tissue fragility, decreased tissue resistance and increased mobility requiring less force to produce movement. Hypermobile joints frequently have an ‘empty’, ‘boggy’ or ‘soggy’ end-feel which may help to alert the clinician to the diagnosis. In JHS the skin is often observed to be extensible and soft. Skin pliability and elasticity can be assessed by picking up the skin on the back of the hand and assessing the excursion as in Fig. 5. 3. Management The management of individuals with JHS can be very challenging. Patience, coupled with good communication and sensitive handling skills are required as physical problems are often longstanding and include secondary complications and psycho-social issues. Patients frequently arrive in the hope of finding a miracle cure having been treated by an array of allopathic and complementary practitioners. Management, is the operative word, as progress is often slow and hampered by frequent set backs and flare-ups. Very little has been reported or written about the physiotherapy management and treatment efficacy of

JHS. Of note, however is an article by Cherpel and Marks (1999), which provides a good review including well-reasoned, evidence based suggestions for management. Further to this, a seminal physiotherapy case report by Russek (2000) gives a thoughtful overview of the assessment, prognosis and management of an athletic 28 year old chronic JHS sufferer. Russek’s report highlights the importance and need for education, therapeutic exercise, adaptation and modification of work and lifestyle activities. Detailed, evidence based and clinically reasoned strategies with good inclusion of case scenarios are also reported in the text produced by Keer and Grahame (2003). As with most patients, developing a prioritised problem list along with agreed short, medium and longterm goals is the key to successful client care. Initial management will often involve modulation of an acute episode of pain or injury (Keer, 2003). This may be achieved through advice and discussion regarding rest, pacing activities, joint care and use of a range of modalities including ultrasound and transcutaneous nerve stimulation, tape and splinting, heat and ice, gentle mobilisations of associated hypomobile areas, massage, muscle energy techniques and acupuncture. In some cases of extreme joint hypermobility and laxity, we have found advising patients to wear firm fitting underwear, lycra cycling shorts and upper body clothing helpful for improving perceived joint stability and reducing pain. Patients usually respond well to these modalities, although recovery and healing is often slow (Grahame, 2000). Extra care should be taken with manual therapy, as pain is often latent and easily aggravated. The increased vulnerability and fragility of the connective tissue has to be recognised and considered when deciding on dosage. It is generally considered that high velocity thrust techniques (HVT) or Grade V’s are contra-indicated in the hypermobile patient, although in skilled hands gentle precise HVT’s or Grade V’s can be beneficially applied to a stiff thoracic spine. The therapist should be mindful of the effect a mobilisation applied to a stiff area can unintentionally have at an adjacent hypermobile section, as vigorous treatment can often cause an exacerbation or flare-up with deleterious effects. At its worst, tissue damage occurs. There may also be other effects, which the therapist may not be aware of as the patient may not return for further sessions due to a loss of confidence in the therapist or therapy, leading to another downturn for the patient and further searching for help. This can be an important factor in the downward spiral, which frequently occurs in hypermobile individuals. Pain can become a debilitating unremitting symptom, leading to kinesiphobia and de-conditioning. If an individual reaches this stage, referral to a pain management programme is advised where the patient will receive both psychological and physiological input.


Once the acute injury and pain has been attended to, consideration needs to be given to the underlying condition and chronic management issues. This may include additional podiatric assessment with a view to provision of orthotics to improve foot biomechanics and support. The management will almost certainly require a degree of behaviour modification including pacing techniques, coping strategies and addressing ergonomics, work and lifestyle issues. Furthermore dietary advice with regard to irritable bowel symptoms, supplements, nutrition and weight management may also be required. JHS is more common in females and therefore attention may need to be given to issues such as incontinence, pregnancy and caring for young children. Readers are directed to chapters by Harding, Mangharam and Keer, Edwards-Fowler and Mansi, in Keer and Grahame (2003), where these concepts are explored in greater detail. As stated earlier, patients with JHS often present in a de-conditioned state due to fear avoidance and reduced activity, making them a high-risk group for other disorders. This is of key importance to the JHS patient group, where a multitude of conditions have been associated with the syndrome (Grahame, 2003b), some of which may be averted or managed by regular exercise and improved levels of fitness. Therefore, developing and identifying ways to encourage physical activity is an important part of the management of JHS, as reduced physical activity is known to be a major modifiable risk factor for numerous systemic diseases and complex disorders (DoH, 2004).

305

Research is required in this area to explore and further evidence this. Muscle endurance training is also an important part of the reconditioning process as the slow twitch type I muscle fibres are purported to atrophy at a faster rate than type II fibres (Harrelson, 1998). This suggestion has significant implications for postural muscles where the endurance capacity is crucial to function and may be part of the explanation as to why individuals with JHS, tend to fidget and appear unable to sustain sitting and standing postures. 3.2. Early rehabilitation It is recommended that rehabilitation in the very early stage focuses on improving body awareness, proprioception and proximal joint stability. In particular the authors have found Swiss ball and hydrotherapy to be particularly useful, especially when dealing with patients where protective muscle spasm is an issue. It is important, particularly in the early stages, that exercises given to the patient either during a therapy session or as home exercises are pain free. A distinction needs to be drawn between training pain and exacerbation of their pain. This may mean modifying even the most simple exercise to ensure that it is being performed correctly and is appropriate for the patients’ stage of rehabilitation. Where possible recruitment of stability muscles, once learnt, can be encouraged during normal activities, such as walking, sit to stand, stairs and housework. Manual guidance, joint approximation techniques and the use of tape to facilitate proprioception (Callaghan et al., 2002) may be helpful, although prudence is required where skin is fragile and sensitive.

3.1. Principles of rehabilitation 3.3. Middle and late stage rehabilitation Application of the principles of exercise physiology and motivational strategies are advised when constructing and implementing rehabilitation and physical activity programmes. The primary principle of readiness or preparedness of the individual to undertake or participate in a rehabilitation programme is fundamental to the process (Simmonds, 2003). Other principles, including specificity of training in order to target the appropriate physiological systems, and overload, intensity and frequency of training should be considered and continuously monitored. Strength in particular, is known to be highly specific to training and therefore consideration of the type of muscle activity, number and sets of repetitions and frequency of training is necessary (Wilmore and Costill, 2004; Arnold and Gentry, 2005). Initial strength gains have been attributed to neurological adaptation while gains due to muscle hypertrophy come later (Sale, 1988). It is our observation that strength gains are slower in this group of patients and this may be attributed to alterations in both central and peripheral neuromuscular physiological processes.

Once a reasonable level of proximal stability has been achieved, individuals should be encouraged to continue to improve their strength, endurance, balance and coordination and to engage in more regular physical activity. Graded exercises using theraband, aimed at improving both concentric and eccentric strength and endurance is recommended along with the use of mirrors to enhance proprioception, see Fig. 6. A study by Kerr et al. (2000), demonstrated positive benefits of a stabilising exercise programme and a recent study by Ferrell et al. (2004), showed significant improvement in knee joint proprioception and balance, following an eight week exercise programme employing progressive closed chain kinetic exercises. The study also showed improvements in quality of life, reduction of pain and improved muscle strength. Achievable goals should continue to be discussed, agreed and monitored using diaries, pedometers and accelerometers. The programme of rehabilitation reconditioning should be integrated and should address



out of door bicycling where target heart rates can be monitored. 3.4. Sport, the performing arts and physical activity

Fig. 6. Closed chain exercises using theraband and mirrors aid proprioceptive feedback.

Those wishing to take up athletic activity or return to sport or performance activities should undergo a functional training or rehabilitation approach, whereby both skill acquisition and sport specific training is undertaken. The relationship between generalised hypermobility and increased injury risk is not conclusive, however, there is mounting evidence to suggest that it is an intrinsic injury risk factor in many sports and performance activities including; American football (Nicholas, 1970), gymnastics (Kirby et al., 1981), basketball (Gray et al., 1985), female soccer (Soderman et al., 2001), professional ballet (McCormack et al., 2004), male rugby (Stewart and Burden, 2004) and junior netball (Smith et al., 2005). Therefore a degree of caution is recommended when advising patients with regard to sport and performance participation. A gradual return to training and match play with education regarding joint and tissue protection and care to coaches, parents and players is recommended. Maintenance of physical fitness through regular safe physical activity is considered paramount for continued self-management of the condition and patients should be encouraged to develop a life-long commitment to physical activity and to remain fit through activities which are focussed on neuro-musculo-skeletal control. Recommended activities therefore include, recreational swimming, Pilates, tai chi, chi gung, some forms of yoga and dance. Whatever form of physical activity is recommended or adopted after the therapy intervention, it should be enjoyable, pain free and relevant to the individual. 3.5. Support groups When required and as necessary, patients can be directed to the Hypermobility Syndrome Patient Association, UK (HMSA, www.hypermobility.org), a wellorganised charity which has an active interactive website and is supported by medical and allied health practitioners with specialist interests and knowledge.

Fig. 7. Deep water walking and running is an excellent means of increasing and maintaining fitness.

4. Conclusion

the three primary systems that influence normal movement, the cardiorespiratory, musculo-skeletal and neurological systems. Cardiorespiratory conditioning and weight control can be achieved through a suitably designed low intensity aerobic programme of walking, deep water running (Fig. 7), cross trainer, stationary and

Hypermobility syndrome is a complex, under recognised and poorly managed inherited connective tissue disorder often resulting in a great deal of pain and suffering. Physiotherapists working alongside other members of the multidisciplinary team have an important role in both the identification and management of the condition. The Brighton Criteria and a simple 5-point questionnaire


devised by Hakim and Grahame (2003) are both valid tools, which can be used in the clinical and research setting to identify the condition. Because of the ubiquitous nature of connective tissue proteins (Grahame, 2003c), the possible consequences of tissue trauma are vast and patient presentations are therefore variable. Setting and monitoring carefully considered shared goals along with behaviour modification are important strategies for achieving the ultimate goals of independence and long-term functional fitness. Progress is often slow and hampered by setbacks and exacerbation of pain and psychological distress. However, with persistence and insight into the pathogenesis of the disorder, rewarding outcomes are possible. Future clinical research involving both qualitative and quantitative methods will aid the further development of clinical guidelines. Part two of this Masterclass will be available online from November 2007. Acknowledgement The authors wish to thank Professor Rodney Grahame CBE MD FRCP FACP, Consultant Rheumatologist, University College Hospital and Honorary Professor, University College London, in the Department of Medicine, for his contribution to this paper and ongoing support for our work in this field. References Acasuso-Diaz M, Collantes-Estevez E. Joint hypermobility in patients with fibromyalgia syndrome. Arthritis Care and Research 1998;11: 39–42. Al-Rawi ZS, Al-Rawi ZT. Joint hypermobility in women with genital prolapse. Lancet 1982;1:1439–41. Al-Rawi ZS, Al-Aszawi AJ, Al-Chalabi T. Joint mobility among university students in Iraq. British Journal of Rheumatology 1985; 24:326–31. Arendt-Nielsen L, Kaalund P, Bjerring P, Hogsaa B. Insufficient effect of local analgesics in Ehlers-Danlos type III patients (connective tissue disorder). Acta Anaesthesiologica Scandinavica 1990;34: 358–61. Arnold P, Gentry M. Strength training: what the team physician needs to know. Current Sports Medicine Reports 2005;4(6): 305–8. Beighton P, Grahame R, Bird HA. Genetic aspects of the hypermobility syndrome. In: Beighton P, Grahame R, Bird HA, editors. Hypermobility of joint. 2nd ed. Berlin: Springer; 1989a (Chapter 5). p. 55–66. Beighton P, Grahame R, Bird HA. Clinical features of hypermobility syndrome. In: Beighton P, Grahame R, Bird HA, editors. Hypermobility of joints. 2nd ed. Berlin: Springer; 1989b (chapter 6). p. 67–84. Beighton P, Grahame R, Bird HA. Introduction to hypermobility. In: Beighton P, Grahame R, Bird HA, editors. Hypermobility of joints. 2nd ed. Berlin: Springer; 1989c (chapter 1). p. 1–6. Beighton P, Grahame R, Bird HA. Biochemistry of hypermobility. In: Beighton P, Grahame R, Bird HA, editors. Hypermobility of joints. 2nd ed. Berlin: Springer; 1989d (chapter 3). p. 25–52.

307

Beighton PH, Solomon L, Soskolne CL. Articular mobility in an African population. Annuals Rheumatic Diseases 1973;32:413–7. Biro F, Gewanter HL, Baum J. The hypermobility syndrome. Pediatrics 1983;72(5):701–6. Birrell FN, Adebajo A, Hazleman BL, Silman AJ. High prevalence of joint laxity in West Africans. British Journal of Rheumatology 1994;33:56–9. Bridges A. Joint hypermobility in adults referred to rheumatology clinics. Annals of the Rheumatic Diseases 1992;51:793–6. Bulbena A, Duro JC, Porta M, Faus S, Vallescar R, Martin-Santos R. Clinical assessment of hypermobility of joints: assembling criteria. Journal of Rheumatology 1992;19:115–22. Bulbena A, Duro JC, Porta M, Martin-Santos R, Mateo A, Molina A, et al. Anxiety disorders in the joint hypermobility syndrome. Psychiatry Reserve 1993;46(1):59–68. Cachupe JC, Shifflett B, Kahanov L, Wughalter EH. Reliability of biodex system measures. Measurement in Physical Education and Exercise 2001;5(2):97–108. Callaghan MJ, Selfe J, Bagley PJ, Oldham JA. The effects of patellar taping on knee joint proprioception. Journal of Athletic Trainers 2002;37(1):19–24. Cherpel A, Marks R. The benign joint hypermobility syndrome. New Zealand Journal of Physiotherapy 1999;27(3):9–22. Child AH. Joint hypermobility syndrome: inherited disorder of collagen synthesis. Journal of Rheumatology 1986;13:239–43. Clarke C, Simmonds, J. High prevalence of benign joint hypermobility syndrome in Oman. In: Poster abstract: the 15th Congress of the World Confederate for Physical Therapy, Vancouver June 2–6, 2007. Department of Health (DOH). (2004) At least 5 a week. Evidence on the effect of physical activity and it’s impact on health. A report from the chief medical officer. London TSO; 2004. /http://www. dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicy AndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en? CONTENT_ID=4080994&chk=1Ft1OfS. (Accessed February, 2007). DeQuecker J. Benign familial hypermobility syndrome and Trendelenburg sign in a painting ‘‘The Three Graces’’ by Peter Paul Rubens (1577–1640). Annals of the Rheumatic Diseases 2001;60: 894–5. Dolan A, Hart D, Doyle D, Grahame R. The relationship of joint hypermobility, bone mineral density and osteoarthritis in the general population: the Chingford study. Journal of Rheumatology 2003;30:799–803. El-Garf AK, Mahmoud GA, Mahgoub EH. Hypermobility among Egyptian children: prevalence and features. Journal of Rheumatology 1998;5:1003–5. El-Shahaly HA, El-Sherif AK. Is the benign hypermobility syndrome benign? Clinical Rheumatology 1991;10:302–7. Ferrell WR, Tennant N, Sturrock RD, Ashton L, Creed G. Amelioration of symptoms by enhancement of proprioception in patients with joint hypermobility syndrome. Arthritis & Rheumatism 2004;50:3323–8. Finsterbush A, Pogrund H. The hypermobility syndrome. Musculoskeletal complaints in 100 consecutive cases of generalized joint hypermobility. Clinical Orthopaedics 1982;168:124–7. Francis H, March L, Terenty T, Webb J. Benign joint hypermobility with neuropathy: documentation of tarsal tunnel syndrome. Journal of Rheumatology 1987;14:577–81. Gazit Y, Nahir AM, Grahame R, Jacob G. Dysautonomia in the joint hypermobility syndrome. American Journal of Medicine 2003; 115(1):33–40. Grahame R. Joint hypermobility: clinical aspects. Proceedings of the Royal Society of Medicine 1971;64:32–4. Grahame R. The hypermobility syndrome. Annals of Rheumatological Diseases 1990;49:199–200.



Grahame R. Joint hypermobility and genetic collagen disorders: are they related? Archives of Diseases in Childhood 1999;80:188–91. Grahame R. Pain distress and joint hyperlaxity. Joint Bone Spine 2000;67:157–63. Grahame R. Time to take hypermobility seriously (in adults and children). Rheumatology 2001;40:485–7. Grahame R. Hypermobility and hypermobility syndrome. In: Keer R, Grahame R, editors. Hypermobility syndrome—recognition and management for physiotherapists. London: Butterworth-Heinemann; 2003a (chapter 1). p. 1–14. Grahame R. Hypermobility and the heritable disorders of connective tissue. In: Keer R, Grahame R, editors. Hypermobility syndrome— recognition and management for physiotherapists. London: Butterworth-Heinemann; 2003b (chapter 2). p. 15–26. Grahame R. Overall management of the joint hypermobility syndrome. In: Keer R, Grahame R, editors. Hypermobility syndrome—recognition and management for physiotherapists. London: Butterworth Heinemann; 2003c (chapter 3). p. 27–32. Gray J, Tauton JE, McKenzie DC, Clement DB, McConkey JP, Davidson RG. A survey of injuries to the anterior cruciate ligament of the knee in female basketball players. International Journal of Sports Medicine 1985;6(6):314–6. Gulbahar S, Sahin K, Baydar M, Bircan C, Kazil R, Manisali M, et al. Hypermobility Syndrome increases the risk for low bone mass. Clinical Rheumatology 2006;25(4):511–4. Gurley- Green S. Living with the hypermobility syndrome. Rheumatology 2001;40:487–9. Hakim A, Grahame R. A simple questionnaire to detect hypermobility: and adjunct to the assessment of patients with diffuse musculoskeletal pain. International Journal of Clinical Practice 2003;57(3):163–6. Hakim A, Grahame R. Non-musculoskeletal symptoms in joint hypermobility syndrome. Indirect evidence for autonomic dysfunction? Rheumatology 2004;43(9):1194–5. Hakim A, Grahame R. Presentation to the London and South East Hypermobility Club. University College London Hospital, 2004, (personal communication). Hall M, Ferrell W, Sturrock R, Hamblen D, Baxendale R. The effect of the hypermobility syndrome on knee joint proprioception. British Journal of Rheumatology 1995;34:121–5. Harrelson GL. Physiological factors of rehabilitation. In: Andrews JR, Harrelson GL, Wilk KE, editors. Physical rehabilitation of the injured athlete. 2nd ed. London: WB Saunders; 1998 (chapter 2) p. 13–37. Harrelson GL, Leaver-Dunn D. Physiological factors of rehabilitation. In: Andrews JR, Harrelson GL, Wilk KE, editors. Physical Rehabilitation of the Injured Athlete. 2nd ed. London: WB Saunders; 1998 (chapter 7). p. 175–217. Hypermobility Syndrome Patient Association (HMSA) /www. hypermobility.orgS. Jessee EF, Owen DS, Sagar KB. The benign hypermobility syndrome. Arthritis Rheumatology 1980;23:1053–6. Johansson H, Pedersen J, Bergenheim M. Peripheral afferents of the knee: their effects on central mechanisms regulating muscle stiffness, joint stability and proprioception and co-ordination. Proprioception and neuromuscular control. In: Johansson H, Pedersen J, Bergenheim M, editors, Joint stability, Human Kinetics, Champaign, 2000; (chapter 1). p. 5–22. Kaplinsky C, Kenet G, Seligsohn U, Rechavi G. Association between hyperflexibility of the thumb and an unexplained bleeding tendency: is it a rule of thumb? British Journal of Haematology 1998;101:260–3. Keer R. Management of the hypermobile adult. In: Keer R, Grahame R, editors. Hypermobility syndrome—recognition and management for physiotherapists. London: Butterworth-Heinemann; 2003 (chapter 7). p. 87–106.

Keer R, Grahame R. Hypermobility syndrome—recognition and management for physiotherapists. London: Butterworth-Heinemann; 2003. Kerr A, Macmillan C, Uttley W, Luqmani R. Physiotherapy for children with hypermobility syndrome. Physiotherapy 2000;86(6):313–6. Kirby A, Sugden DA. Children with developmental co-ordination disorders. Journal of the Royal Society of Medicine 2007;100(4): 82–186. Kirby RL, Simms C, Symington VJ, Garner JB. Flexibility and musculoskeletal symptomology in female gymnasts and age matched controls. American Journal of Sports Medicine 1981;9: 160–4. Kirk JA, Ansell BM, Bywaters EL. The hypermobility syndrome. Annals Rheumatological Diseases 1967;26:419–25. Larsson LG, Baum J, Mudholker GS, Kollia GD. Hypermobility: features and differential incidences between the sexes. Arthritis Rheumatism 1987;30:1426–30. Larsson LG, Baum J, Mudholker GS, Kollia GD. Hypermobility: prevalence and features in a Swedish population. British Journal of Rheumatology 1993a;32:116–9. Larsson LG, Baum J, Mudholker GS, Kollia GD. Benefits and disadvantages of joint hypermobility among musicians. New England Journal of Medicine 1993b;329:1079–82. Lewkonia R, Ansell BM. Articular hypermobility simulating chronic rheumatic disease. Archives of Disease in Childhood 1983;58: 988–92. Maillard S, Murray KJ. Hypermobility syndrome in children. In: Keer R, Grahame R, editors. Hypermobility syndrome: recognition and management for physiotherapists. Edinburgh: Butterworth-Heinemann; 2003 (chapter 4). p. 33–50. Malfait F, Symoens S, Coucke P, Nunes L, De Almeida S, De Paepe A. Total absence of the a2(I) chain of collagen type I causes a rare form of Ehlers-Danlos syndrome with hypermobility and propensity to cardiac valvular problems. Journal of Medical Genetics 2005;25:28–37. Mallik AK, Ferrell WR, McDonald AG, Sturrock RD. Impaired proprioceptive acuity at the proximal interphalangeal joint in patients with the hypermobility syndrome. British Journal of Rheumatology 1994;33:631–7. March LM, Francis H, Webb J. Benign joint hypermobility with neuropathies: documentation of median, sciatic and common peroneal nerve compression. Clinical Rheumatology 1988;7:35–40. Matthias Grunewald (1460–1528). Saint Cyriaque /http://images. google.co.ukS (Accessed February 2007). McCormack M, Grahame R, Briggs J. Joint laxity and the benign joint hypermobility syndrome in student and professional ballet dancers. Journal of Rheumatology 2004;31:173–8. Mishra MB, Ryan R, Atkinson P, Taylor H, Bell J, Calve D, et al. Extra-articular features of benign joint hypermobility syndrome. British Journal of Rheumatology 1996;35:861–6. Murray K, Woo P. Benign joint hypermobility in childhood. Rheumatology 2001;40:489–91. Nicholas JA. Injuries to knee ligaments: relationship to looseness and tightness in football players. Journal of the American Medical Association 1970;212:2236–9. Oliver J. Hypermobility: recognition and management. In Touch 2000; 94:9–12. Qvindesland A, Jonsson H. Articular hypermobility in Icelandic 12 year-olds. Paediatric Rheumatology 1999;38:1014–6. Russek L. Hypermobility syndrome. Physical Therapy 1999;79(6): 591–7. Russek LN. Examination and treatment of a patient with hypermobility syndrome. Physical Therapy 2000;80:386–98. Sahrmann SA. Diagnosis and treatment of movement impairment syndromes, Mosby, 2002 (Chapter 3). p. 90.

ARTICLE IN PRESS J.V. Simmonds, R.J. Keer / Manual Therapy 12 (2007) 298–309 Sale DG. Neural adaptation to resistance training. Medicine and Science in Sport and Exercise 1988;20:S135–45. Simmonds JV. Rehabilitation, fitness, sports and performance for individuals with joint hypermobility. In: Keer R, Grahame R, editors. Hypermobility syndrome—recognition and management for physiotherapists. London: Butterworth-Heinemann; 2003 (chapter 8). p. 107–126. Smith R, Damodaran AK, Swaminathan S, Campbell R, Barnsley L. Hypermobility and sports injuries in junior netball players. British Journal of Sports Medicine 2005;39:628–31. Soderman K, Alfredson H, Pietila T, Werner S. Risk factors for leg injuries in female soccer: a prospective investigation during one out-door season. Knee Surgery Sports Traumatology Arthroscope 2001;9:313–21.

309

Stewart DR, Burden SB. Does generalised ligamentous laxity increase seasonal incidence of injuries in male first division club rugby players? British Journal of Sports Medicine 2004;38:457–60. Stillman B, Tully E, McMeeken J. Knee joint mobility and position sense in healthy young adults. Physiotherapy 2002;8(9):553–60. U¨mit S, Birkan S, O¨zlem Y, lker Y, Hatice B, Tansu A. The prevalence of joint hypermobility among high school students. Rheumatology International 2005;25:260–3. Wilmore JH, Costill DL. Neuromuscular adaptations to resistance training. In: Wilmore JH, Costill DL, editors. Physiology of sport and exercise. 3rd ed., Human Kinetics. 2004. (chapter 3). p. 84–110. Zweers MC, Hakim A, Grahame R, Schlkwijk J. Joint hypermobility syndromes: the pathophysiological role of tenascin-x gene defects. Arthritis and Rheumatism 2004;50(9):2742–9.

ARTICLE IN PRESS


Systematic review

Advice for the management of low back pain: A systematic review of randomised controlled trials S. Dianne Liddlea,, Jacqueline H. Graceya, G. David Baxterb a

Health and Rehabilitation Sciences Research Institute, University of Ulster at Jordanstown, Shore Road, Newtownabbey Co. Antrim, BT37 OQB, Northern Ireland b Centre for Physiotherapy Research, School of Physiotherapy, University of Otago, New Zealand Received 29 September 2005; received in revised form 15 December 2006; accepted 15 December 2006

Abstract To synthesise the evidence relating to the effectiveness of advice, the relevance of its content and frequency, and to compare the advice being offered to acute, subacute and chronic low back pain (LBP) patients. A systematic review of Randomised Controlled Trials (RCTs) using advice, either alone or with another intervention. The QUOROM guidelines and the Cochrane Collaboration Back Review Group Guidelines for Systematic Reviews were followed throughout: methodological assessment identified RCTs of ‘high’ or ‘medium’ methodological quality, based on their inclusion of at least 50% of the specified internal validity criteria. Outcome measures were analysed based on five recommended core outcome domains; pain, work disability, back-specific function, generic health status and satisfaction with care. Relevant RCTs (n ¼ 56) were scored for methodological quality; 39 RCTs involving 7347 patients qualified for inclusion, based upon their methodological quality. Advice as an adjunct to exercise was most effective for improving pain, back-specific function and work disability in chronic LBP but, for acute LBP, was no more effective for improving these outcomes than simple advice to stay active. Advice as part of a back school was most effective for improving backspecific function in subacute LBP; these trials generally demonstrated long-term positive results. Advice as an adjunct to exercise was the most common form of treatment for acute and chronic LBP; advice as part of a back school was most commonly used for subacute LBP. Fifteen percent of acute LBP trials had a positive outcome, compared to 86% and 74% of subacute and chronic LBP trials respectively. A wide variety of outcome measures were used, making valid comparisons between treatment outcomes difficult. The advice provided to patients with LBP within RCTs varied considerably depending on symptom duration. The findings of this review have important implications for clinical practice, and for the design of further clinical trials in this area. Advice to stay active is sufficient for acute LBP; however, it appears that RCTs do not commonly reflect these recommendations. No conclusions could be drawn as to the content and frequency of advice that is most effective for subacute LBP, due to the limited number and poor quality of RCTs in this area: this review provides preliminary support for advice as part of a back school approach. Given that the effectiveness of treatment for subacute symptoms will directly influence the development of chronicity, these results would suggest that education and awareness of the causes and consequences of back pain may be a valuable treatment component for this patient subgroup. For chronic LBP there is strong evidence to support the use of advice to remain active in addition to specific advice relating to the most appropriate exercise, and/or functional activities to promote active self-management. More investigation is needed into the role of follow-up advice for chronic LBP patients. r 2007 Elsevier Ltd. All rights reserved. Keywords: Advice; Low back pain; Randomised controlled trials; Outcome measures

1. Introduction Corresponding author. Tel.: +353 2890 366423;

fax: +353 2890 368068. E-mail address: [email protected] (S. Dianne Liddle). 1356-689X/$ - see front matter r 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.12.009

The socio-economic burden of low back pain (LBP) continues to increase due largely to disproportionate rises in LBP disability. Indeed, in the 3 years from

ARTICLE IN PRESS S. Dianne Liddle et al. / Manual Therapy 12 (2007) 310–327

1992–1995, days of work disability in the UK are reported to have escalated from 27 to 125 million (Waddell, 1998, p. 296). Whilst it is estimated that about 90% of acute back pain patients return to work within three months, many experience symptom recurrence and functional limitation (Waddell, 1998, p.103–117; Ehrlich, 2003). Advice constitutes all the information that the patient receives verbally, in written, audiovisual, or electronic format during the course of treatment. Its value to the physiotherapist is well recognised (Foster et al., 1999; Trede, 2000; Gracey et al., 2002; Armstrong et al., 2003), and as such is a common component in the management of LBP; the use of ‘The Back Book’, produced by the Royal College of General Practitioners (RCGP), has been widely endorsed as a means of encouraging LBP patients to stay active (Roland et al., 2004). At present, the provision of advice to promote an understanding of LBP, and the importance of the patient playing an active role in their recovery, is largely dependent on the individual clinician, their available time and resources (Kerssens et al., 1999; Trede, 2000). As a result, the most efficacious means of delivering advice, what such advice may comprise, and the frequency with which it is provided, has not been widely investigated in the LBP literature (Trede, 2000). While back schools have aimed to maximise the value of group-based advice and education, trials in this area to date have largely been of poor quality (Koes et al., 1994; Ross, 1997); furthermore, variations in the content of back schools have made it difficult to isolate their most beneficial features (Koes et al., 1994; Lonn et al., 1999; Hazard et al., 2000a; Maier-Riehle and Harter, 2001; van Tulder et al., 2002a) and, as a result, their cost-effectiveness is debatable (McReynolds, 1992). Waddell et al. (1997) have indicated that patients need clear and unambiguous advice about LBP and its management, with individually tailored treatment being purported to improve outcomes (Maluf et al., 2000; von Korff and Moore, 2001). Tailored programmes are thought to promote adherence to treatment (Sluijs et al., 1993; Kerssens et al., 1999), increased patient responsibility, and sustainable behaviour change (Trede, 2000). Current guidelines are in place to recommend that acute LBP patients are best to stay active for faster return to work and less chronic disability (Waddell et al., 1997, 1999; Hilde et al., 2002; Pengel et al., 2002). Little attention has been directed at the specific type of advice offered to patients with LBP, whether this advice varies depending on symptom duration, the value of advice used in conjunction with other interventions, and its relevance in terms of LBP treatment outcomes.

2. Aims of the review The primary aim of this review was to examine the evidence pertaining to the use of advice in the manage-

311

ment of LBP, focussing on the relevance of advice content and frequency to the clinical effectiveness of advice in the management of LBP. Secondary objectives included assessment of the effectiveness of interventions in relation to LBP phase, the influence of supplementary information and followup advice on results, and the relevance of instruments used for outcome assessment.

3. Materials and methods 3.1. Inclusion and exclusion criteria 3.1.1. Type of study

Randomised controlled trials (RCTs) of either pragmatic or explanatory design were included, these being regarded as the criterion standard for assessing the clinical effectiveness of interventions (Moher et al., 1999; Davidson and Hillier, 2002; Haughton and Fine, 2003). Trials using the alternate allocation method of randomisation were excluded in accordance with the recommendations of Altman and Bland (1999). Trials having only their abstracts available were also excluded, as there was insufficient information available to reach a methodological quality (MQ) score. Trials published since 1985 were included: it is reported that there has been a marked increase in back pain research since then, due to an increased availability of research funding (Cherkin, 1998). Trials were required to contain at least 10 patients in each group, in line with the RCGP selection criteria (Waddell et al., 1999). Where duplications of trials were sourced, the trial with the highest MQ was included (van Tulder et al., 1997); where MQ was equal the most recent trial was used. All trials of ‘low’ or ‘very low’ MQ were excluded given that higher quality trials have the most impact on the overall results of a review (de Vet et al., 1997). Note: Trials of ‘low’ and ‘very low’ MQ were assessed to see if trial quality affected reported treatment outcome.

3.1.2. Type of participants

Males and females were included, between the ages of 16 and 79 years and diagnosed with acute (o4 weeks), subacute (4–12 weeks) or chronic (412 weeks) LBP (Frank et al., 1996; Waddell, 1998; Elders et al., 2000). Note: Bouter et al. (1998) indicate that LBP may occur in multiple episodes over the year; for the purposes of this review this is classified as chronic


S. Dianne Liddle et al. / Manual Therapy 12 (2007) 310–327

LBP. Two studies fell into this category (Donchin et al., 1990; Soukup et al., 1999). Trials based on patients with possible serious spinal pathology and spinal surgery patients (if the surgery had been completed less than one year) were excluded, as they are not considered representative of the majority of LBP patients (Teasell and Harth, 1996; Snook et al., 1998). Trials providing insufficient information on the category of LBP, combining different phases of LBP, or if participants were asymptomatic were excluded (van Tulder et al., 2003). Trials counting patients with fibromyalgia were also excluded.

3.1.3. Type of intervention The categorisation of trials by advice content was based on keywords used by the International Task Force on Back Pain (Abenhaim et al., 2000). Each trial was initially categorised according to the main types of advice included; however, this proved to be problematic, given the wide variety employed. For the purposes of this review, and to reflect the variety of advice types offered within programmes, the following broad categories were used:

Advice only: the importance of remaining active as opposed to resting is emphasised. Advice as the main treatment including the Back School approach: advice to remain active along with postural advice, ergonomics, education on the structure, function and maintenance of spinal structures. Advice as an adjunct to exercise: advice to remain active with additional advice regarding the carrying out of a specific exercise programme. Advice as part of a functional restoration programme: advice to remain active along with advice on how to restore functionally relevant activities, and cognitive behavioural techniques directed at decreasing fearavoidance and illness behaviour. Advice with another LBP intervention: advice to remain active along with mobilisations, electrotherapy, and other ‘passive’ treatments. The frequency of advice was categorised as follows:

Once only (in verbal, written, audiovisual, electronic format). Throughout the treatment programme. Throughout the treatment programme along with supplementary information. Throughout the treatment programme and at shortterm follow-up. Throughout the treatment programme and at intermediate follow-up.

Throughout the treatment programme and at longterm follow-up. Any combinations of the above follow-up categories.

The use of an outcomes questionnaire only at followup was not considered a form of advice; therefore, while certain trials may have incorporated this form of followup, for the purposes of this review, such trials were not considered to have provided any advice at this stage. In accordance with the most recent Methodological Guidelines for Systematic Reviews (van Tulder et al., 2003), the following criteria were used to delineate short, intermediate and long-term follow-up:

Short term ¼ o3 months post randomisation. Intermediate term ¼ between 3 and 12 months post randomisation. Long term ¼ X12 months post randomisation.

For the purposes of this review, if a trial reported follow-up at 12 months but no follow-up between 3 and 12 months, this was considered intermediate follow-up. Follow-up reported both between 3 and 12 months and at 12 months was considered to have incorporated both intermediate and long-term follow-up. 3.1.4. Type of outcome In accordance with the World Health Organisation (WHO) International Classification of Functioning, Disability and Health (WHO, 2000; Ustun et al., 2003), the health of an individual is based on the categories of impairment, activity (previously disability) and participation (previously handicap). Since LBP can influence any or all of these categories, outcome measures must adequately reflect the effects and influences that treatment programmes may have on all areas of the patient’s life. Trials scored in this review were considered as having relevant outcome measures if they included three or more of the five core domains recommended by Deyo et al. (1998) and updated by Bombardier (2000). This cut-off point was chosen to enable the review to identify those trials that used valid and reliable outcome measures that reflected the multidimensional effects of LBP on the individual. The recommended five core outcome domains, along with examples of valid and reliable outcome measures, are represented below: the WHO classification is reflected in these five domains as detailed:

Back-specific function: Roland-Morris/Oswestry Disability Questionnaires. These instruments reflect the level of activity limitation that patients experience as a result of their LBP. Generic health status: Short-form 36 (SF-36)/EuroQol Questionnaire. This domain gives a more comprehensive assessment of the patient’s health status than ‘back-specific’


instruments, and can reflect the overall impact of the patient’s health status (including co-morbidities) on their role in society. Pain: frequency and severity of LBP/Body Pain Scale of the SF-36. This measures impairment but also gives an indication of the extent to which pain interferes with the patient’s habitual activities. Work disability: days off work/days of cut-down work/work status/time to return to work. This domain reflects the extent to which the patient’s condition has a negative influence on their usual role in society. Patient satisfaction: Patient Satisfaction Scale/Global question on overall satisfaction with treatment outcome. This domain is considered an important outcome of care (Bombardier, 2000). It can assess the patient’s response to treatment (Liebenson and Yeomans, 1997), and allows feedback between patient and therapist.

The McGill Pain Questionnaire, Aberdeen Back Pain Scale, Sickness Impact Profile and Waddell Disability Index were included in the criteria for acceptability for the domains of pain and back-specific function as there is support for their reliability, validity and responsiveness (Kopec and Esdaile, 1995). 3.2. Search strategy RCTs of experimental and pragmatic design, incorporating advice and/or patient education were sourced. Literature searches were conducted monthly between April 14th 2003 and September 30th 2004 using MEDLINE–Biomed (1985–September 2004), Amed (1985–September 2004), CINAHL (1985–September 2004), PsycInfo (1985–September 2004), COCHRANE– Dare and Central Register of Controlled Trials and PUBMED–National Library of Medicine (1985–2004). The following search terms were used: ACUTE/SUBACUTE/CHRONIC LOW BACK PAIN, ADVICE, EDUCATION, PHYSIOTHERAPY, PHYSICAL THERAPY, INFORMATION, PAMPHLETS, BOOKLETS, CLINICAL TRIALS and RANDOMISED CONTROLLED TRIALS. The following terms were exploded: advice, information, education, and RCTs. Studies were selected for review based on their randomised controlled design, and their inclusion of advice or education as the intervention under investigation. The reference lists of all included trials were searched for further relevant studies that may not have been identified by the databases above (citation tracking). Supplementary hand-searches of relevant journals, review articles and meta-analyses were also performed.

313

3.3. Study selection Two independent reviewers conducted study selection using pre-piloted standardized forms. In cases of disagreement a consensus method was used. 3.4. MQ assessment of included articles The QUOROM Guidelines and Cochrane Back Review Group Guidelines were used as a methodological template for this review (Moher et al., 1999; van Tulder et al., 1997, 2003). The Cochrane Back Review Group Guidelines represent the current ‘state of the art’ of review methods in back pain research, and were, therefore, considered to be the most appropriate for this review. RCTs were included or excluded based on their MQ, with a specific emphasis on their internal validity (IV) (see Table 1). The MQ items and codes used for scoring each item are detailed in the key to Table 2. The most recent Cochrane Guidelines for Systematic Reviews (van Tulder et al., 2003) focus on the five specific quality items listed below, all of which are also included in the 1997 version of the Guidelines:

Concealment of treatment allocation. Drop-out rate. Blinding of patients. Blinding of outcome assessor. Intention to treat analysis.

To facilitate comparison with previous LBP reviews that have used the 1997 guidelines, and to enhance the consistency of results (van Tulder et al., 1997), each trial was categorised as being of ‘high’, ‘medium’, ‘low’ or ‘very low’ MQ according to the criteria detailed in Table 1. This criteria stipulates that at least five out of a possible ten IV criteria must be met to include the trial in the review: these criteria include the five items of MQ detailed above. ‘High’ and ‘medium’ quality RCTs (satisfying at least 50% of the specified IV criteria) were included in the review; ‘low’ and ‘very low’ quality trials (satisfying less than 50% of the IV criteria) were excluded. In addition, outcome measures used within trials were categorised according to the five core domains described by Deyo et al. (1998) and Bombardier (2000). 3.5. Data abstraction Two independent reviewers conducted data abstraction for key study characteristics noted in Table 3, as well as adverse events using pre-piloted standardised forms. The agreement between these reviewers was high (k-statistic x ¼ .894),



Table 1 Criteria for the categorisation of trial quality Quality of RCT

Stipulated criteria

High

At least 70% of the methodological criteria met plus internal validity of X6/10

Medium

At least 50% of the methodological criteria met plus internal validity of X5/10

Low

At least 50% of the methodological criteria met plus internal validity of o5/10

Very low

Less than 50% of the methodological criteria met plus internal validity o5/10

3.6. Data analysis and synthesis An intervention was considered positive if there was a significant difference (po0.05), in one of the recommended categories of outcome measure post-treatment, when compared to other interventions provided in the trial. For those trials using no outcome measures within the recommended categories, a significant difference in two other outcome measures was stipulated; this applied to three trials (Alaranta et al., 1994; Friedrich et al., 1998; Tritilanunt and Wajanavisit, 2001; Table 3). A qualitative description of the direction of effect was noted by treatment approach. Trials were evaluated in terms of clinical homogeneity, but were found to be divergent both in treatment (type of advice given) and outcome measure used. Subgroup analysis was assessed based on the following factors: (1) The relevance of advice content to LBP phase. (2) The influence of advice at follow-up. (3) The relevance of instruments used for outcome assessment. 4. Results 4.1. Description of studies A total of 717 articles were retrieved using the search strategy detailed in the materials and methods section. Fig. 1 identifies the procedure adopted to identify ‘high’ and ‘medium’ quality trials suitable for inclusion in this review. Twelve low quality trials (Keijsers et al., 1989; Jessep, 1991; Elnaggar et al., 1991; Hurri et al., 1991; Altmaier et al., 1992; Lindstrom et al., 1992a; Mitchell and Carmen, 1994; Indahl et al., 1995; Wilkinson, 1995; Gillan et al., 1998; Chok et al., 1999; Moseley, 2002), and five very low quality trials (Mellin et al., 1990; Callaghan, 1994; Basler et al., 1997; Kankaanpaa et al., 1999; Fanello et al., 2002) were excluded from the review. 4.2. Participants A total of 7347 males and females between the ages of 16–79 years were included in the review; one trial

exclusively used 57 year-old women (Bentsen et al., 1997). The mean sample size of the control and intervention groups across trials was 75 and 77 patients, respectively (median sample size was 56 intervention group/65 control group). The mean size of the smallest group in each trial was 72 patients (median size of the smallest group in each trial was 54 patients: range 21–229). 4.3. Adverse effects Intervention was reported to have caused no adverse effects in three of the 39 included RCTs. Seventeen included trials did not report on adverse effects, and four gave insufficient information to reach a score (see Table 2). Adverse effects were specifically described in 15 included RCTs: these ranged from the development of paresis (Vroomen et al., 1999), to hospitalisation due to back pain (Bendix et al., 1998); 328 out of a total of 7347 patients were reported to have experienced adverse effects. However, these adverse effects were not confined to those patients who received advice, and in some cases it was unclear in which group of patients adverse effects occurred (Bendix et al., 1998). Therefore, it cannot be assumed from these limited results that adverse effects were the result of advice. It is only by reporting the occurrence or lack of occurrence of adverse effects in future trials that more clarity can be reached on this subject. 4.4. MQ summary From the 56 RCTs scored for MQ (van Tulder et al., 1997, 2003), 25 were of high, 14 were of medium, 12 were of low and five were of very low MQ (see Table 2). Table 2 provides a summary of the IV, descriptive quality and statistical validity of each RCT scored. ‘High’ and ‘medium’ quality RCTs (n ¼ 39) were also analysed according to the five MQ items identified in the most recent Cochrane Guidelines for Systematic Reviews (van Tulder et al., 2003) (detailed in the materials and methods section). Seventy-two percent (28/39) incorporated at least three out of the five MQ items, and of the remaining trials, 26% (10/39) incorporated at least two of the recommended quality items. Had the

Alaranta et al., 1994 Altmaier et al., 1992 Basler et al., 1997 Bendix et al., 2000 Bendix et al., 1998 Bendix et al., 1997 Bentsen et al., 1997 Burton et al., 1999 Callaghan, 1994 Cherkin et al., 2001 Cherkin et al., 1998 Chok et al., 1999 Donchin et al., 1990 Elnaggar et al., 1991 Evans et al., 1987 Faas et al., 1995 Faas et al., 1993 Fanello et al., 2002 Friedrich et al., 1998 Frost et al., 1998 Gilbert et al., 1985 Gillan et al., 1998 Hagen et al., 2000 Harkapaa et al., 1989 Hazard et al., 2000b Hurri et al., 1991 Indahl et al., 1995 Jessep, 1991 Kankaanpaa et al.,1999 Karjalainen et al., 2004 Keijsers et al., 1989 Klaber Moffett et al., 1999 Klaber Moffett et al., 1986 Von Korff et al., 1998 Leclaire et al., 1996 Lindstrom et al., 1992a Lindstrom et al., 1992b Little et al., 2001 Malmivaara et al. 1995 Mellin et al., 1990

Trial

? + + + + + + ? + + + + + + ? + + + + + + + + + ? + + + +

+ + + + + + + + ? + ? + + + + + + + + + ? + + + + + + + + + + + + ? + + + +

+ + + + + + + + + + + + + + + + + + + + ? + ? ? + + + + + + +

+ + ? + ? + ? + + ? ? ? + + + + + + + + ? + ? ? + ? + + ? + ? ? ? +

g + ? + ? + + + + + + + ? + + + + + +

h ? + + + + + + + + + + + + ? ? + + + + + + +

i + + + + + + +

j + + + + ? + + ? + + + ? + + + + + +

l + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

n + + + + + + + + ? ? + + +

p + + ? + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

? + + + + + + + + + + + + + + + + + + + ? + + + + + + + + +

c + + + + + + + ? + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

d

a

f

b1

b2

Descriptive quality

Internal validity

Table 2 van Tulder methodological quality criteria for n ¼ 56 scored RCTs (from a format used by Liddle et al., 2004)

+ + + + + + + + + + + ? + + + + + + + + + +

k + + + + + + + + + + + + + + + + + + + + + + + + +

m1 + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

m2 + + + + + + + + + + + + + + + + + + + + + + + + +

m3 + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

o

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

q

Stats validity

High Low Very low High High Medium High Medium Very low High High Low Medium Low High High High Very low High High High Low Medium Medium High Low Low Low Very low High Low High Medium High High Low Medium Medium High Very low

Quality

ARTICLE IN PRESS

S. Dianne Liddle et al. / Manual Therapy 12 (2007) 310–327 315

g

h

i

j

l

n

+ + + + + + + + + + + +

+ + ? + + + + + + + + + + +

+ + + + + + + + + + + + +

+ + + ? ? + ? + ? + + ? + + + ? + + + + ? ? ?

+ + + + ? + + + ? + ?

+ + + +

+ + + + + ? + +

+ + + + + + + + + + + + + + + +

Key to abbreviations: a: Where eligibility criteria specified? b1: Was the method of randomisation performed? (including explanation of randomisation) b2: Was the treatment allocation concealed? c: Groups similar at baseline (most important prognostic indicators)? d: Were index and control interventions explicitly described? f: Were the co-interventions avoided or comparable? g: Was compliance acceptable in all groups h: Patient blinded to intervention? (patient given minimal information about intervention) i: Outcome assessor blinded to intervention? j: Relevant outcome measures used? (at least 3 of 5 categories from Bombardier, 2000) k: Adverse effects described? l: Withdrawal/drop out rate described and acceptable? (o10% of total patient sample) m1: Was there short-term follow-up measurement? (o3 months post randomisation) m2: Was there intermediate follow-up measurement? (between 3 and 12 months post randomisation) m3: Was there long-term follow-up measurement? (X12 months post randomisation) n: Was the timing of outcome assessment in both groups comparable? o: Was the sample size in each group described? p: Did analysis included intention-to-treat analysis? q: Were point estimates and measures of variability presented for primary outcome measures?

+: criterion achieved : criterion not achieved ?: insufficient description to determine

p + + + + + + +

+ + + + + + + + + + + + + + + +

+ + + + ? + + + + + + + + +

c + + + + + + + + + + + + + + + +

d

a

f

b1

b2

Descriptive quality

Internal validity

+ + ? + ? + ? + + +

k + + + + + + + + +

m1 + + + + + + + + + + + + +

m2 + + + + + + + +

m3 + + + + + + + + + + + + + + +

o + + + + + + + + + + + + + + + +

q

Stats validity

Low Low High High High Medium Medium Medium High Medium High High Medium Medium High Low

Quality

316

Mitchell and Carmen, 1994 Moseley, 2002 O’Sullivan et al., 1997 Preyde, 2000 Roberts et al., 2002 Rossignol et al., 2000 Snook et al., 1998 Soukup et al., 2001 Soukup et al., 1999 Stankovic and Johnell, 1990 Tortensen et al., 1998 Triano et al., 1995 Tritilanunt and Wajanavisit, 2001 Turner et al., 1990 Vroomen et al., 1999 Wilkinson, 1995

Trial

Table 2 (continued )

ARTICLE IN PRESS


Acute LBP High

Acute LBP High

Acute LBP High

Hazard et al., 2000b Leclaire et al., 1996

Roberts et al., 2002

Acute LBP High

Gilbert et al., 1985

Acute LBP High

Acute LBP High

Faas et al., 1993

Malmivaara et al., 1995

Acute LBP High

Faas et al., 1995

Acute LBP Medium

170

Acute LBP High

Evans et al., 1987

Little et al., 2001

486

Acute LBP High

Cherkin et al., 1998

64

176

311

252

473

363

252

321

162

Acute LBP Medium

Once only

Throughout Rx & suppl. info.


Throughout Rx & suppl. info. Throughout Rx & LT f’up

Advice only plus GP care

Advice as an adjunct to exercise


Advice only


ST & IT Negative (advice to stay active best)

ST

ST, IT & LT

No difference

No difference

ST

ST, IT & LT

No difference

No difference

ST & IT

Usual GP care No difference ST, IT & LT (exptl gp perceived themselves as being better able to control their LBP than ctls)

Throughout Advice only Rx & ST f’up

Once only

usual health care standard back care (rest: analgesics; NSAIDS; daily physio)

bed rest

No difference

ST, IT & LT

No difference

Advice only (or placebo ultrasound) Advice only (or placebo ultrasound)

ST, IT & LT

No difference

ST, IT & LT

ST, IT & LT

Positive (BPS model important)

No difference

Follow-up

Rx outcome

analgesics only

Advice only

advice only (and given a different booklet)

Once only


Comparison intervention(s)

Frequency of advice

Throughout Advice as main (includes Rx BS)

Advice only



Advice as an adjunct to exercise Advice as an adjunct to exercise


Advice only (and given ‘The Back Book’)

Number of Class of patients intervention (experimental group)

Burton et al., 1999

Method quality

Type of LBP

Study

Table 3 Included RCTs (n ¼ 39) of low back pain and advice

N/A

N/A

YES (at 3 week f’up)

N/A

N/A

N/A

N/A

N/A

N/A

N/A

YES

Positive result m’tained at followup

Back Specific function

ODQ/WORK DISABILITY/Sat. with care

Sat. with care/Aberdeen Back Pain Scale

RMDQ/ODQ/WORK DISABILITY/Sat. with care

WORK DIASABILITY

PAIN

PAIN

WORK DIASABILITY/ PAIN

PAIN

RMDQ/Sat. with care/ GEN H/S/PAIN

RMDQ

Recommended outcome measures used

RMDQ

PAIN

WORK DISABILITY

SLR; Lsp flexion; Health related quality of Life

Knowledge & attitude towards back care; observed behaviour

Sat. with care

WORK DISABILITY WORK DISABILITY

PAIN

PAIN

Knowledge of back pain

Pain (intensity); Health care visits LBP recurrence; Schober Test; F’tips—floor; Lateral bending; active SLR

Activity discomfort scale; SLR; Lsp flexion; Restricted ADL’s & compliance

Number & duration of LBP recurrences; Nottingham Health Profile (functional health status); Health care use; Exercise compliance

Activity discomfort scale; PAIN SLR; Lumbar flexion; Patient diary of activity & rest Compliance; Use of advice at WORK work & in ADL’s; Pain killer DISABILITY use

LBP recurrence; Health care use; National Health Interview Survey

o0.05

o0.05

o0.05

o0.05

o0.05

o0.05

o0.05

o0.05

o0.05

o0.05

o0.05

Outcome(s) on Level of which result of significance (P) intervention was based

RMDQ VAS (pain intensity); Fear avoidance beliefs; Beliefs about inevitable consequences of back trouble

Other outcome measures used

ARTICLE IN PRESS


Acute LBP High

Subacute LBP

Subacute LBP

Subacute LBP

Subacute LBP

Subacute LBP

Subacute LBP

Subacute LBP

Chronic LBP

Chronic LBP

Vroomen et al., 1999

Hagen et al., 2000

Karjalainen et al., 2004a

Klaber Moffett et al., 1999

Lindstrom et al., 1992b

Rossignol et al., 2000

Triano et al., 1995

von Korff et al., 1998

Alaranta et al., 1994

Bendix et al., 2000

High

High

High

High

Medium

Medium

High

138

293

255

209

110

174

187

164

457

183

100


Once only


Advice as main (BS involved)

Usual care & leaflet

Advice only

Advice as part Throughout Outpatient of FR prog. Rx & ST f’up intensive physical training

Advice as part Throughout of FR prog. Rx

Advice as Throughout main (includes Rx & suppl. BS) info.

Other— manipulation

IT & LT

ST & IT

Positive

IT & LT

Positive (more improvt in Exptl gp)

Positive

YES (overall Ax at 1year)

YES

YES

N/A

No difference ST (manip had ST benefits but advice cumulative lasting effect)

YES

YES (at 6 months & 1 year f’up)

YES

YES

N/A

YES (1 year f’up)


YES

IT & LT

ST, IT & LT

IT & LT

IT & LT

ST & IT

ST & IT

Follow-up

IT

Usual GP care Positive

Usual GP care Positive

Positive

Positive

No difference

Positive

Rx outcome

Throughout Usual GP care Positive Advice as main (includes Rx & ST f’up BS)



Advice only/ usual health care

Usual health care

Throughout Advice only Rx & ST f’up

Throughout Mini Back Rx & ST f’up School

Frequency of advice

Advice as Once only main (includes BS)

Advice only

Other—bed rest



BDI; Health care use; Million Pain & Disability Index; Lsp flex/ext; Strength & endurance of back & legs; subjective performance

ADL assessment; Patient’s quality of life

WORK DISABILITY/ PAIN

Back pain worries; attitudes towards self-care

None

RMDQ/PAIN/GEN H/S (SF-36)

WORK DISABILITY

Million Pain & Disability Index; Lsp flex/ext; Strength & endurance of back & legs

o0.05

o0.05

o0.01

o0.05 ODQ ODQ

RMDQ

o0.05 ODQ Pain (intensity); Health care use; FABQ; Dallas Pain Q’aire; Quebec back pain disability scale

ODQ/WORK DISABILITY/Sat. with care

VAS (pain intensity); Modified Zung Depression Index

o0.01 WORK DISABILITY Lsp ROM; Finger-floor distance; Modified Schober test; Exercise group— mobility, strength, fitness


o0.05 RMDQ

FABQ; Health care use

RMDQ/GEN H/S (EuroQol—5D)/PAIN (Aberdeen Back Pain Scale)

o0.001 Sat. with care/ o0.05 PAIN

WORK DISABILITY

Health care use; Health related quality of life

None

o0.05

Patient & outcome assessor perception of improvement

RMDQ

o0.05


LBP recurrence in one year; WORK Patient’s ability to self-help; DISABILITY Pain (intensity); Spinal ROM


WORK DISABILITY/ PAIN/ODQ/Sat. with care

WORK DISABILITY

PAIN/RMDQ/ODQ/Sat. with care/WORK DISABILITY

WORK DIASABILITY


318

High

Medium

Acute LBP Medium

Stankovic and Johnell, 1990

Method quality

Type of LBP

Study


ARTICLE IN PRESS


Chronic LBP

Chronic LBP

Chronic LBP

Chronic LBP

Chronic LBP

Chronic LBP

Chronic LBP

Frost et al., 1998a

Harkapaa et al., 1989

Klaber Moffett et al., 1986

O’Sullivan et al., 1997

Preyde, 2000

Snook et al., 1998

Soukup et al., 2001

Medium

Medium

High

High

Medium

Medium

High

High

High

Chronic LBP

Chronic LBP

Cherkin et al., 2001

High

Friedrich et al., 1998

Chronic LBP

Bentsen et al., 1997

Medium

Medium

Chronic LBP

Bendix et al., 1997

High

Donchin et al., Chronic 1990 LBP

Chronic LBP

Bendix et al., 1998a

73

85

107

44

78

459

71

93

142

262

74

123

238


Advice only

Other – soft tissue manipulation with exercise & advice)



Positive

Positive

Positive

Same physical exam as exptl group but no Rx

No difference

sham exercises Positive

Advice to exercise

Throughout Rx


GP advice to exercise regularly

Exercise & handouts

Throughout Rx

Advice as Throughout main (includes Rx BS)

Positive (inpatient group better than outpatient group)

Positive (motivation important)

Throughout Advice only Advice as main (includes Rx & LT f’up BS) inpatient & outpatient groups)

Exercise only

Throughout Rx

No difference

Positive

Back School

Advice as part Throughout Back School of FR prog. Rx & ST f’up

Advice as an adjunct to exercise (including motivation)


Throughout Rx

Advice only


Other (massage with exercises & stretching)

No difference

No difference

Advice only

Throughout Rx & ST, IT & LT f’up


Positive (more improvt in Exptl gp)

Advice as part Throughout Back School of FR prog. Rx & ST f’up

Advice as part Throughout Same as exptls Positive (more improvt in of FR prog. Rx & ST f’up but no psychological Exptl gp) support

IT & LT

IT & LT

ST

ST, IT & LT

N/A

YES

YES

YES

YES (16 weeks f’up)

YES

IT & LT

ST & IT

YES

ST, IT & LT

WORK DISABILITY

PAIN

RMDQ/PAIN

ODQ

PAIN/ODQ

PAIN/Sat. with care

DISABILITY; PAIN (intensity) ODQ

NO (not at None LT f’up)

ST, IT & LT

ODQ

RMDQ/WORK DISABILITY/Sat. with care

WORK DISABILITY

WORK DISABILITY

WORK DISABILITY

N/A

N/A

YES

YES

YES

IT & LT

ST & IT

IT & LT

ST & LT

ST & LT

WORK DISABILITY

o0.05 WORK VAS (pain intensity); VAS DISABILITY (back function); Dartmouth COOP (health status); Health care use

o0.05

o0.05

o0.01

RMDQ; PAIN

ODQ

o0.05

o0.05 PAIN

PAIN

o0.05

o0.001

o0.05

o0.05

ODQ

ODQ

WORK DISABILITY

WORK DISABILITY

o0.01

o0.05

Difficulty with ADL’s; Use of PAIN medication; level of impairment

State Anxiety index; Modified Schober Test

VAS (intensity); Lsp ROM; Abdominal recruitment patterns

Knowledge & understanding of back care; Spinal ROM

Compliance; LBP disability index; Physical activity; Spinal & hip ROM; Trunk muscle strength

o0.05 LBP disability index

Disability (low back outcome scale); Pain (intensity); Physical impairment; Motivation (Psychotherapy q’aire); Compliance

SLR; Schober test; Isometric spinal extensor strength; Abdominal muscle strength

Pain (intensity); use of analgesia

Schober test; SLR; Million q’aire

Pain; Health care/medication WORK use; Subjective disability; DISABILITY Physical activity

ADL assessment; Pain (intensity); Health care/ medication use; Physical activity

ARTICLE IN PRESS


High

Medium

Chronic LBP

Chronic LBP

Chronic LBP

Tortensen et al., 1998

Tritilanunt and Wajanavisit, 2001

Turner et al., 1990

Exercise & advice +/behavioural treatment

Advice (main) plus flexion exercises

YES

N/A

ST, IT & LT

No difference (all groups positive results)

YES

N/A


IT

IT & LT

IT & LT

Follow-up

Positive

Positive

Advice only

Throughout Rx & suppl. info. Throughout Rx

Positive

Rx outcome

Advice only







Frequency of advice

Back specific function/ Sat. with care

None

ODQ/Sat. with care/ WORK DISABILITY



WORK DISABILITY

Pain; HR rest decrease

Sickness Impact Profile; Pain Back specific function behaviour checklist; CES-D (depression); Physical work capacity; Spinal ROM

VAS (pain intensity); HR rest; HDL-C

o0.01

o0.05

o0.05

o0.05


VAS (pain intensity); Schober ODQ test; Back & abdominal muscle strength

General functional status


LBP ¼ low back pain; Lsp ¼ lumbar spine; ROM ¼ range of movement; ST ¼ short-term; IT ¼ intermediate-term; LT ¼ long-term; f’up ¼ follow-up; Suppl. info ¼ supplementary information; RMDQ ¼ Roland Morris Disability Questionnaire; GEN H/S ¼ generic health status; ODQ ¼ Oswestry Disability Questionnaire; Sat. with care ¼ satisfaction with care; CES-D ¼ Center for Epidemiologic Studies-Depression scale; Dartmouth COOP ¼ functional status assessment charts; BDI ¼ Beck Depression Inventory; VAS ¼ Visual Analogue Scale; FABQ ¼ Fear avoidance Beliefs Questionnaire; SLR ¼ straight leg raise; ADL’s ¼ activities of daily living; Q’aire ¼ questionnaire; NSAID’S ¼ non-steroidal anti-inflammatory drugs; physio ¼ physiotherapy; Rx/ Ax ¼ treatment/assessment; manip ¼ manipulation; GP ¼ general practitioner; FR prog. ¼ functional restoration programme; F’tips ¼ fingertips; HR rest ¼ resting heart rate; HDL-C ¼ high density lipoprotein cholesterol; BS ¼ back school; flex/ext ¼ flexion/extension; N/A ¼ not applicable; exptl ¼ experimental; improvt ¼ improvement; ctls ¼ control group; m’tained ¼ maintained. a Denotes duplicate study.

96

72

208

77


320

Medium

High

Chronic LBP

Soukup et al., 1999

Method quality

Type of LBP

Study


ARTICLE IN PRESS



321

Fig. 1. Flow chart of literature search for low back pain and advice. Key to abbreviations: RCTs ¼ randomised controlled trials; LBP ¼ low back pain.

inclusion of more than three of these items of MQ been used solely as a basis for the inclusion of trials in this systematic review, a further 11 trials would have been excluded leaving 28 included trials. Of these, 17 (61%) reported a positive result, and 11 (39%) reported no difference in outcome between the experimental and control interventions; this represents a similar outcome to the more inclusive criteria used here. 4.5. Advice as an adjunct to exercise This was the most common type of intervention used in acute (n ¼ 8/13; 62%), and chronic (n ¼ 8/19; 42%) LBP trials respectively, but was not used in any subacute LBP trials. Advice as an adjunct to exercise was most effective for improving pain, back-specific function and

work disability in chronic LBP, but for acute LBP patients was no more effective for improving these outcomes than simple advice to stay active. 4.6. Advice as part of a back school This approach was most commonly used for the management of subacute LBP (n ¼ 3/7; 43%), and was most effective for improving back-specific function in this sub-group of patients. 4.7. Subgroup analysis Table 3 details the characteristics of included trials following MQ assessment (n ¼ 39). Twenty-two (56%) reported a positive result in the experimental versus the



control group; 16 (41%) reported no difference between the experimental and control groups, and one reported a negative outcome when the experimental intervention was compared to the control. Advice to stay active, or usual GP care, were the most common comparison interventions (62% of included trials), especially in acute (26%) and subacute (18%) LBP trials (see Table 3). 4.8. The relevance of advice content to LBP phase A positive result was obtained in 15% (2/13) of all trials investigating advice for the management of acute LBP, compared to 86% (6/7) of those investigating subacute, and 74% (14/19) of chronic LBP trials, respectively. Of the nine acute LBP trials in which there was no difference reported, five used advice as an adjunct to exercise as the experimental intervention. Of the positive results obtained in subacute LBP trials, the back school was the most common experimental intervention (n ¼ 3) followed by functional restoration incorporating cognitive behavioural methods (n ¼ 2). The most common experimental interventions resulting in a positive outcome in chronic LBP trials were advice as an adjunct to exercise (n ¼ 5), or as part of a functional restoration approach (n ¼ 5). 4.9. The influence of advice at follow-up Advice was not commonly incorporated into followup, especially for subacute LBP patients; nevertheless, positive treatment results were maintained at follow-up in this subgroup of patients. Six (43%) chronic LBP trials with a positive result incorporated advice into follow-up; advice incorporated into short-term followup was predominantly used. A further six positive chronic LBP trials provided advice throughout treatment only; only one of these trials did not maintain its positive results at all follow-up points. However, there were observed differences in the length of follow-up between these two groups of chronic LBP studies; therefore, it is difficult to ascertain from these observations if, indeed, follow-up advice plays a role in the maintenance of positive results. This will require more detailed enquiry. 4.10. The relevance of instruments used for outcome assessment Table 3 details the use of the five specific recommended categories of outcome measure within included trials. A median of four different outcome measures was used in each included trial: a median of two outcome measures fell into any of the five recommended categories (Deyo et al., 1998; Bombardier, 2000): categories most commonly represented were ‘back specific function’ (n ¼ 19), ‘work disability’ (n ¼ 18),

and ‘pain frequency and intensity’ (n ¼ 17). Six trials used three, and four trials used four of the recommended categories of outcome measure. Only three trials used none of the recommended categories, which contrasts markedly with a recent review of exercise and chronic LBP (Liddle et al., 2004): nonetheless, chronic LBP trials in this review used fewer recommended categories of outcome measure than acute and subacute LBP trials. Physical outcome measures (such as straight leg raise, Schober test, abdominal endurance) were used in 33% of included trials (n ¼ 13). Twenty-eight percent (n ¼ 11) of the included trials used outcome measures directed at assessing the influence of psychological factors on patient progress (behavioural, emotional and cognitive) (see Table 3). 5. Discussion This is the first systematic review that has attempted to assess the effectiveness of advice, focussing on the relevance of both content and frequency of advice, given to LBP patients, and the relevance of symptom chronicity to the type of advice offered. Trials involving acute, subacute and chronic LBP patients were reviewed, and results are based on 39 ‘high’ and ‘medium’ quality RCTs. Fifty-six percent (22/39) of included trials had a positive result, with 95% (21/22) of these maintaining their positive results at follow-up. Whilst the heterogeneity of interventions makes it difficult to be specific about the content and frequency of advice, the results of this review do appear to indicate that there are differences in the type of advice provided to acute, subacute, and chronic LBP patients. This review has demonstrated a level of evidence similar to that underpinning existing UK guidelines for acute LBP: the RCGP Clinical Guidelines for the management of acute LBP based their recommendations on the value of advice on eight trials from 1984 to 1995; lack of support for bed rest is based on nine trials from 1961 to 1995 (Waddell et al., 1999). 5.1. Type of advice Although acute and chronic pain are recognised as being very different (Wolff, 1983; Waddell, 1987; Keijsers et al., 1989; Waddell, 1998), this review has identified that RCTs most commonly use advice as an adjunct to exercise for both of these phases of LBP. This occurs in spite of the fact that current guidelines for acute LBP patients do not recommend the prescription of specific exercise programmes, but rather more simple advice to remain active, for acute LBP patients (CSAG, 1994; Waddell et al., 1999; van Tulder et al., 2000, 2002b); the results of this review provide further support for the existing guidelines on acute LBP, (i.e. advice to


stay active is sufficient). The authors do not claim that advice to remain active alone is superior to advice plus specific exercises but the above references relating to the management of acute LBP, and the findings of this review indicate that simple advice to stay active is sufficient for this patient group. Therefore, the authors suggest that perhaps wider use of ‘The Back book’ (Roland et al., 2004), an existing resource containing the necessary information on how to stay active and why this is important, may help to reinforce this key message to patients in the early stages of LBP, and dispel the fears and mistaken illness attributions that can often contribute to symptom chronicity. In comparison, the back school approach was favoured (over advice as an adjunct to exercise) in subacute LBP trials, all with a positive outcome. The use of functional restoration, incorporating a cognitive behavioural approach, was also common in both subacute and chronic LBP phases, again with a predominance of positive results. The highest percentage of positive results was achieved in subacute LBP trials (86%), along with maintenance of these results at intermediate and long-term follow-up (100%). This result tentatively suggests that a back school or functional restoration approach may have positive long-term effects on the subacute LBP patient; however, it is unclear whether the frequency of advice affects the maintenance of positive results with this clinically important subgroup of patients. More high quality trials are required within the subacute LBP phase before any more definitive pronouncements on treatment effectiveness are possible. In this respect it is interesting to note that 10 years have passed since Faas called for more high-quality trials investigating subacute LBP (Faas, 1996). The use of simple advice to stay active (continue normal activities) as the experimental intervention was less likely to be used in trials in which LBP symptoms had reached the chronic phase; rather advice to stay active combined with specific advice relating to exercise, and/or restoration of functional activities were more commonly used to manage this patient subgroup. This observation reflects the generally accepted view of an increase in the complexity of LBP with prolonged symptom duration. However, it is unclear why the back school is not more commonly used in chronic LBP trials: this may be partly explained by the conflicting evidence on the benefits of back schools, and/or reports that individually tailored instructions are more effective with chronic LBP patients (Maluf et al., 2000; von Korff and Moore, 2001; Descarreaux et al., 2002). It may also be explained by the fact that a number of trials using a back school approach were excluded from the review. It would, therefore, appear that more highquality back school trials are required to allow comparisons with other interventions, such as exercise

323

or functional restoration. As part of this, the use of a standardised back school programme within trials would be useful to improve the reliability and validity of such comparisons. 5.2. Frequency of advice Follow-up advice was apparently not instrumental in maintaining positive results, in the short or long-term, within subacute LBP trials. In contrast, for chronic LBP patients, it has been suggested that the use of refresher programmes at follow-up may help to maintain the positive results of treatment (Harkapaa et al., 1989; Bendix et al., 1998). Whilst only one chronic LBP trial did not maintain its positive results at all follow-up points, there were wide differences in the lengths of follow-up carried out within chronic LBP trials having a positive outcome. If a relationship exists between the provision of advice after the completion of treatment and long-term maintenance of results for chronic LBP patients, this can only be determined from further trials designed specifically to test this hypothesis. 5.3. Outcome measures As reported in a recently published review of exercise and chronic LBP (Liddle et al., 2004), this review identified an over-emphasis on the use of measures of impairment within RCTs at the expense of outcomes representing the restoration of activity (previously disability) and participation (previously handicap) (WHO, 2000). This is despite the fact that LBP patients can experience improvements in function with little or no effect on their level of impairment (Waddell et al., 1992; Beattie and Maher, 1997; Seeger, 2001). Roland and Torgerson (1998) indicate that the use of ‘physiological surrogates’, not clearly related to health outcomes, must be viewed with caution; outcome measures need to be able to reflect the ‘real world’ concerns of patients, clinicians, and policy-makers (Hotopf, 2002). 5.4. Limitations of the review A key limitation with this review is the influence that publication bias may have had on the results. It is widely recognised that trials demonstrating a positive effect of intervention are more likely to be published than those trials not demonstrating an effect. Similarly, the vote count method used in this review is recognised as having limitations as it does not reflect the magnitude of the clinical effect. However, the authors considered this the most suitable method given the level of information available. The interpretation of trial outcomes can also be misleading as in the case of the trial by Roberts et al. (2002). Whilst the results of this



trial showed no difference in back-specific function between a group of acute LBP patients receiving simple advice plus usual GP care, compared to a group receiving usual GP care only, the group receiving advice to stay active in addition to usual GP care were reported to perceive themselves as better able to control their LBP than the usual GP care group. This may indicate that the addition of advice to GP care in this case may have had a more clinically important effect on patients as they felt more able to manage their condition, supporting the use of advice to stay active for this patient subgroup. Similarly, the trial undertaken by Triano et al. (1995), demonstrated no difference in functional outcomes between a group receiving manipulation and another receiving advice. However, the trial results do indicate that there was a more instant effect with manipulation that was not maintained when manipulation was stopped whereas the advice group had a more cumulative and lasting benefit. 6. Conclusions The main clinical implication of this review centres on the relevance of chronicity to the type of advice that is required to produce effective outcomes with LBP patients. Whilst the nature of the evidence available makes it difficult to be specific about the content and frequency of advice that should be provided, this review supports the current recommendation that advice to stay active (such as that provided in ‘The Back Book’) (Roland et al., 2004) is sufficient for acute LBP patients, and could perhaps be more widely implemented in practice. For the effective management of chronic LBP, this review provides strong evidence that patients require advice to stay active plus specific advice relating to appropriate exercise(s) and/or restoration of functional activities to promote active self-management; advice on staying active is not sufficient. The research implications centre around the need for more high-quality trials within the subacute LBP phase, the development and use of a standardised back school programme, the putative relevance of follow-up advice for chronic LBP patients, and a greater emphasis on the appropriate use of clinically relevant outcome measures within RCTs in order to accurately assess the effectiveness of interventions and promote a standardisation of outcome measures within clinical practice. Acknowledgement The support of the Department for Employment and Learning (Northern Ireland) is gratefully acknowledged. There are no conflicts of interest

References Abenhaim L, Rossignol M, Valat J-P, et al. The role of activity in the therapeutic management of back pain: report of the International Paris Task Force on Back Pain. Spine 2000;25(Suppl):1S–33S. Alaranta H, Rytokoski U, Rissanen A, et al. Intensive physical and psychosocial training program for patients with chronic low back pain: a controlled clinical trial. Spine 1994;19:1339–49. Altmaier EM, Lehmann TR, Russell DW, et al. The effectiveness of psychological interventions for the rehabilitation of low back pain: a randomised controlled trial evaluation. Pain 1992;49:329–35. Altman D, Bland J. Treatment allocation in controlled trials: why randomise? British Medical Journal 1999;318:1209. Armstrong MP, McDonough S, Baxter GD. Clinical guidelines versus clinical practice in the management of low back pain. International Journal of Clinical Practice 2003;57:9–13. Basler HD, Jakle C, Kroner-Herwig B. Incorporation of cognitivebehavioural treatment into the medical care of chronic low back pain patients: a controlled randomized study in German pain treatment centres. Patient Education and Counselling 1997;31:113–24. Beattie P, Maher C. The role of functional status questionnaires for low back pain. Australian Journal of Physiotherapy 1997;43:29–38. Bendix AF, Bendix T, Lund C, et al. Comparison of three intensive programs for chronic low back pain patients: a prospective, randomized, observer-blinded study with one-year follow-up. Scandinavian Journal of Rehabilitation Medicine 1997;29:81–9. Bendix AF, Bendix T, Haestrup C, et al. A prospective, randomised 5-year follow-up study of functional restoration in chronic low back pain patients. European Spine Journal 1998;7:111–9. Bendix T, Bendix A, Labriola M, et al. Functional restoration versus outpatient physical training in chronic low back pain. Spine 2000;25:2494–500. Bentsen H, Lindgarde F, Manthorpe R. The effect of dynamic strength back exercise and/or a home training program in 57 year-old women with chronic low back pain: results of a prospective randomised study with a 3-year follow-up. Spine 1997;22: 1494–500. Bombardier C. Outcome assessments in the evaluation of treatment of spinal disorders. Spine 2000;25:3100–3. Bouter LM, van Tulder MW, Koes BW. Methodologic issues in low back pain research in primary care. Spine 1998;23:2014–20. Burton AK, Waddell G, Tillotson M, et al. Information and advice to patients with back pain can have a positive effect: a randomised controlled trial of a novel educational booklet in primary care. Spine 1999;24:2484–91. Callaghan MJ. Evaluation of a back rehabilitation group for chronic low back pain in an out-patient setting. Physiotherapy 1994;80:677–81. Cherkin DC. Primary care research on low back pain: the state of the science. Spine 1998;23:1997–2002. Cherkin DC, Deyo RA, Battie M, et al. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. New England Journal of Medicine 1998;339:1021–9. Cherkin DC, Eisenberg D, Sherman KJ, et al. Randomized trial comparing traditional Chinese medical acupuncture, therapeutic massage, and self-care education for chronic low back pain. Archives of Internal Medicine 2001;161:1081–8. Chok B, Lee R, Latimer J, et al. Endurance training of the trunk extensor muscles in people with subacute low back pain. Physical Therapy 1999;79:1032–42. Clinical Standards Advisory Group (CSAG). Report on Back Pain. London: HMSO; 1994. Davidson I, Hillier VF. Comparison of four methods of allocation for clinical trials with small sample sizes. Physiotherapy 2002;88: 722–9.

ARTICLE IN PRESS S. Dianne Liddle et al. / Manual Therapy 12 (2007) 310–327 de Vet HCW, de Bie RA, van der Heijden GJ, et al. Systematic reviews on the basis of methodological criteria. Physiotherapy 1997;83: 284–9. Descarreaux M, Normand MC, Laurencelle L, et al. Evaluation of a specific home exercise programme for low back pain. Journal of Manipulative and Physiological Therapeutics 2002;25:497–503. Deyo RA, Battie M, Beurskens AJ, et al. Outcome measures for low back pain research: a proposal for standardised use. Spine 1998;23:2003–13. Donchin M, Woolf O, Kaplan L, et al. Secondary prevention of low back pain: a clinical trial. Spine 1990;15:1317–20. Ehrlich GE. Back pain. The Journal of Rheumatology 2003;30(Suppl. 67):26–31. Elders LA, van der Beek A, Burdorf A. Return to work after sickness absence due to back disorders: a systematic review on intervention strategies. International Archives of Occupational and Environmental Health 2000;73:339–48. Elnaggar IM, Nordin M, Sheikhzadeh A, et al. Effects of spinal flexion and extension exercises on low-back pain and spinal mobility in chronic mechanical low-back pain patients. Spine 1991;16: 967–72. Evans C, Gilbert JR, Taylor W, et al. A randomized controlled trial of flexion exercises, education and bed rest for patients with acute low back pain. Physiotherapy Canada 1987;39:96–101. Faas A. Exercises: which ones are worth trying, for which patients, and when? Spine 1996;21:2874–9. Faas A, Chavannes AW, van Eijk JT, et al. A randomised, placebocontrolled trial of exercise therapy in patients with acute low back pain. Spine 1993;18:1388–95. Faas A, van Eijk JT, Chavannes AW, et al. A randomized trial of exercise therapy in patients with acute low back pain. Spine 1995;20:941–7. Fanello S, Jousset N, Roquelaure Y, et al. Evaluation of a training program for the prevention of lower back pain among hospital employees. Nursing and Health Sciences 2002;4:51–4. Foster N, Thompson K, Baxter GD, et al. Management of non-specific low back pain by physiotherapists in Britain and Ireland: a descriptive questionnaire of current clinical practice. Spine 1999; 24:1332–42. Frank JW, Kerr MS, Brooker A-S, et al. Disability resulting from occupational low back pain. Part 1: what do we know about primary prevention? A review of the scientific evidence on prevention before disability begins. Spine 1996;21:2908–17. Friedrich M, Gittler G, Halberstadt Y, et al. Combined exercise and motivation program: effect on the compliance and level of disability of patients with chronic low back pain: a randomised controlled trial. Archives of Physical Medicine and Rehabilitation 1998;79:475–87. Frost H, Lamb SE, Klaber Moffett JA, et al. A fitness programme for patients with chronic low back pain: 2-year follow-up of a randomised controlled trial. Pain 1998;75:273–9. Gilbert JR, Taylor DW, Hildebrand A, et al. Clinical trial of common treatments for low back pain in family practice. British Medical Journal 1985;291:791–4. Gillan MGC, Ross JC, McLean IP, et al. The natural history of trunk list, its associated disability and the influence of McKenzie management. European Spine Journal 1998;7:480–3. Gracey JH, McDonough S, Baxter GD. Physiotherapy management of low back pain: a survey of current practice in Northern Ireland. Spine 2002;27:406–11. Hagen EM, Eriksen HR, Ursin H. Does early intervention with a light mobilization program reduce long-term sick leave for low back pain? Spine 2000;25:1973–6. Harkapaa K, Jarvikoski A, Mellin G, et al. A controlled study on the outcome of inpatient and outpatient treatment of low back pain: Part 1. Pain, disability, compliance, and reported treatment benefits

325

three months after treatment. Scandinavian Journal of Rehabilitation Medicine 1989;21:81–9. Haughton VM, Fine J. Measuring the effect of novel therapies for back pain. American Journal of Neuroradiology 2003;24:784–7. Hazard RG, Reid S, Clark AA. Educating back-injured workers: what should we be teaching? Work 2000a;15:159–66. Hazard RG, Reid S, Haugh LD, et al. A controlled trial of an educational pamphlet to prevent disability after occupational low back injury. Spine 2000b;25:1419–23. Hilde G, Hagen KB, Jamtvedt G, et al. Advice to stay active as a single treatment for low back pain and sciatica (Cochrane Review). The Cochrane Library 2002;3. Hotopf M. The pragmatic randomised controlled trial. Advances in Psychiatric Treatment 2002;8:326–33. Hurri H, Mellin G, Korhonen O, et al. Aerobic capacity among chronic low-back-pain patients. Journal of Spinal Disorders 1991;4:34–8. Indahl A, Velund L, Reikeraas O. Good prognosis for low back pain when left untampered: a randomised clinical trial. Spine 1995;20:473–7. Jessep S. Comparison study of the effectiveness of two methods of back education: a pilot study. New Zealand Journal of Physiotherapy 1991;19:32–9. Kankaanpaa M, Taimela S, Airaksinen O, et al. The efficacy of active rehabilitation in chronic low back pain: effect on pain intensity, self-experienced disability and lumbar fatigability. Spine 1999;24: 1034–42. Karjalainen K, Malmivaara A, Mutanen P, et al. Mini-intervention for subacute low back pain: two-year follow-up and modifiers of effectiveness. Spine 2004;29:1069–76. Keijsers JF, Groenman NH, Gerards FM, et al. A back school in the Netherlands: evaluating the results. Patient Education and Counselling 1989;14:31–44. Kerssens JJ, Sluijs EM, Verhaak PFM, et al. Back care instructions in physical therapy: a trend analysis of individualized back care programs. Physical Therapy 1999;79:286–95. Klaber Moffett JA, Chase SM, Portek I, et al. A controlled, prospective study to evaluate the effectiveness of a back school in the relief of chronic low back pain. Spine 1986;11:120–2. Klaber Moffett JA, Torgerson D, Bell-Syer S, et al. Randomised controlled trial of exercise for low back pain: clinical outcomes, costs and preferences. British Medical Journal 1999;319:279–83. Koes BW, van Tulder MW, van der Windt DA, et al. The efficacy of back schools: a review of randomised clinical trials. Journal of Clinical Epidemiology 1994;47:851–62. Kopec JA, Esdaile JM. Spine update: functional disability scales for back pain. Spine 1995;20:1943–9. Leclaire R, Esdaile JM, Suissa S, et al. Back school in a first episode of compensated acute low back pain: a clinical trial to assess efficacy and prevent relapse. Archives of Physical Medicine and Rehabilitation 1996;77:673–9. Liddle SD, Baxter GD, Gracey JH. Exercise and chronic low back pain: what works? Pain 2004;107:176–90. Liebenson C, Yeomans S. Outcomes assessment in musculoskeletal medicine. Manual Therapy 1997;2:67–74. Lindstrom I, Ohlund C, Eek C, et al. The effect of graded activity on patients with subacute low back pain: a randomised prospective clinical study with an operant-conditioning behavioural approach. Physical Therapy 1992a;72:279–93. Lindstrom I, Ohlund C, Eek C, et al. Mobility, strength and fitness after a graded activity program for patients with subacute low back pain. A randomised prospective clinical study with a behavioural therapy approach. Spine 1992b;17:641–52. Little P, Roberts L, Blowers H, et al. Should we give detailed advice and information booklets to patients with back pain? A randomised controlled factorial trial of a self-management booklet and



doctor advice to take exercise for back pain. Spine 2001;26: 2065–72. Lonn JH, Glomsrod B, Soukup MG, et al. Active Back School: prophylactic management for low back pain. A randomised, controlled, 1-year follow-up study. Spine 1999;24:865–71. Maier-Riehle B, Harter M. The effects of back schools—a metaanalysis. International Journal of Rehabilitation Research 2001;24:199–206. Malmivaara A, Hakkinen U, Aro T, et al. The treatment of acute low back pain—bed rest, exercises, or ordinary activity? New England Journal of Medicine 1995;332:351–5. Maluf KS, Sahrmann SA, Van Dillen LR. Use of a classification system to guide nonsurgical management on patient with chronic low back pain. Physical Therapy 2000;80:1097–111. McReynolds M. Managing the high cost of low back injury. Occupational Health and Safety 1992;61:58–61. Mellin G, Harkapaa K, Hurri H, et al. A controlled study on the outcome of inpatient and outpatient treatment of low back pain: Part 4. Long-term effects on physical measurements. Scandinavian Journal of Rehabilitation Medicine 1990;22:189–94. Mitchell RI, Carmen GM. The functional restoration approach to the treatment of chronic pain in patients with soft tissue and back injuries. Spine 1994;19:633–42. Moher D, Cook DJ, Eastwood S, (for the QUOROM group), et al. Improving the quality of reports of meta-analyses of randomised controlled trials: The QUOROM statement (review). The Lancet 1999;354:1896–900. Moseley L. Combined physiotherapy and education is efficacious for chronic low back pain. Australian Journal of Physiotherapy 2002;48:297–302. O’Sullivan PB, Twomey L, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylosis or spondylolisthesis. Spine 1997;22:2959–67. Pengel HM, Maher C, Refshauge KM. Systematic review of conservative interventions for sub-acute low back pain. Clinical Rehabilitation 2002;16:811–20. Preyde M. Effectiveness of massage therapy for subacute low back pain: a randomized controlled trial. Journal of the Canadian Medical Association 2000;162:1815–20. Roberts L, Little P, Chapman J, et al. The back home trial: general practitioner-supported leaflets may change back pain behaviour. Spine 2002;27:1821–8. Roland M, Waddell G, Klaber Moffett J, Burton K, Main C. The Back Book: The best way to deal with back pain—Get back active. Norwich: TSO; 2004. Roland M, Torgerson D. Understanding controlled trials: what outcomes should be measured? British Medical Journal 1998; 317:1075–80. Ross M. Manipulation and back school in the treatment of low back pain. Physiotherapy 1997;83:181–3. Rossignol M, Abenhaim L, Seguin P, et al. Coordination of primary health care for back pain: a randomized controlled trial. Spine 2000;25:251–9. Seeger D. Physiotherapy in low back pain—indications and limits. Der Schmertz 2001;15:461–7. Sluijs EM, Kok GJ, van der Zee J. Correlates of exercise compliance in physical therapy. Physical Therapy 1993;73:771–86. Snook SH, Webster BS, McGorry RW, et al. The reduction of chronic non-specific low back pain through the control of early morning lumbar flexion: a randomized controlled trial. Spine 1998;23: 2601–7. Soukup MG, Glomsrod B, Lonn JH, et al. The effect of a Mensendieck exercise program as secondary prophylaxis for recurrent low back pain: a randomised controlled trial with 12-month follow-up. Spine 1999;24:1585–92.

Soukup MG, Lonn J, Glomsrod B, et al. Exercise and education as secondary prevention for low back pain. Physiotherapy Research International 2001;6:27–39. Stankovic R, Johnell O. Conservative treatment of acute low-back pain. A prospective randomised trial: McKenzie method of treatment versus patient education in Mini Back School. Spine 1990;15:120–3. Teasell RW, Harth M. Functional restoration: returning patients with chronic low back pain to work—revolution or fad? Spine 1996;21:844–7. Tortensen TA, Ljunggren AE, Meen HD, et al. Efficiency and costs of medical exercise therapy, conventional physiotherapy and selfexercise in patients with chronic low back pain. A pragmatic, randomized, single-blinded, controlled trial with 1-year follow-up. Spine 1998;23:2616–24. Trede FV. Physiotherapists’ approaches to low back pain education. Physiotherapy 2000;86:427–33. Triano JJ, McGregor M, Hondras MA, et al. Manipulative therapy versus education programs in chronic low back pain. Spine 1995; 20:948–55. Tritilanunt T, Wajanavisit W. The efficacy of an aerobic exercise and health education program for treatment of chronic low back pain. Journal of the Medical Association of Thailand 2001; 84(Suppl.):S528–33. Turner JA, Clancy S, McQuade KJ, et al. Effectiveness of behavioural therapy for chronic low back pain: a component analysis. Journal of Consulting and Clinical Psychology 1990;58: 573–9. Ustun TB, Chatterji S, Bickenbach J, Kostanjsek N, Schneider M. The International Classification of Functioning, Disability and Health: a new tool for understanding disability and health. Disability and Rehabilitation 2003;25:565–71. van Tulder MW, Assendelft WJJ, Koes BW, et al. Method guidelines for systematic reviews in the Cochrane Collaboration Back Review Group for Spinal Disorders. Spine 1997;22: 2323–30. van Tulder M, Malmivaara A, Esmail R, et al. Exercise therapy for low back pain; a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 2000;25: 2784–96. van Tulder MW, Esmail R, Bombardier C, et al. Back schools for nonspecific low back pain. The Cochrane Library 2002a;3. van Tulder M, Malmivaara A, Esmail R, et al. Exercise therapy for low back pain. The Cochrane Library 2002b;3. van Tulder MW, Furlan A, Bombardier C, et al. Updated method guidelines for systematic reviews in the Cochrane collaboration back review group. Spine 2003;28:1290–9. von Korff M, Moore JC. Stepped care for back pain: activating approaches for primary care. Annals of Internal Medicine 2001;134:911–7. von Korff M, Moore JE, Lorig K, et al. A randomised trial of a layperson led self-management group intervention for back pain patients in primary care. Spine 1998;23:2608–15. Vroomen PC, de Krom MC, Wilmink JT, et al. Lack of effectiveness of bed rest for sciatica. New England Journal of Medicine 1999;340:418–23. Waddell G. A new clinical model for the treatment of low back pain. Spine 1987;12:632–44. Waddell G. The Back Pain Revolution. London: Churchill Livingstone; 1998. Waddell G, Somerville D, Henderson I, et al. Objective clinical evaluation of physical impairment in chronic low back pain. Spine 1992;17:617–28. Waddell G, Feder G, Lewis M. Systematic reviews of bed rest and advice to stay active for acute low back pain. British Journal of General Practice 1997;47:647–52.

ARTICLE IN PRESS S. Dianne Liddle et al. / Manual Therapy 12 (2007) 310–327 Waddell G, McIntosh A, Hutchinson A, et al. Low Back Pain Evidence Review. London: Royal College of General Practitioners; 1999. Wilkinson M. Does 48 hours’ bed rest influence the outcome of acute low back pain? British Journal of General Practice 1995;45: 481–4.

327

Wolff B. Laboratory methods of pain measurement. In: Melzack R, editor. Pain Measurement and Assessment. Raven Press: New York; 1983. p. 11. World Health Organisation (WHO). International Classification of Functioning and Disability (ICIDH-2), Geneva: Beta-2 draft, Full version, Strand, 10 April 2000.

ARTICLE IN PRESS


Original article

Construct validity of lumbar extension measures in McKenzie’s derangement syndrome$ Helen A. Clarea,, Roger Adamsb, Christopher G. Maherb a

16 Ayres Road St Ives, NSW 2075, Sydney, Australia School of Physiotherapy, The University of Sydney, Sydney, Australia

b

Received 21 March 2005; received in revised form 15 May 2006; accepted 10 July 2006

Abstract The McKenzie treatment model advocates extension-based treatments for sub-groups of low back pain (LBP) patients and an improvement in extension range is seen as a positive outcome. The treatment model states that patients who fit the McKenzie derangement classification respond faster than other patients. The validity of this treatment model and of the clinical measures of extension has not yet been established. Fifty patients with LBP were classified as derangement (n ¼ 40) or non–derangement (n ¼ 10) based on a McKenzie assessment and then treated with extension procedures. Lumbar extension was measured in two positions, standing and prone, with three methods, inclinometer, Schober and finger tip to floor, on Day 1 and Day 5 of treatment. Patients completed a global perceived effect (GPE) scale on Day 5. Construct validity was tested, by comparing extension improvement and the GPE scores between the two groups. Responsiveness of the six extension measures was calculated. All patients gained extension range however the derangement group had significantly higher GPE scores and greater improvement in extension range. The modified Schober method in standing was the most responsive method for measuring lumbar extension. The results of this study support the measurement of lumbar extension, for patients, treated with extension procedures and provides evidence for the construct validity of one aspect of the McKenzie treatment model. The modified Schober method is the preferred protocol for a clinical setting. r 2006 Elsevier Ltd. All rights reserved. Keywords: Low back pain; Lumbar extension measures; McKenzie derangement classification

1. Introduction A number of tests are used in the determination of functional capacity of patients with low back pain (LBP). While physical measures are being used less commonly to determine functional outcomes, the assessment of lumbar spinal motion is one of the tests that remains in common use (Waddell, 1991; Hazzard, 1994). There is evidence to suggest that measures of $ This study was approved by the Human Research Ethics Committee of the University of Sydney. Corresponding author. Tel./fax: +61 02 94491027. E-mail address: [email protected] (H.A. Clare).


physical impairment do not correlate highly with measures of disability in patients with LBP (Michel et al., 1977; Cox et al., 2000; Parks et al., 2003). Despite this, changes in lumbar mobility are still used as a tool to guide clinicians as to the appropriateness of the clinical intervention and as a means of monitoring progress (McKenzie, 1981; Maitland, 1986; Hahne et al., 2004). Limitation of lumbar extension in patients with LBP is reported by McKenzie (1979), as a common finding in patients with LBP and he advocates the use of treatment procedures that move the lumbar spine into extension to assist with the resolution of symptoms (McKenzie, 1981). McKenzie and May (2003) identify subgroups of

ARTICLE IN PRESS H.A. Clare et al. / Manual Therapy 12 (2007) 328–334

patients within the non-specific LBP population and utilize a classification system of derangement, dysfunction, postural and other to group patients whose symptoms respond similarly to a mechanical assessment. A high proportion of patients who fit the derangement classification demonstrate a limitation of extension range, which improves when treatment procedures that cause a reduction, abolition, or centralization of symptoms, are applied (McKenzie and May, 2003). In a recent study by Long et al. (2004) this preference for extension has been demonstrated to be present in 83% of subjects who were classified as derangement. Patients fitting the other McKenzie subgroups may also present with a loss of extension but the recovery of both their symptoms and their range of movement is said to be slower (McKenzie, 1981). Clinically an improvement in extension range is often seen as the patient’s pain and level of function improves however measurement of change in extension range has not been well documented. McKenzie (1972) noted in a group of patients presenting with a sciatic scoliosis that lumbar extension was grossly restricted but following correction of the scoliotic deformity and centralization of the patient’s symptoms their extension range was able to be restored by the patient performing extension movements in standing. Kopp et al. (1986) demonstrated that the ability of patients with herniated nucleus pulposus to achieve full passive lumbar extension was a useful predictor of a favourable response to conservative management. Smith and Mell (1987) demonstrated that prone spinal extension exercises increased lumbar extension range in a group of non-symptomatic adults, however; we were unable to locate any studies where the effect of lumbar extension exercises on patients with LBP and restricted lumbar extension had been investigated. A narrative review of the literature (Clare, 2005) revealed four approaches that would be appropriate to measure lumbar extension in a clinical setting; inclinometer methods (20 studies), Schober variants (6 studies), fingertip to floor (FTF) method (1 study) and the use of a tape measure to determine the distance from the sternal notch to the supporting surface in the prone-press-up position (1 study). A wide variation in measurement protocols was apparent. The inclinometer protocols differed in terms of (i) whether they measured isolated lumbar or total lumbar and pelvic extension, (ii) the use of analogue or a digital inclinometer, (iii) use of a single or two inclinometers, (iv) the reference points for the placement of the inclinometer and (v) subject position in which extension was measured. The Schober variants differed in terms of the cephalad and caudad reference landmarks. Only one measurement protocol was found for both the FTF method and the sternal notch to supporting surface method. The reliabilities reported for the various measuring devices varied considerably both in the statistic used to

329

describe reliability and the absolute values reported (Clare, 2005). The most optimistic values for inclinometer measures of inter-rater reliability was an intraclass correlation coefficient (ICC) of 0.93 and a coefficient variation (CV) of 2.8% whereas the least optimistic was an ICC of 0.16 and a CV of 28.5%. The reliabilities reported for the various Schober methods were more consistent ranging from an ICC of 0.65–0.97 for intra-rater and from 0.54 to 0.94 for inter-rater. A single study reported inter-rater reliability of ICC ¼ 0.96 for the finger tip to floor method of measuring extension (Hahne et al., 2004). A single study utilizing the measurement of the distance from the sternal notch to the supporting surface when the patient performed extension in lying exercises reported interrater reliability of ICC ¼ 0.85 (Bandy and Reese, 2004). Few studies evaluated criterion validity. Correlations with radiographic assessment and inclinometer measures varied from 0.60 to 0.76 and a correlation of 0.49 with a modified Schober measure has been reported (Clare, 2005). Longitudinal construct validity (internal and external responsiveness) of extension range has not been widely studied. Pengel et al. (2004) noted that extension range of motion, measured with a single inclinometer, was the most responsive of the range of motion measures evaluated. Interestingly the responsiveness was similar to that of the Roland Morris disability scale but less than that of the Patient Specific Functional Scale or pain numerical rating scale (Pengel et al., 2004). The primary aims of the study therefore were to investigate whether:

Lumbar extension range improves with the use of McKenzie’s extension treatment procedures. In patients treated with the use of McKenzie’s extension treatment procedures, those classified as derangement show a greater improvement in extension range and report greater recovery, than those in all other McKenzie classifications.

The secondary aims of the study therefore were

to compare the responsiveness of the six extension measures and to investigate the relationship between six simple clinical measures of extension range of motion.

2. Methods 2.1. Subjects Consecutive new patients attending a private physiotherapy clinic for LBP were invited to participate in


H.A. Clare et al. / Manual Therapy 12 (2007) 328–334

the study with the data being collected over a 6-month period. The criteria for inclusion were that they were currently experiencing non-specific mechanical LBP of any duration, with or without radiation to the leg. Patients were excluded if they had non-mechanical spinal pain, if medical conditions limited their ability to perform the McKenzie procedures or if they had a history of spinal surgery. All subjects gave written consent prior to participating. Information was collected from the subjects regarding their gender, age, location of symptoms, duration of symptoms, previous history of LBP, pain intensity and functional status. 2.2. Procedure The patients underwent a standardized McKenzie assessment, and were classified as either, derangement or non–derangement, according to the operational definitions described by McKenzie and May (2003) (Appendix A). All the assessments were performed by the one examiner, (researcher HC), who had 18 years experience using the McKenzie method. All the patients classified as derangement demonstrated a directional preference for extension during the assessment and based on the assessment findings extension procedures were the treatment of choice for the non–derangement patients. At the conclusion of the assessment the measures of extension range were taken. Standard protocols for the measurement procedures were defined and practiced by the therapist who performed all the measurements (Appendix B). With the subject in relaxed standing and the therapist kneeling behind the patient the left and the right posterior superior iliac spines (Dimples of Venus) were identified and a line was drawn between them. The point where this line was bisected by the spine was marked and a second mark was made on the spine at a distance of 15 cm above this. The subject was then taught how to perform extension in standing with their feet placed shoulder width apart, with a minimum of three extension movements being performed as practice. Three measures of extension in standing were then taken (finger tip to floor, single inclinometer, and modified Schober) with the measures taken in a random order. The subject was then taught how to perform extension in lying as described by McKenzie (1981) again with a minimum of three being performed to familiarize the subject with the movement. Two measures of extension were taken of extension in lying (inclinometer and modified Schober). The subjects were then provided with the extension treatment procedures deemed appropriate by the treating physiotherapist for their classification and clinical presentation. The treatment procedures included the

following: extension in lying exercises, extension in lying with over-pressure, extension mobilization, extension in standing exercises, and extension in sitting with maintenance of the lumbar lordosis by the use of a lumbar support (McKenzie and May, 2003). All subjects were provided with a home program of extension exercises and advice. Modalities, drug therapy, corsets, spinal manipulative therapy other than extension mobilization were not provided. After five treatment sessions the extension measures were repeated in the same manner and the subjects completed a 7-point global perceived effect (GPE) scale which ranged from 1—completely recovered to 7— vastly worse (Beurskens et al., 1996). This study was approved by the Human Research Ethics Committee of the University of Sydney.

2.3. Data analysis To evaluate the hypothesis that lumbar extension range improves with the use of McKenzie’s extension treatment procedures, the Day 1 and Day 5 extension measures were compared using paired-samples t-tests. To evaluate the hypothesis that in patients treated with the use of McKenzie’s extension treatment procedures, those classified as derangement would show a greater improvement in extension range than those classified as non–derangement, linear regression analyses were conducted to predict the Day 5 extension score based upon the Day 1 extension score and type of McKenzie syndrome. The hypothesis would be supported if the McKenzie syndrome was a significant predictor of Day 5 extension range. To evaluate the hypothesis that with patients treated with the use of McKenzie’s extension treatment procedures, those classified as derangement would report greater recovery (GPE score) than those classified as non–derangements, GPE scores for the two groups were compared using a Mann–Whitney U-test. To evaluate the relationship between six simple clinical measures of extension range of motion, Pearson’s product moment correlations (PMC) were calculated. To describe the responsiveness of the six extension measures the effect size (ES) and standardized response mean (SRM) were calculated. The ES was the mean change divided by the baseline standard deviation and the SRM was the mean change divided by the standard deviation of the change amounts. We calculated 84% confidence intervals for direct comparison of ES. These were chosen because non-overlapping 84% confidence intervals are equivalent to a Z test of means at the 0.05 level (Tryon, 2001). Lastly the GPE scores and the change scores for each of the extension measures were correlated using Pearson’s Product Moment Correlation with 95% CI.


331

Table 1 Baseline characteristics of the subjects Characteristics of subjects

All subjects (n ¼ 50)

Derangements (n ¼ 40)

Non-derangement (n ¼ 10)

Age (years) Female, gender Pain intensity (VAS cm) Quebec disability score Previous episodes LBP % yes % derangement

50.3 (14.54) 50% 5.10 (1.64) 54.8 (14.32) 92% 80%

48.32 (13.62) 50% 4.90 (1.62) 53.20 (13.17) 93% N/A

58.36 (16.06) 50% 5.75 (1.64) 61.32 (17.56) 90% N/A

Location of symptoms Central back pain Radiation to the knee Radiation below the knee

38% 40% 22%

40% 40% 20%

30% 40% 30%

Duration of symptomsa Acute (o7days) Subacute (47 days–7 weeks) Chronic (47 weeks)

14% 24% 62%

17.5% 27.5% 55%

0% 10% 90%

Data for continuous variables are means (standard deviations) and categorical variables are percentages. a Spitzer et al. (1987).

Table 2 Change in extension range from Day 1 to Day 5 Extension measure

Day 1 (mean (SD))

Day 5 (mean (SD))

Extension improvement (mean (SD)) Total group (n ¼ 50)

Inclinometer standing (deg) Inclinometer prone (deg) Schober standing (cm) Schober prone (cm) Finger tip to floor standing (cm) Finger tip to floor standing (cm) (normalized for height)

18.2 23.9 1.24 1.80 64.2

(5.32) (6.00) (0.49) (0.62) (5.32)

0.38 (0.02)

26.5 32.5 2.12 2.64 60.1

(6.16) (8.18) (0.623) (0.79) (5.54)

0.36 (0.03)

8.3 8.56 0.88 0.84 4.14

(3.59) (5.29) (0.37) (0.46) (1.97)

0.025 (0.01)

Derangement (n ¼ 40)

Nonderangement (n ¼ 10)

9.13 9.82 0.97 0.98 4.52

5.00 3.50 0.50 0.30 2.00

(3.56) (5.06) (0.36) (0.39) (2.17)

0.03 (0.01)

(0.00) (2.42) (0.00) (0.26) (0.66)

0.01 (0.01)

In the group of 50 patients extension range improved with treatment (all Po0.001). Regression analyses revealed that the improvement was greater for the derangement group (all Po0.001).

3. Results The baseline characteristics of the subjects who participated in the study are described in Table 1. The group mean and standard deviation for Days 1 and 5 extension scores are shown in Table 2. All six measures of extension improved significantly from Days 1 to 5 (all Po0.001). The improvements in extension range for the derangement and non-derangement groups are shown in Table 2. For each regression analysis the baseline score and McKenzie group (derangement versus non-derangement) were significant predictors of the Day 5 score (all Po0.001). These results show that in patients treated with the use of McKenzie’s extension treatment procedures, those classified as derangement achieve a

significantly greater improvement in extension range than those in all other McKenzie classifications. In patients treated with the use of McKenzie’s extension treatment procedures, those classified as derangement also reported greater perceived recovery than other subjects. The median GPE score at Day 5 in the derangement group was 2, i.e. much improved, (range 1–2) and in the non-derangement groups it was 3, i.e. slightly improved (range 3–3). Results from a Mann– Whitney U-test revealed that the derangement group had greater GPE scores than the non-derangement group (all Po0.001). The PMC results revealed a complex relationship between the six extension measures (Table 3). The baseline inclinometer and modified Schober measures performed in standing and prone were highly correlated


332

Table 3 Pearson product moment correlations between the 6 extension measures

Inc/std Inc/prone Mod Sch std Mod Sch prone FTF FTFnorm

Inc/std

Inc/prone

Mod Sch std

Mod Sch prone

FTF

FTF norm

1 0.82 (0.65) 0.70 (0.57) 0.74 (0.58) 0.02 (0.48) 0.04 (0.38)

1 0.60 (0.61) 0.79 (0.66) 0.10 (0.48) 0.02 (0.40)

1 0.84 (0.82) 0.12 (0.50) 0.13 (0.40)

1 0.04 (0.50) 0.10 (0.52)

1 0.84 (0.83)

1

The baseline correlations are non-bold, the correlations between the change scores are bold and are in brackets. Inc, inclinometer, Mod Sch, modified schober, std, standing, FTF, finger tip to floor, FTFnorm, finger tip to floor normalized.

Table 4 Responsiveness of the 6 extension measures

Inclinometer standing Inclinometer prone Modified Schober standing Modified Schober prone Finger tip to floor standing Finger tip to floor standing (normalized for height)

Effect size (84% CI)

Standardised response mean (84% CI)

Correlation (95% CI)

1.56 1.43 1.81 1.35 0.78 1.07

2.31 1.62 2.37 1.84 2.10 1.94

0.58 0.51 0.60 0.66 0.54 0.51

(1.42–1.70) (1.25–1.60) (1.66–1.96) (1.20–1.49) (0.70–0.86) (0.96–1.18)

(r ¼ 0.60–0.84), however; these measures were unrelated to the baseline FTF scores (absolute value of all correlations less than 0.15). The correlations between the change scores for the inclinometer and the modified Schober measures were slightly lower (r ¼ 0.57–0.82) than observed for the baseline correlations. Contrary to the results for baseline scores, changes in the FTF measures were moderately correlated with changes in other scores (r ¼ 0.38 to 0.52). Three measures of responsiveness were calculated for the six measures and are provided in Table 4. The modified Schober measurement taken in standing had both the largest ES and the highest SRM. In addition, its correlation was second to the modified Schober measurement taken in the prone position.

4. Discussion The results of this study support the aspect of the McKenzie treatment model that was evaluated. Consistent with the treatment model, patients treated with an extension approach improved both their extension range and amount of reported improvement in their condition. Moreover, those classified as derangement showed greater improvement, as seen in measurements of extension range and GPE ratings. This is in keeping with the findings of Werneke et al. (1999) who demonstrated that patients whose symptoms centralize

(2.12–2.51) (1.42–1.82) (2.17–2.56) (1.64–2.04) (1.88–2.32) (1.74–2.14)

(0.36–0.74) (0.27–0.69) (0.39–0.75) (0.47–0.80) (0.30–0.71) (0.26–0.69)

(derangement) improve faster and have better outcomes than those patients whose symptoms did not centralize (non-derangement). The concept of sub-classification of patients within the spectrum of non-specific LBP is supported by this study. Using well-defined classification criteria (McKenzie and May, 2003) the patients were classified into derangements or non-derangements. Although both groups of patients were treated with extension procedures the patients with derangements recovered extension faster than the patients with non-derangement and reported better satisfaction with treatment. Identification of the derangement sub-group appears to allow prediction of their short-term outcomes, both by a physical measure and with a patient orientated measure. Waddell et al. (1992) found only a weak association between pain, disability and physical impairment in a group of patients with chronic LBP and others have advocated that more emphasis should be placed on change in pain and disability scores than on change in physical impairment when gauging treatment outcomes (Deyo et al., 1994; Pengel et al., 2004). However in specific sub-groups of patients with LBP who present with a loss of extension the physical measure of lumbar extension appears to be a useful tool in determining short-term outcomes along with measures of function. Further research needs to determine if these improvements in physical measures are correlated with longterm functional improvements.


The degree of extension loss forms part of the physical assessment of the LBP patient as described by McKenzie (1981), however observation rather than measurement of extension is advocated. The results of this study suggest that lumbar extension can be measured effectively in a clinical setting with an inexpensive measuring tool and that the measurement can provide valuable clinical information. Accordingly, we would advocate that practitioners who use the McKenzie approach make an objective measurement of lumbar extension rather than a subjective one through observation. Review of the literature revealed a number of different ways of measuring lumbar extension, and the results of this study show that the different methods are not interchangeable. The inclinometer measures and the modified Schober measures appeared to be measuring similar things (both are measuring isolated lumbar extension as they are ‘on the skin’ measures) however the finger tip to floor method was very distinct with minimal relationship to the other methods, especially at baseline. At present, there is not yet agreement on the optimal design and analysis to evaluate responsiveness (Stratford et al., 1996). Accordingly, three of the most commonly used approaches were employed. Considering all three approaches, the most responsive measure was the modified Schober in standing followed by the inclinometer in standing. Whilst there was little difference between these two, the FTF method was considerably less responsive. For example the ES for the modified Schober in standing was 1.81 (1.66–1.96) and for FTF 0.78 (0.70–0.86). This result argues against the use of the FTF method. Over the past decade there has been a move away from the previous use of range of movement as an outcome measure and there is now more emphasis on self-report measures of pain and disability for the determination of outcomes following treatment (Deyo et al., 1994). The results of this study suggest that in specific sub-groups of patients who present with a loss of lumbar extension and are treated with extension procedures it would be appropriate to supplement the pain and disability measures with the measurement of extension. An advantage that extension measures have over disability measures such as the Quebec LBP disability scale (Kopec et al., 1995) is that they can be re-administered over much shorter time intervals. It would be appropriate to measure extension pre and post a single treatment session but not disability using the Quebec scale, as the patient would not have had the opportunity to perform the functional activities described in the Quebec scale items. The limitations of this research project include the lack of blinding of the therapist taking the extension measures to the classification of the patient, that there was a single treating therapist and a modest number of

333

patients. Now that a responsive measure of lumbar extension has been determined the study needs to be replicated on a larger LBP population, and in a variety of health care settings. Multiple, McKenzie-trained therapists should be utilized to perform the assessments and treatments with an independent examiner performing the extension measures. A further limitation of the study was that there was no measurement of pain and disability on Day 5. This data may have assisted in determining outcomes. In future studies the extension measures and pain and disability measures should be repeated both at short- and long-term follow-ups.

5. Conclusion The results of this study provide evidence for the construct validity of one aspect of the McKenzie treatment model. Extension range improved in all the patients who were treated with extension procedures, but a greater improvement in extension range and in GPE was demonstrated in the sub-group of patients classified as derangement. These findings provide support for the measurement of lumbar extension along with pain and disability for patients who are treated with extension procedures. Of six extension measures, the modified Schober method was supported as the preferred method for clinical settings.

Acknowledgements Christopher Maher’s research fellowship is funded by Australia’s National Health and Medical Research Council.

Appendix A. Operational definition (McKenzie and May, 2003) A.1. Derangement Centralization: In response to therapeutic loading strategies pain is progressively abolished in a distal to proximal direction, AND each progressive abolition is retained over time, until all symptoms are abolished, AND if back pain only is present this moves from a widespread to a more central location and then is abolished OR pain is decreased and then abolished during the application of therapeutic loading strategies. The change in pain location, or decrease or abolition of pain remain better, and should be accompanied or preceded by improvements in the mechanical presentation (range of movement and/or deformity). NB: In this study only derangement cases where there was a directional preference for extension were included.


H.A. Clare et al. / Manual Therapy 12 (2007) 328–334

Appendix B. Protocol for measurement procedures B.1. Finger tip to floor (FTF) The subject is asked to stand with the feet placed shoulder width apart. They are then asked to arch backwards as far as they can, reaching their fingertips down the backs of their legs whilst keeping their knees straight. The rater checks that the finger tips of each hand are at equal levels, marks the fingertip level with a skin marker. The perpendicular distance between the marked point and the floor is then measured with a wooden ruler. B.2. Modified Schober: standing/lying With the subject in relaxed standing the rater marks the level of the bisector of the line running between the left and the right posterior superior iliac spines and then makes a mark on the spine 15 cm directly above the first. The patient is asked to bend backwards as far as possible whilst keeping their knees straight/by pushing up as high as they can.1 Whilst in this position the distance between the two marks is measured again with the tape resting on the skin. B.3. Single inclinometer: standing/lying A single straight-edged inclinometer is placed on the spinous process of T12 and a base reading is taken. The subject is asked to arch backwards as far as possible whilst keeping their knees straight/by pushing up as high as they can.1 Whilst in this position a second reading is taken from the inclinometer. The range of extension is the difference between the two measures. References Bandy WD, Reese NB. Strapped versus unstrapped technique of the prone press-up for measurement of lumbar extension using a tape measure: differences in magnitude and reliability of measurements. Archives of Physical Medicine and Rehabilitation 2004;85:99–103. Beurskens A, de Vet HC, Kokee AJ. Responsiveness of functional status in low back pain: a comparison of different instruments. Pain 1996;65:71–6. Clare HA. Evaluation of the McKenzie method. PhD thesis, USyd. 2005. p. 117–9 [Chapter 8]. Cox ME, Asselin S, Gracovetsky SA, Richards MP, Newman NM, Karakusevic V, et al. Relationship between functional measures and self-assessment in non-acute LBP. Spine 2000;25:1817–26. Deyo R, Andersson G, Bombardier C, Cherkin D, Keller R, Lee C, et al. Outcome measures for studying patients with low back pain. Spine 1994;19:2032S–6S.

1 The pelvis was not stabilized by a belt when the extension was performed in prone.

Kopec J, Esdaile J, Abrahamowicz M, Abenhaim L, Wood-Dauphinee S, Lamping D, et al. The Quebec back pain disability scale. Measurement properties. Spine 1995;20:341–52. Kopp J, Alexander H, Turocy R, Levrini M, Lichtman D. The use of lumbar extension in the evaluation and treatment of patients with acute herniated nucleus pulposus. Clinical Orthopaedics 1986;202:211–8. Hahne A, Keating J, Wilson S. Do within-session changes in pain intensity and range of motion predict between-session changes in patients with low back pain? Australian Journal of Physiotherapy 2004;50:17–23. Hazzard R, Williams M, McKenzie R. Reliability of three methods for measuring prone lumbar extension. New Zealand Journal of Physiotherapy 1994;1:11–3. Long A, Donelson R, Fung T. Does it matter which exercise? Spine 2004;29:2593–602. Maitland G. Vertebral manipulation, fifth ed. London: Butterworths; 1986. p. 144 [Chapter 9]. McKenzie RA. Manual correction of sciatic scoliosis. New Zealand Medical Journal 1972;76:194–9. McKenzie RA. Prophylaxis in recurrent low back pain. New Zealand Medical Journal 1979;89:22–3. McKenzie RA. The lumbar spine: mechanical diagnosis and therapy, first ed. Waikanae: Spinal Publications; 1981. p. 39 [Chapter 7]. McKenzie RA, May S. The lumbar spine: mechanical diagnosis and therapy, second ed. Waikanae: Spinal Publications; 2003. p. 557 [Chapter 23]. Michel A, Kohlmann T, Raspe H. The association between clinical findings on physical examination and self-reported severity in back pain: results of a population based study. Spine 1977;22: 296–303. Parks KA, Crichton KS, Golford RJ, McGill SM. A comparison of lumbar range of motion and functional ability scores in patients with low back pain. Spine 2003;28:380–4. Pengel L, Refshauge K, Maher C. Responsiveness of pain, disability, and physical impairment outcomes on patients with low back pain. Spine 2004;29:879–83. Smith R, Mell D. Effects of prone spinal extension exercise on passive lumbar extension range of motion. Physical Therapy 1987;67: 1517–21. Spitzer W, Le Blanc FE, Dupuis M, et al. Scientific approach to the activity assessment and management of activity-related spinal disorders. Spine 1987;12:S1–S55. Stratford P, Binkley JM, Riddle DL. Health status measures: strategies and analytic methods for assessing change scores. Physical Therapy 1996;76:1109–23. Tryon W. Evaluating statistical difference, equivalence, and indeterminancy using inferential confidence intervals: an integrated alternative method of conducting null hypothesis statistical tests. Psychological Methods 2001;6:371–86. Waddell G, Allan D, Newton M. Clinical evaluation of disability in low back pain. In: Frymoyer J, editor. The adult spine: principles and practice. first ed. New York: Raven Press; 1991. p. 155–68 [Chapter 5]. Waddell G, Somerville D, Henderson I, Newton M. Objective clinical evaluation of physical impairment in chronic low back pain. Spine 1992;17:617–27. Werneke M, Hart D, Cook D. A descriptive study of the centralization phenomenon: a prospective analysis. Spine 1999;24:676–83.

ARTICLE IN PRESS


Original article

The development and use of mass media interventions for health-care messages about back pain: What do members of the public think? Karen L. Barkera,, Catherine J. Minns Lowea,b, Margaret Reidc a

Physiotherapy Research Unit, Nuffield Orthopaedic Centre NHS Trust, Oxford, OX3 7LD, UK b The School of Health Sciences, University of Birmingham, UK c Margaret Reid Research and Planning, UK Received 13 January 2006; received in revised form 12 May 2006; accepted 10 July 2006

Abstract The study sought to identify and explore the opinions, beliefs and views of members of the public regarding the use of media interventions for the delivery of health-care messages. It used a draft back pain campaign looking at the level of credibility, acceptability and trust in the authority of these messages. Sixty-eight members of the public participated in the study. A qualitative study design was used with semi-structured focus groups and a sampling frame including gender, age, socio-economic group, and experience of back pain. Three main themes were identified. 1. Media consumption. 2. Credibility. 3. Specific issues surrounding the proposed sample media campaign. The use of media to provide health-care information was viewed positively, with the NHS perceived as the most trustworthy source, and Government bodies viewed with scepticism. Issues surrounding the language, terminology and tone of campaigns were raised. A closer collaboration between health-care professionals and the public is advocated to achieve valuable and effective media campaigns. r 2006 Elsevier Ltd. All rights reserved. Keywords: User’s views; Mass media; Non-specific low back pain

1. Introduction Government initiatives have emphasized the need for population approaches to health care and concern for patients’ views of the National Health Service (NHS) has been encouraged by several government reports in the last few decades (Department of Health, 1998, 2001, 2005). Use of the media is one method of achieving this goal. There is widespread use of mass media campaigns to inform the general public about health messages; ranging from discouraging smoking in young people to the promotion of sun protection (Sowden and Arblaster, 1998; Smith et al., 2002). A recent survey found 75% of respondents rely on media coverage when making health-care decisions. Few other options exist apart Corresponding author. Tel.: +44 1865 227773.

E-mail address: [email protected] (K.L. Barker). 1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.07.010

from the use of mass media with potential to alter and influence social attitudes and norms, although altering awareness and beliefs within the population may not automatically lead to changes in health-care behaviour (Cavill and Bauman, 2004). A systematic review concluded that mass media interventions have an important role in influencing the use of health-care services and in providing health-care information to the public (Grilli et al., 2001). Although mass media is widely used to inform the general public, there is little published data regarding general public involvement in the development and evaluation of these interventions. The role of ‘consumers’ in health care and research is strongly advocated to enhance its relevance and quality (Liberati, 1997; Tallon et al., 2000; DoH, 2004). Whilst research exists which explores perceptions of existing media messages, such as smoking images (Watson et al., 2003) and how


K.L. Barker et al. / Manual Therapy 12 (2007) 335–341

public perception is affected by the media, there is a lack of research involving the general public in the development of campaigns and about the public’s perception of the use of mass media interventions to deliver healthcare messages (Searle, 2003). This research aims to explore opinions of members of the public about the use of health media campaigns with specific reference to a sample low back pain campaign. Back pain is one of the most common reasons for seeking health care and is considered a public health challenge due to its considerable functional, psychological and social implications (Main and Watson, 1999; Vlaeyen and Crombez, 1999). Back pain was considered to be a topic suited to exploring the trustworthiness and acceptability of mass media campaigns because recent evidence conflicts with popular opinion. Traditionally, low back pain has been treated using rest; now strong evidence exists advising staying active and continuing activities as normally as possible (Klaber Moffett et al., 2000; Staal et al., 2003). There has, as yet, been no mass media campaign to promote effective self-management of non-specific low back pain in England (the location for this research) so there has been no prior exposure to the effects of an advertising campaign, which might have affected the results of this study. Such mass media campaigns have been run in Scotland with the ‘Working Backs Scotland’ campaign and in Victoria, Australia. Whilst the former has yet to be fully evaluated, positive results are reported for the latter (Buchbinder et al., 2001a, b; Buchbinder and Jolley, 2004). No study yet has explored the acceptability, value and credibility of a campaign from the perspective of the consumer. This study will identify and explore the opinions, beliefs and views of members of the public regarding the use and value of media interventions for the delivery of healthcare messages. Secondly, it will investigate credibility, acceptability and trust in the authority of the various potential sources of health information campaign.

2. Method Local Research Ethics Committee approval was gained. An advertising agency experienced in healthcare mass media campaigns developed draft advertisements. The key campaign messages were those summarized by Klaber Moffett et al. (2000); including advice to stay active. Two main creative routes were proposed and developed to create draft television, radio and print advertisements. This enabled the use of different modes of media for the same material to be discussed as well as the creative content itself. In addition two further radio commercials, dramatizing how to optimize recovery from back pain were also developed. Overall therefore, eight pieces of stimulus material were used. These were

used in the focus groups as stimulus material for discussion about media (Fig. 1). 2.1. Sample A purposive approach was used. The sampling frame (Table 1) included key factors thought to influence people’s views and beliefs and to enhance group dynamics; these were: gender, age, socio-economic group, rural or urban locations and experience of back pain. No attempt was made to define an episode of low back pain since no universally accepted definition exists. The participants decided whether they had experienced low back pain. Sixty-eight people participated in the research. Data saturation was achieved and no further data collection was considered necessary. 2.2. Recruitment Members of the public were approached on the street and invited to a local focus group, held at convenient venues for participants such as hotels and community centres. Informed consent was sought at the groups. All focus groups were lead by MR, an experienced social scientist. Discussions lasted approximately 90 min and were audiotaped. The stimulus material used in the groups was rotated to control for any order effect. At the end of the group, participants were requested to complete a brief questionnaire to collect information about back pain history, used to aid the contextualization of the data. 2.3. Data analysis Audio recordings were listened to until familiarity with the data was achieved. Full transcripts of each focus group underwent line by line analysis, identifying concepts and their properties. Data were coded to describe and relate categories and subcategories of concepts and constant comparison was used to allow each item to be checked or compared against the rest of the data (Pope et al., 2000). These data analysis processes were independently undertaken by two authors who then discussed their findings, reaching full agreement. Two transcripts were recoded three months after initial analysis finished.

3. Results Table 1 shows the sampling framework and Table 2 the participant’s back pain characteristics. Although the language and tone of the groups varied according to gender, age and socio-economic group,

ARTICLE IN PRESS K.L. Barker et al. / Manual Therapy 12 (2007) 335–341

337

Fig. 1. Diagram to illustrate the discussion flow guide for the focus groups. Table 1 The sampling frame for the study

Group Group Group Group

1 2 3 4b

Group 5 Group 6 Group 7b Group 8 Group 9 Group 10

Number in group

Gender

Age

SEGa

Back pain?

Location

n¼5 n¼6 n¼5 An¼5 Bn¼4 n¼5 N¼6 An¼3 Bn¼6 n¼8 n¼8 n¼7

Male Male Male Male

20–39 20–39 20–39 40–60

ABC1 C2DE C2DE ABC1

Yes No Yes No

Oxford Urban Peterborough Rural South Devon Rural Peterborough

Male Female Female

40–60 20–39 20–39

C2DE ABC1 C2DE

Yes No Yes

Urban South Devon Urban South Devon Rural Peterborough

Female Female Female

40–60 40–60 40–60

C2DE ABC1 ABC1

No Yes No

Oxford Urban Peterborough Rural Devon

a

Socio-economic group. Due to the low turn out rates initially in these groups, further groups were held to ensure the sampling frame was sufficiently representative. For ease of understanding these results have been combined. b

there was general consistency across the groups about the issues identified and the views expressed. An order, or exposure, effect was observed. Initial stimulus material, regardless of which advertisement was shown, was generally viewed less positively than material shown later on in the focus groups when the participants had already heard key messages and

considered and discussed them. There were three main emergent topics. 3.1. Acceptance of mass media health messages There was broad acceptance across the groups of the positive value of health messages delivered via mass


338

Table 2 Back pain characteristics of the study participants Questions asked (n ¼ )

Group 1

Group 2

Group 3

Group 4

Group 5

Group 6

Group 7

Group 8

Group 9

Group 10

Have you ever had back pain? Yes No

5 0

0 6

5 0

2 7

5 0

4 2

9 0

3 5

8 0

6 1

Do you have back pain today? Yes No

2 3

N/A

4 1

1 1

1 4

1 3

2 7

0 3

1 7

0 6

1

N/A 2 3

4 2

How many episodes of back pain lasting more than 24 h have you had in your life? None 1 A few Quite a lot (less than 10) Lots (more than 10)

2

Have you ever been to see any health professional about your back pain? Yes No

2 3

1 1 1

1 2

N/A

1 1

3 2

4

1

2

2

4

4 1

1 1

4 1

3 1

7 2

2 1

3

2 1

7 1

3 3

Key: Since some members of the non back pain groups answered that they had experienced back pain, all groups are included in this table. Some responses are missing, therefore not all columns add up to the total number of group participants.

media, on the basis that it is always good to be better informed:

Well medicine moves on, dunnit? People find out more things as technology advances (Group 3)

That’s really the only way you’re going to learn it (Group 2)

The use of television is regarded as the most effective media to reach most people and is consumed relatively passively and easily. This makes it attractive to participants since little effort is needed to receive the message:

However, certain health messages from previous campaigns, specifically regarding healthy eating and the MMR vaccine, were perceived to be conflicting and confusing: We don’t know what to believe, one minute you are told something is good for you, the next minute it’s not (Group 4) There was a suggestion that the new low back pain advice was believed to be more convincing because the advice has been slow to develop, without frequent changes in the previous advice given. This was in contrast to healthy eating where participants were confused by new, contradictory, advice frequently appearing in the public domain. It appeared that if experts were seen to repeatedly contradict each other, then unacceptable confusion ensued, whereas when the experts agreed about a new approach this was accepted and considered as progress.

You might reach a lot more people going through TV because a lot of people have got TVs (Group 3) One picture is worth a thousand words. I mean TV is your best medium (Group 3) It’s far more visual isn’t it, it takes less effort sort of, you (see) it a newspaper you have to read; you have to make more effort (Group 7) Television is also believed to convey a sense of commitment and importance to the message, due to its expensive nature: It has to be important to spend that sort of money (Group 9) I mean to put it on TV, it must be a high percentage of people suffer it (Group 2)


Press advertising was seen as likely to be an effective medium to provide information for low back pain sufferers ‘you are going to notice that, if it’s personal to you’ (Group 7) rather than for the general public. Radio was considered least able to reach the whole target audience; a recurring debate emerged in the group discussions about radio as background and radio as personally involving: Television has more of an impact; well it does for me, definitely. I agree thaty.it’s just background noise, radio for me (Group 9) A few individuals across the sample expressed the belief that the proposed low back pain message deserved multiple, even blanket, media delivery. All groups thought that the proposal to develop a mass media campaign regarding how to self manage back pain was worthwhile.

339

off work with back pain and they are saying ‘‘it doesn’t exist, carry on’’ (Group 4) There was debate within the groups regarding whether saying all professions, such as doctors, physiotherapists, osteopaths and chiropractors, agreed on the message would be believable and strengthen a media campaign. If experts agree, as earlier mentioned, this is reassuring since: ythey are all the experts aren’t they? I would sayy.they are the ones that you are likely to believe (Group 4) But doubt was expressed by many participants whether these professional groups would actually all agree and also whether the advice could be applied to all people with back pain: I speak from experience; they don’t prescribe the same thing (Group 5)

3.2. Credibility The stimulus material did not indicate a source for the advertisements and a variety of potential sources, such as the NHS, relevant Government bodies and professional bodies were discussed. An NHS source was deemed both acceptable and credible in that participants largely trust the NHS to deliver accurate information regarding health-care messages. Messages from the NHS were considered reliable, allowing participants to be ‘confident in it (the health message)’ (Group 10): You know they (the NHS) aren’t motivated by anything other than a desire to help people (Group 1) Generally though, although the NHS is funded by public money, and run by the Department of Health, participants strongly differentiated the NHS from the Government. The NHS was considered: a proper organisation who don’t benefit by people using their services (Group 6) The Government was viewed with more scepticism. Participants felt that a Government source was less likely to be motivated by health concerns and more likely to be driven by financial concerns: Back pain is the biggest cause of sickness in the UK isn’t it and it costs billions every year. I was getting cynical about whether the Government are about to cut sick benefit (Group 1) The word Government was synonymous with the Department of Work and Pensions whose motivation was seen solely as getting people back to work to aid the economy: It (one of the pieces of stimulus material) worries me that it is a Government initiative to stop people being

3.3. Issues surrounding the specific mass media intervention to self-manage low back pain The findings suggested the introduction of a mass media campaign around managing low back pain was welcomed. Two distinct roles for advertising emerged; to reassure those who currently treat their low back pain by keeping active that they are doing the right thing(s) and to inform those who are open to persuasion that previous advice about rest has been replaced by the keep active message. Keep active. It’s the reverse really of all the advice that used to be given you about back pain (Group 10) It’s reassuring you in a way (Group 1) I think it’s quite interesting because most people are under the impression that if you’ve got a bad back you lie down, don’t you, and rest (Group 6) One barrier to accepting the ‘keep active’ message was the apparent claim that this would benefit everyone with any form of low back pain. Group members wanted the message to identify/warn those people who should seek further advice: It might do more harm than good, you might have broken a vertebrae or something (Group 9) There doesn’t seem to be any warning with that, that it might not be suitable for everyone (Group 6) The tone of the message was also commented upon. The feedback on draft advertisements demonstrated this clearly. One of the voices used in an advertisement was perceived as unsympathetic. Where an advertisement was perceived as unsympathetic this drew a negative response: ‘‘sounded a bit naggy’’ (Group 7) yit’s like it’s haranguing you (Group 1)


340

Any advertisements that mentioned work were also viewed more negatively. There was concern that advertisements advocating return to work could potentially provide ammunition for unsympathetic bosses and label people as malingerers: ‘‘Is it trying to say to people we’re not taking these excuses any more; you shouldn’t stay at home saying you are resting your back you should go to work’’? (Group 10) Reference to work was perceived as insensitive towards people genuinely in pain. Another issue raised was how members of the public and health professionals define terms differently and the effects this can create. For example, some of the stimulus material suggested ‘gentle exercise’ as beneficial. This is a term used by health-care professionals in media campaigns to denote activities such as walking and swimming. However, whilst ‘gentle’ was considered both credible and acceptable in being sympathetic and acknowledging pain, the term ‘exercise’ suggested specific activity to participants: that’s where you go down to the gym or something (Group 5) Suggesting ‘exercise’ could in fact provoke a degree of resentment rather than reassurance among those with low back pain who do try to keep active: It only applies to the over sixties, because anyone with a family, you can’t do gentle exercise every day, you’ve got to go out and earn a living (Group 3) I think the gentle exercise one implies that you have got to go and do something whereas with the active one says you are just being active, just keep moving (Group 4) I think people generally know what sort of things keeps them active (Group 7)

4. Discussion The findings of the study show that messages from bodies such as the NHS are rated as credible and trustworthy. The source of interventions was shown to matter. Government or commercial sources were regarded with scepticism and even anger. Given the size of the economic burden of back pain, the Government is understandably keen to reduce back pain costs but explaining this to the public in an acceptable way is obviously difficult. Members of the public in this study would prefer the message to solely be a health care one rather than a political or economic one. Health-care sourced messages are perceived as more sympathetic in tone than Government ones. Advertisements mentioning return to work were perceived negatively. It is

known that back pain sufferers fear the reality of their back pain being questioned (Glenton, 2003) and the participants in this study too voiced concern that the key message of the proposed campaign, namely to keep active, might contribute to this problem. Employers may doubt the legitimacy and severity of back pain if people keep active. Since back pain usually carries no visible signs of disability, the back pain sufferer’s inability to carry out certain activities is often used to demonstrate proof of suffering (Glenton, 2003). The need to be believed by society may conflict with the advice to return to normal activities. When work was included in the stimulus material this conflict was voiced. This research indicates that the appropriateness of the source of health-care messages needs to be ensured prior to delivery. Participants valued the use of media to inform them about health care and all groups felt that the suggested back pain campaign would be worthwhile. The research supports the findings of Steinbrook (2000) and the opinion of Johnson (1998) regarding the importance of the media to inform the public. Participants did not seem to feel over-bombarded with health-care messages and approved of their use. They were generally open to progress in medical care. Health-care messages that seemed to be contradictory were not considered helpful; apparent contradictions and reasons for change need to be explained. There was also doubt expressed whether the health professions did actually agree with the key messages, since some participants recounted experiences to the contrary. One of the problems this study highlighted was how people defined whether or not they had experienced back pain. The recruiter and the recruitment questionnaire specifically asked participants whether they had ever had back pain. Additionally, after the first supposedly non-back pain group, where it became evident that some of this group actually had experienced back pain, all subsequent non-back pain group participants were telephoned by the recruiter to ask again whether or not they had ever had any back pain. Yet, as Table 2 demonstrates, some of these participants later said they had had back pain. The groups revealed reasons for this discrepancy. Some participants thought back ache or injury is not the same as back pain. Participating in these groups may have altered this view which, since the background questionnaires were completed at the end of the groups, may have altered their response to the question in the questionnaire. Interestingly in Group 2, the only group where no respondents reported a history of back pain in the questionnaire, no participants volunteered they had previously experienced back pain/ache during the focus group itself, unlike other groups. It may be worth future research studies which rely on the self report of back pain, asking respondents whether they have ever


experienced back pain, back ache or back injury rather than just back pain or the true prevalence may be underestimated. It was highlighted that clinicians need to be aware that patients/members of the public may interpret language differently and recognize the importance of checking how intended messages are understood by their target audience. In this instance, even though the key message of keeping active was generally acceptable to participants, the use of the phrase ‘gentle exercise’ was misinterpreted. Since attitudes and beliefs are relevant to recovery and return to work (Symonds et al., 1996) message rejection is a serious issue. The earlier study in Australia acknowledges that unexpected or possibly unwanted effects of their campaign were not measured and highlighted the need for future qualitative research in this area (Buchbinder et al., 2001b). This study illustrates the importance of research taking place in the developmental stages of campaigns to minimize or prevent the occurrence of unwanted effects and to explore the possible impact of these effects. In conclusion, although the relationship between health-care professionals and the media can be an uneasy one (Nelkin, 1996), participants in this study generally valued and trusted health-care messages if they were sourced by the NHS. Issues regarding the language and tone of the messages were raised. The meaning, understanding and acceptability of mass media campaign health-care messages needs to be explored with the target audience prior to implementation. A closer collaboration between health-care professionals and the public is advocated to achieve valuable, effective media campaigns.

Acknowledgements The Modernization Agency Spinal Collaborative Programme supported this work. The input of Jeanette Hucey, Sharon Barrington, Fiona Jenkins, Sue Brandrick, Paula Renshaw, Anne Daykin, Francine Toye & Jane Reeback is gratefully acknowledged. The Department of Health Occupational Health Department, Department of Health Directorate of Access and Choice, Department for Work and Pensions and the Health and Safety Executive funded the project. References Buchbinder R, Jolley D. Population based intervention to change back pain beliefs: three year follow up population survey. British Medical Journal 2004;328:321. Buchbinder R, Jolley D, Wyatt M. Population based intervention to change back pain beliefs and disability: three part evaluation. British Medical Journal 2001a;322:1516–20.

341

Buchbinder R, Jolley D, Wyatt M. Volvo award winner in clinical studies: Effects of a media campaign on back pain beliefs and its potential influence on management of low back pain in general practice. Spine 2001b;23:2535–42. Cavill N, Bauman A. Changing the way people think about healthenhancing physical activity: do mass media campaigns have a role? Journal of Sports Sciences 2004;22:771–90. Department of Health. A first class service: quality in the new NHS. Wetherby: Department of Health; 1998. Department of Health. The NHS plan—implementing the performance improvement agenda, a policy position statement and consultation document. London: Department of Health; 2001. Department of Health. /http://www.dh.gov.uk/PolicyAndGuidance/ OrganisationPolicy/PatientAndPublicInvolvement/InvolvingPatients PublicHealthcare/InvolvingPatientsPublicHealthcareArticle/fs/en? CONTENT_ID=4000457&chk=V44bEbS. 2004. Department of Health. Creating a patient-led NHS. London: Department of Health; 2005. Glenton C. Chronic back pain sufferers—striving for the sick role. Social Science & Medicine 2003;57:2243–52. Grilli R, Ramsay C, Minozzi S. Mass media interventions: effects on health services utilisation. The Cochrane database of systematic reviews 2001; (1). Art. No.: CD000389. DOI:10.1002/ 14651858.CD000389. Johnson T. Medicine and the media. New England Journal of Medicine 1998;339:87–92. Klaber Moffett JA, Newbronner E, Waddell G, Croucher K, Spear S. Public perceptions about low back pain and its management: a gap between expectations and reality? Health Expectations 2000; 3:161–8. Liberati A. Consumer participation in research and health care. British Medical Journal 1997;315:499. Main CJ, Watson PJ. Psychological aspects of pain. Manual Therapy 1999;4:203–15. Nelkin D. An uneasy relationship: the tensions between medicine and the media. Lancet 1996;347:1600–3. Pope C, Ziebland S, Mays N. Qualitative research in health care analysing qualitative data. British Medical Journal 2000;320:114–6. Searle C. Health and media: an overview. Sociology of Health and Illness 2003;25:513–31. Smith BJ, Ferguson C, McKenzie J, Bauman A, Vita P. Impacts from repeated mass media campaigns to promote sun protection in Australia. Health Promotion International 2002;17:51–60. Sowden AJ, Arblaster L. Mass media interventions for preventing smoking in young people. The Cochrane Database of Systematic Reviews 1998; (4). Art. No.: CD001006. DOI:10.1002/14651858. CD001006 Staal JB, Hlobil H, van Tulder MW, et al. Occupational health guidelines for the management of low back pain: an international comparison. Occupational and Environmental Medicine 2003; 60:618–26. Steinbrook R. Medical journals and medical reporting. New England Journal of Medicine 2000;342:1668–71. Symonds TL, Burton AK, Tillotson KM, Main CJ. Do attitudes and beliefs influence work loss due to low back trouble? Occupational Medicine 1996;46:25–32. Tallon D, Chard J, Dieppe P. Consumer involvement in research is essential. British Medical Journal 2000;320:380–1. Vlaeyen JWS, Crombez G. Fear of movement/(re)injury, avoidance and pain disability in chronic low back pain patients. Manual Therapy 1999;4:187–95. Watson NA, Clarkson JP, Donovan RJ, Giles-Corti B. Filthy or fashionable? Young people’s perceptions of smoking in the media. Health Education Research 2003;18:554–67.

ARTICLE IN PRESS


Original article

Manual fixation versus locking during upper cervical segmental mobilization. Part 1: An in vitro three-dimensional arthrokinematic analysis of manual flexion–extension mobilization of the atlanto-occipital joint E. Cattrysse, J.P. Baeyens, J.P. Clarys, P. Van Roy Department of Experimental Anatomy (EXAN), Vrije Universiteit Brussel, Laarbeeklaan 103, B1090 Brussels, Belgium Received 29 November 2005; received in revised form 11 May 2006; accepted 12 July 2006

Abstract Background: Segmental manual spinal mobilization techniques are used to restrict the effects of interventions to one spinal segment. It is, however, not known whether it is possible to generate such a localization of effects. Segmental motion in the cervical spine was previously studied by applying pure moments of force on cadaver specimens. So far, no studies have been performed on the segmental three-dimensional (3D)-kinematic aspects of cervical manual flexion–extension mobilization. Methods: 3D-aspects of manual flexion–extension motion in the atlanto-occipital and atlanto-axial segments were analysed in vitro using an electromagnetic tracking device. Segmental bony reference points were registered using a 3D-digitizing stylus to define bone-embedded coordinate frames. Six spinal specimens—five embalmed and one fresh—were analysed in this study. Segmental motions were analysed in the atlanto-occipital and the atlanto-axial joints during manual mobilization through the full range of flexion–extension mobility. The 3D-kinematic analysis of two different segmental mobilization techniques—manual fixation of C1 versus locking of the inferior cervical spine—is presented. Results: A significant reduction (Po0:05) of the associated axial rotation and lateral bending motions was observed during the manual fixation technique without influencing the main motion component of flexion–extension. The locking technique did not significantly influence the movements on the mobilized atlanto-occipital segment, but reduced all movement components in the atlanto-axial joint. Interpretations: The results suggest that, for manual segmental flexion–extension mobilization of the upper cervical spine, manual fixation or locking might be chosen in different situations according to the desired effects. r 2006 Elsevier Ltd. All rights reserved. Keywords: Upper-cervical; In vitro; Flexion–extension; Kinematic analysis; Manual mobilization; Coupled motion

1. Introduction In manual therapy, segmental spinal mobilization is proposed as a way of restricting the desired effect of the intervention to one specific motion segment. It is, however, not known whether and to what extent such Corresponding author. Tel.: +32 2 4774423; fax: +32 2 4774421.

E-mail address: [email protected] (E. Cattrysse). 1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.07.015

a restriction can be achieved. Understanding the segmental three-dimensional (3D) kinematics of upper cervical manual mobilization techniques is especially relevant in appreciating the possible risks and effects of such interventions. Although regional as well as segmental mobilizations are generally intended to be uni-planar, this might be a questionable simplification. The 3D aspects of movements are described in terms of coupling between

ARTICLE IN PRESS E. Cattrysse et al. / Manual Therapy 12 (2007) 342–352

343

Table 1 Mean ranges of atlanto-occipital and atlanto-axial flexion–extension motion in degrees, reported from literature Method Werne (1957) Fielding (1957) Penning (1978) Worth (1985) Dvorak et al. (1988) Panjabi et al. (1988) Dhimitri et al. (1998) Ordway et al. (1999) Amiri et al. (2003)

Cineroentgenography CT In vitro—radiographic Radiographic In vitro—stereophotogrammetry In vivo—CROM In vivo—radiographic In vivo—Fastrak (electromagnetic tracking device)

different motion components. These associated motions are usually unintended and, in the upper cervical spine, they are described as occurring in a mainly contra-lateral coupling pattern during axial rotation. Associated or coupled motions, however, may also occur during the socalled planar flexion–extension mobilization. Several movement analysis studies of the cervical region (Table 1) have been based on two-dimensional (2D) kinematic analysis methods (Panjabi et al., 1975; Penning and Wilmink, 1987; Panjabi, 1997; Hino et al., 1999). More recently, a number of 3D studies of motion coupling in the cervical spine have focused on regional motion coupling patterns (Harrison et al., 1998; Van Roy et al., 2001; Koerhuis et al., 2003). Limited but important information on 3D segmental coupled motions of the cervical spine is derived from studies applying well-controlled, pure moments of force in an in-vitro laboratory set-up (Panjabi et al., 1986, 1993; Milne, 1993). Particularities of flexion–extension motion in the cervical (Dvorak et al., 1992) and upper cervical spine have been studied in vitro and in vivo during both passive and active mobilization (Fielding, 1957; Werne, 1957; Penning, 1978; Worth, 1985; Dvorak et al., 1988; Panjabi et al., 1988; Dhimitri et al., 1998; Ordway et al., 1999). Amiri et al. (2003) have described the coupled lateral bending and axial rotation motion, observed during the examination of active regional flexion–extension mobilization of the upper cervical spine. They observed a mean of 1.6171.11 coupled left lateral bending and 2.5171.21 coupled right axial rotation during C0–C2 flexion. During extension, 1.6171.41 coupled right lateral bending and 3.1173.91 coupled left axial rotation were observed. To the best of the authors’ knowledge, no information is present regarding segmental ranges of movement of main and coupled motions during manual passive mobilization of the upper cervical spine. The purpose of this study was to register and analyse 3D aspects of manual flexion–extension mobilization

C0–C1

C1–C2

13.41 351 301 18.41 / 24.51 4.01 261

101 151 301 14.11 121 22.41 11.21 11 38.351

using a previously developed method combining an electromagnetic tracking device and a 3D-digitizer (Cattrysse et al., 2005d).

2. Materials and methods 2.1. Specimens Six human cadaveric spinal specimens were used in this study: five embalmed and one fresh. Each specimen consisted of the skull and cervical spine down to the first thoracic vertebra. The exact age of each specimen was not available, but all specimens were over 50 years of age.1 Room temperature was controlled between 151 and 201 and humidity was above 60% to prevent dehydration of the specimens during the test procedure. 2.2. Instruments A ‘Flock of Birds’ electromagnetic tracking system (Ascension technologies Corporation, USA) was used in this study. Several authors have documented the reliability and accuracy of the system (Milne et al., 1996; Bull and Amis, 1997; Meskers et al., 1999; Mc Quade et al., 2002; LaScalza et al., 2003). The electromagnetic tracking device was used in conjunction with a 3D digitizing device. The MicroscribeTM G2X (Immersion Corporation, USA) digitizing stylus offers the possibility to register 3D features of an object in order to reconstruct the object digitally or process the data mathematically. The model has an accuracy of 0.00900 (0.23 mm) and a workspace size of 5000 (1.27 m) (Immersion Corporation, USA). 1 The specimens were gathered at the anatomical laboratory of the Vrije Universiteit Brussel. Most of the anatomical specimens were provided by people who died aged 50–90 years and had bequeathed the use of their bodies for scientific purposes. For reasons of confidentiality, no personal history or medical antecedents were available.


E. Cattrysse et al. / Manual Therapy 12 (2007) 342–352

Fig. 1. Experimental set-up with sensor holders and specimen fixating system.

Kinematic results were thus related to bone-embedded reference frames defined on the upper cervical spine segments. It has been demonstrated using a two-hinge phantom that cross-talk effects occur because of small differences between the true axis of motion and the defined local frame (Cattrysse et al., accepted for publication). These can rise to 9% of the main motion. However, the analysed coupled rotations largely exceeded this percentage, thereby indicating true coupled motion. Kinematic data were calculated using ‘Mathcad Professional’ mathematical software (r1986–2000 MathSoft, Inc.) and statistically analysed with repeated measures ANOVA and Student t-test for significance (Po0:05). 2.3. Methodology 2.3.1. Test procedure Three sensors were rigidly attached to the skull, atlas and axis of the specimens after dissection of all muscular tissues, but keeping the joint capsules, ligaments and tendons intact. The sensors were fixed on the bony segments using specially developed hard plastic sensor holders. These sensor holders were used in previous arthrokinematic studies on the shoulder and elbow joint (Baeyens et al. 2005; Cattrysse et al. 2005a, d). The first sensor holder was mounted directly on the skull. The other two sensors were fixed on the transverse processes of the atlas and axis using a newly developed nonferromagnetic sensor holder. These sensor holders were designed in such a way that they could be screwed into

the bone and hold the sensor rigidly away not to limit normal joint motion. The specimen was fixed in a wooden frame by two non-ferromagnetic metal pins drilled through the vertebral body of the first thoracic vertebra (Fig. 1). This set-up allowed for functional anatomical movements of the specimens. First, the specimens were guided manually by the occiput through the full range of flexion–extension motion. Subsequently, two different segmental mobilization techniques were performed on the C0–C1 level. First, by manually fixating the axis and, secondly, by using a 3D locking of the lower and mid-cervical segments up to C1–C2 (Figs. 2 and 3). During the manual fixation technique, the therapist fixed the atlas manually by the posterior arc while mobilizing the head in a flexion–extension direction. In the locking technique, the lower and mid cervical spine were brought into a 3D end-range position combining flexion, lateral bending and contra-lateral rotation up to the segment C1–C2, before mobilizing the atlantooccipital joint. During the mobilizations, the positions and orientations of each sensor were collected. Subsequently, the spatial coordinates of local anatomical landmarks were digitized using the 3D drawing stylus. Digitization was performed twice and results were accepted when the difference between the two measurements was less than 0.05 in (1.25 mm). Measurements were repeated until all results of two consecutive registrations were within this limit of agreement. Simultaneously with the regional mobilizations and segmental mobilizations of the atlanto-occipital joint,


345

Fig. 2. Manual mobilization of the atlanto-occipital joint with manual fixation of C1.

Fig. 3. Manual mobilization of the atlanto-occipital joint with locking of the lower and mid cervical spine.

the movements of the atlanto-axial segment were observed and analysed. In this study, each sequence of manipulative intervention consisted of at least three cycles in which the specimen was manually moved through its full range of motion. Mobilizations were performed passively and no axial preload was applied in an attempt to mimic basic muscular tonus. A horizontal set-up was chosen to simulate the clinical situation in which optimal muscular

relaxation of the patient is provided in the supine position. 2.4. Calculation of the finite helical axis (FHA) The sensor Spoor 1980),

position vector and rotation matrix of each were recorded by the FOB-system. Using the and Veldpaus algorithm (Spoor and Veldpaus, the finite helical axis (FHA) was calculated for



Fig. 4. Bone embedded coordinate system on C1.

discrete sampling ranges of motion. The FHA can be regarded as the 3D equivalent of the finite centre of rotation in a 2D-analysis of motion and is defined by its orientation, its position, the shift along and rotation about the estimated axis.2 The derived angles, later called finite helical angles (y0, y1, y2) are the result of the mathematical decomposition of the rotation around the FHA according to the defined boneembedded co-ordinate frames. The term finite is used when a limited number of motion steps are evaluated. When a large number of steps, also called motion attitudes, is analysed and providing the interval of time between each step approaches zero, the term instantaneous helical axis may be used (Woltring et al., 1985). This method was preferred to the Euler angle approach for methodological reasons, among which the sequence independency is very important (Woltring, 1994; Baeyens et al., 2005). The approach was validated in a previous study using a two-hinge phantom and proved to be valid for analysing coupled motion components (Cattrysse et al., 2005c). In the present study, all tests were performed by one investigator. 2.5. Construction of the bone-embedded coordinate system

ments were performed with reference to the cervical spine in the regional frame. The anatomical data registered by the digitizing system were used for the definition of segmental or local bone-embedded coordinate axes. The local coordinate system of the atlas is represented in Fig. 4. The coordinate system of the occiput (C0) was constructed on three anatomical bony reference points. The X-axis was defined as the connecting vector between the most inferior points of the mastoid processes. The Z-axis was constructed from the external occipital protuberance, perpendicularly to the first axis. The Y-axis was constructed perpendicularly to the other two. On the atlas and axis, the coordinate system was similarly constructed, interconnecting the transverse processes for the X-axis and constructing a perpendicular through the anterior tubercle (C1) and most central part of anterior corpus (C2), respectively. For both vertebrae, the Y-axis was constructed perpendicularly to the other two axes. Movements were registered simultaneously for the two segments. The analysis of segmental motion was made separately for each motion segment by considering the upper part of the segment moving relative to the lower vertebra of the segment.

The anatomical reference frame served as the general frame for the biomechanical motion analysis. Move-

2.6. Statistical analysis

2 The finite helical axis can be described as a momentary axis in space around which an object rotates while at the same time translating along this axis. The FHA is described by its position in space (position vector), its orientation (orientation vector), the rotation around the axis (rotation angle) and the translation along the axis (shift)— Woltring et al. (1985).

The test–retest results were analysed by calculating the retest Z-scores. Z-scores between 2 and +2 indicate that the retest results do not differ more than 2SD from the test, which can be regarded as not significant.


347

Table 2 Test–retest results of main motion and coupled motion components on C0–C1 and C1–C2 during flexion–extension mobilization Regional

Fixation

Locking

X

Y

Z

X

Y

Z

X

Y

Z

C0–C1 Test mean (and SD) Retest mean Z-score

16 16 0

4 9 5a

8 4 2

13(73) 12 0.33

2(71) 2 0

2(73) 2(71) 0

12(71) 10 2

2(71) 2 0

3(72) 3 00

C1–C2 Test mean (and SD) Retest mean Z-score

14(74) 17 0.75

4(72) 2 1

6(75) 3 0.6

13(74) 16 0.75

1(70) 2 Not relevant

3(71) 1 1

13(72) 16 1.5

0(70) 2 Not relevant

2(71) 2 0

SD ¼ standard deviation. a Significant: 24Z-score 42.

Table 3 Results of main and coupled rotations on C0–C1 and C1–C2 during planar flexion–extension mobilization Regional C0–C1 Mean (SD) Specimens 1–5 Specimens 1–6

X 12(74) 12(74)

Fixation

Y 12(74) 8(74)

Z 12(74 5(73)

Paired t-testa Mean d (SD) C1–C2 Mean (SD) Specimens 1–5

X 16(72)

Y 6(74)

Specimens 1–6

16(72)

6(71)

Z 10(72)

Locking

X 12(7)4 10(74)

Y 12(74) 3(72)

X 12(74) 8(73)

Y 12(74) 3(72)

Z 12(74) 3(71)

b

b

0.34 2(74)

(0.03) 5(73)

0 4(73)

0.13 4(75)

0.16 5(73)

0.16 2(74)

X 11(75)

Y 2(73)

Z 0(71)

X 11(74)

Y 3(71)

Z 3(71)

11(75)

2(73)

1(71)

12(73)

3(71)

2(72)

b

b

b

b

b

0.04

0

0.03

0

0

a

Paired t-test1–6

8(73)

Z 12(74) 1(71)

a

0.06

a

b

Paired t-test1–5 Mean d (SD)

4(74)

3(73)

0 8(74)

b

4(74)

3(71)

0 6(73)

SD ¼ standard deviation.d ¼ difference. a Significant difference between fresh and embalmed specimens (24Z-score 42). b Significant P-value for paired t-test on 95% level.

A repeated measures ANOVA was performed to control for the presence of differences between the results of the different mobilizing situations. Statistical significance of the differences in mean ranges of main and coupled motions is indicated by a positive Student’s t-test (P ¼ 0:05). 2.7. Test–retest During a pilot study, two specimens -one embalmed and one fresh—were tested twice. The results (Table 2) showed no significant differences between the tests for the main motion and the associated motion components (Cattrysse et al., 2005b).

3. Results 3.1. Regional versus segmental flexion–extension mobilization A repeated measures ANOVA revealed significant differences between all three situations—regional mobilization, segmental mobilization with manual fixation and segmental mobilization with locking of the inferior segments. A positive helical angle around the X-axis ((yk)0) reflects the main rotation motion in flexion direction. The observed mean ranges of the main motion in both segments are in the same range (121 versus 161). In the


348

8.464

10

5

( θ k) 0 ( θ k) 1

0

( θ k) 2 5

− 6.908 10

(A) 2.094

( θ k) 0

0

5

10

15

3.05

20

25

30

35 31.25

t

5

0

( θ k) 1 ( θ k) 2

5

− 9.086 10

9.615

( θ k) 0

15

20

25

30

35

40

45

t

16.85

(B)

50

55 51.05

10

5

( θ k) 1 ( θ k) 2

− 1.533

(C)

0

5

15

20

15.65

25 t

30

35 30.05

Fig. 5. Helical angles of C0–C1 during flexion–extension (spec 1): (A) during regional mobilization, (B) with manual fixation, (C) with locking, t ¼ time in seconds, (yk)0: finite helical angle with reference to the X-axis, (yk)1: finite helical angle with reference to the Y-axis, (yk)2: finite helical angle with reference to the Z-axis.

atlanto-axial segment as well as in the atlanto-occipital joint, the main motion is coupled with rotation components around both other axes ((yk)1 and (yk)2) (Table 3; Figs. 5 and 6).

More localized mobilization using segmental manual fixation or locking revealed a general tendency to decrease the range of motion. However, these changes were not statistically significant, except for the


349

15

14.711

10

( θ k) 0 ( θ k) 1 ( θ k)

5

2

0

− 2.949

5

(A)

10

20

30

15.65

4.236

40

50

60 50.45

t

5

0

( θ k) 0 ( θ k) 1 ( θ k)

5

2

10

− 11.938 15

(B) 21.199

0

10

20

30

40

t

0.05

38.45

30

20

( θ k) 0 ( θ k) 1 ( θ k) 2

10

0

10

− 10.148 20

(C)

0

10

5.45

20

30

t

40

50 43.25

Fig. 6. Helical angles of C1–C2 during flexion–extension (spec 2): (A) during regional mobilization, (B) with manual fixation, (C) with locking, t ¼ time in seconds, (yk)0: finite helical angle with reference to the X-axis, (yk)1: finite helical angle with reference to the Y-axis, (yk)2: finite helical angle with reference to the Z-axis.

rotations around the Y-axis—segmental axial rotation— and the Z-axis—segmental lateral bending—during segmental mobilization of C0–C1 with manual fixation of C1.

The fixation as well as the locking technique leaded to a mean decrease in the range of motion around all axes. For the fixation technique, however, the changes concerning the main motion of rotations around the



X-axis—segmental flexion–extension—were not statistically significant. The results also indicate that the helical angles from the fresh specimen did not differ significantly from the group of embalmed specimens, except for the rotations around the transverse Z-axis—segmental lateral bending. Exclusion of specimen 6 for the calculation of significance levels of changes in mean rotations around the Z-axis did not change the results (Table 3).

4. Discussion It has been demonstrated in a previous study using a phantom analysis that the method applied in this study was appropriate for analysing associated motions during flexion–extension mobilization (Cattrysse et al., 2004, 2005c). Although caution is needed when using embalmed specimens for an in vitro analysis of motion (Panjabi et al., 1985; Wilke et al., 1996, 1998), the results of the present study indicate good agreement between the helical angles observed in the fresh and the embalmed specimens. The estimated ranges of motion and coupling patterns of the fresh and embalmed specimens are very similar. This was rather surprising considering the possible effects of the embalming procedure on the biomechanical aspects of the specimens. The agreement may be explained by possible force adaptation by the investigator while manually mobilizing the embalmed versus the un-embalmed specimens. Degeneration may influence certain motion characteristics and mechanical responses especially in older specimens like those involved. Range of motion is expected to be reduced with age (ten Have and Eulderink, 1980, 1981; Eulderink and ten Have 1982). In a 3D-study on active regional motions of the cervical spine it has been demonstrated that the coupled motion component does not necessarily reduces similarly to the main motion due to age (Van Roy et al., 2004). Age may also influence motion coupling patterns as they can be related to specific features such as joint orientation, articular surface area and ligament orientation. Therefore, although results indicate general tendencies within this study sample, the effects of the different mobilizing techniques may be specimen specific. Mobilizing a specimen dissected from all skin, subcutaneous tissue and muscles, is not the same as mobilizing a person in a clinical setting. The investigators, however, noted a great similarity. According to the examiners, not being hindered by soft tissues and being able to get a good fixation grip on the investigated cadaver specimens even offered a slight advantage. None of the investigated segments were rigidly fixed. A dynamic multi-segmental approach was applied in which the investigated segments were free to move

relatively independently of moments originating from fixation. This situation reflects the clinical situation of a patient in the supine position, when the cervico-thoracic spine is only relatively fixed by the body weight, while the cervical spine is free to move. In this aspect, the present investigation is fundamentally different from previous in vitro studies. All mobilizations were performed manually, at least 3 times consecutively for each specimen. Consistent results for each specimen indicate that the repeatability of manually performed mobilizations is acceptable. This is expressed by very small standard deviations per specimen for every range of motion of main and coupled movements (range 0–31). In this study, the 3D aspects of manually induced functional anatomic movements, regarded as uni-planar, were analysed in terms of rotational movements around three axes. Care should be taken in defining these movements as flexion–extension, axial rotation or lateral bending, since these terms are generally used to describe motions of the head with reference to a local coordinate frame of the thorax or body as a whole. The rotations of the motion segment around the X-, Y- and Z-axis can be labelled as ‘segmental flexion–extension’, ‘segmental axial rotation’ and ‘segmental lateral bending’ when they are referred to the predefined boneembedded reference frames. This means that the flexion– extension component of the movement is defined by the FHA component with reference to an axis through the two transverse processes of C1. The lateral bending component is derived from the decomposition of the rotation vector of the FHA approach with reference to an axis through the anterior tubercle of the atlas. This means that this axis will not necessarily be situated in the transversal plane. The axial rotation component refers to a rotation around an axis that is perpendicular to the other two. This implies that the axial rotation axis may not coincide with the dens of C2, which is generally accepted to contain the axis for axial rotation (Penning and Wilmink, 1987; White and Panjabi, 1990; Roche et al., 2002). So far an in vitro approach offers the only possibility for a continuous registration of 3D segmental spinal motions. However, as open 3D MRI will become more available to researchers, new possibilities will be provided in the near future. The results of the present study indicate that manual fixation of the atlas did not significantly influence the flexion–extension component in the mobilized motion segment compared to a regional mobilization. On the other hand, the manual fixation technique significantly reduced the coupled axial rotation and lateral bending components on the mobilized segment. The manual fixation technique similarly influenced the movements in the adjacent atlanto-axial joint, i.e. a significant reduction of the associated movements


around the Y-axis (axial rotation) and Z-axis (lateral bending), but had no significant influence on the X-axis component of the movement (flexion–extension). The locking technique did not influence the main and associated movements in the mobilized segment C0–C1 compared to a regional mobilization. However, it reduced all components in the underlying atlanto-axial joint, main motion as well as coupled motions. The findings of this in vitro study may influence the technique that manual practitioners choose for manual assessment and therapy of the upper cervical spine. When trying to make mobilization techniques as specific as possible, different choices need to be made. If the focus is on the flexion–extension component of upper cervical spine mobility, the segmental fixation technique may offer the possibility to significantly reduce the coupled movement components. Using this technique, a reduction of coupled axial rotation and lateral bending on the atlanto-occipital and atlanto-axial joint may be achieved. If the aim is to localize as much as possible the mobilizing effect on the atlanto-occipital level, the locking technique may offer the best solution to reduce all movement components on the underlying atlantoaxial joint. So, when the atlanto-axial joint is to be controlled for undesired movements, locking might be the preferred technique. The results of the present study indicate that segmental mobilization techniques cannot exclude associated movements within the mobilized segment or in the adjacent segment, but they can significantly reduce these movements. The results of this in vitro analysis will have to be supported by in vivo investigations.

5. Conclusions At present, the 3D segmental aspects of manual mobilization can best be continuously registered and analysed in vitro. Manually induced movements as used in clinical mobilization techniques show 3D aspects. Even during functional anatomical, so-called planar flexion–extension mobilization, small associated movement components occur around the Y (axial rotation) and Z-axis (lateral bending) of a bone-embedded coordinate frame. The present results indicate that a segmental mobilization technique on the atlanto-occipital joint using a manual fixation of C1 can reduce these associated motions. The use of a locking technique reduces all movement components in the adjacent atlanto-axial joint. The results of this in vitro study suggest that manual therapists may have to select specific techniques depending on the desired effect (Osterbauer et al., 1992). When focussing on the flexion–extension component, the technique of choice is manual fixation of C1.

351

When a therapist wishes to localize the mobilizing effect on the atlanto-occipital joint, and so reduce undesired motions in the atlanto-axial joints, the locking technique is to be preferred.

References Amiri M, Jull G, Bullock-saxton J. Measurement of upper cervical flexion and extension with the 3-space fastrak measurment sytem: a repeatability study. The Journal of Manual and Manipulative Therapy 2003;11(4):198–203. Baeyens JP, Cattrysse E, Van Roy P, Clarys JP. Measurement of threedimensional intra-articular kinematics: methodological and interpretation problems. Ergonomics 2005;48(11–14):1638–44. Bull AM, Amis AA. Accuracy of an electromagnetic tracking device. Journal of Biomechanics 1997;30(8):857–9. Cattrysse E, Baeyens JP, Clarys JP, Van Roy P. 3D arthrokinematics of the human upper-cervical spine: in-vitro study of coupled rotations. Fifteenth Congress of the International Society of Electrophysiology and Kinesiology, Boston, USA, 2004. Cattrysse E, Baeyens JP, Clarys JP, Van Roy P. 3D arthrokinematic analysis of coupled motion in the human upper-cervical spine: invitro analysis of high velocity thrust techniques. International Society of Biomechanics XXth Meeting, American Society of Biomechanics 29th Meeting, Cleveland State University, Ohio, USA. International Society of Biomechanics, 2005a. Cattrysse E, Baeyens JP, Clarys JP, Van Roy P. In-vitro 3D arthrokineamtic analysis of coupled rotations in the atlanto-axial joint during axial rotation and lateral bending. Second International Conference on Movement Dysfunction; Pain and Performance: Evidence and Effect, Edinburgh-UK, 2005b. Cattrysse E, Baeyens JP, Clarys JP, Van Roy P. In-vitro 3D arthrokinematic analysis of coupled motions in the atlanto-axial joint during axial rotation and lateral bending. International Society of Biomechanics XXth Meeting, American Society of Biomechanics 29th Meeting, Cleveland State University, Ohio, USA, International Society of Biomechanics, 2005c. Cattrysse E, Baeyens JP, Van Roy P, Van de Wiele O, Roosens T, Clarys JP. Intra-articular kinematics of the upper limb joints: a six degrees of freedom study of coupled motions. Ergonomics 2005d;48(11–14):1657–71. Cattrysse E, Baeyens JP, Clarys JP, Van Roy P. Does manual mobilization influence motion coupling patterns in the atlantoaxial joint? Journal of Electromyography and Kinesiology, accepted for publication. Dhimitri K, Brodeur S, Croteau M, Stephanie R, Seymour CJ. Reliability of the cervical range of motion device in measuring upper cervical motion. The Journal of Manual and Manipulative Therapy 1998;6(1):31–6. Dvorak J, Froehlich D, Penning L, Baumgartner H, Panjabi MM. Functional radiographic diagnosis of the cervical-spine—flexion extension. Spine 1988;13(7):748–55. Dvorak J, Antinnes JA, Panjabi M, Loustalot D, Bonomo M. Age and gender related normal motion of the cervical-spine. Spine 1992;17(10):S393–8. Eulderink F, ten Have HA. Do adjacent joints compensate for decreased mobility in a cervical spine segment? Zeitschrift fur Rheumatologie 1982;41(6):263–7. Fielding JW. Cineroentenopgraphy of the normal spine. Journal of Bone and Joint Surgery—American Volume 1957;A-39:1280. Harrison DE, Harrison DD, Troyanovich SJ. Three dimensional spinal coupling mechanics: Part I. A review of the literature. Journal of Manipulative and Physiological Therapeutics 1998;21(2):101–13.



Hino H, Abumi K, Kanayama M, Kaneda K. Dynamic motion analysis of normal and unstable cervical spines using cineradiography—an in-vivo study. Spine 1999;24(2):163–8. Koerhuis CL, Winters JC, van der Helm F, Hof AL. Neck mobility measurement by means of the ‘Flock of birds’ electromagnetic tracking system. Clinical Biomechanics 2003;18:14–8. LaScalza S, Arico J, Hughes R. Effect of metal and sampling rate on accuracy of flock of birds electromagnetic tracking system. Journal of Biomechanics 2003(36):141–4. Mc Quade KJ, Finley MA, Harris-Love M, McCombe-Waller S. dynamic error analysis of ascension’s Flock of birds electromagnetic tracking device using a pendulum model. Journal of Applied Biomechanics 2002;18:171–9. Meskers CG, Fraterman H, van der Helm FC, Vermeulen HM, Rozing PM. Calibration of the ‘‘Flock of Birds’’ electromagnetic tracking device and its application in shoulder motion studies. Journal of Biomechanics 1999;32(6):629–33. Milne N. Composite motion in cervical disc segments. Clinical Biomechanics 1993;8(4):193–202. Milne AD, Chess DG, Johnson JA, King GJ. Accuracy of an electromagnetic tracking device: a study of the optimal range and metal interference. Journal of Biomechanics 1996;29(6): 791–3. Ordway NR, Seymour RJ, Donelson RG, Hojnowski LS, Edwards WT. Cervical flexion, extension, protrusion, and retraction—a radiographic segmental analysis. Spine 1999;24(3):240–7. Osterbauer PJ, Derickson KL, Peles JD, Deboer KF, Fuhr AW, Winters JM. 3-Dimensional head kinematics and clinical outcome of patients with neck injury treated with spinal manipulative therapy—a pilot-study. Journal of Manipulative and Physiological Therapeutics 1992;15(8):501–11. Panjabi MM. Instantaneous center of rotation and instability of the cervical spine—a clinical study—point of view. Spine 1997;22(6): 647–8. Panjabi MM, White AA, Johnson RM. Cervical-spine mechanics as a function of transection of components. Journal of Biomechanics 1975;8(5):327–36. Panjabi MM, Krag M, Summers D, Videman T. Biomechanical timetolerance of fresh cadaveric human spine specimens. Journal of Orthopaedic Research 1985;3(3):292–300. Panjabi MM, Summers DJ, Pelker RR, Videman T, Friedlaender GE, Southwick WO. 3-Dimensional load–displacement curves due to forces on the cervical-spine. Journal of Orthopaedic Research 1986;4(2):152–61. Panjabi M, Dvorak J, Duranceau J, Yamamoto I, Gerber M, Rauschning W, et al. 3-Dimensional movements of the upper cervical-spine. Spine 1988;13(7):726–30.

Panjabi MM, Oda T, Crisco JJ, Dvorak J, Grob D. Posture affects motion coupling patterns of the upper cervical-spine. Journal of Orthopaedic Research 1993;11(4):525–36. Penning L. Normal movements of cervical-spine. American Journal of Roentgenology 1978;130(2):317–26. Penning L, Wilmink JT. Rotation of the cervical spine. A CT study in normal subjects. Spine 1987;12(8):732–8. Roche CJ, King SJ, Dangerfield PH, Carty HM. The atlanto-axial joint: physiological range of rotation on MRI and CT. Clinical Radiology 2002;57(2):103–8. Spoor CW, Veldpaus FE. Rigid body motion calculated from spatial coordinates of markers. Journal of Biomechanics 1980;13(4): 391–3. ten Have HA, Eulderink F. Degenerative changes in the cervical spine and their relationship to its mobility. Journal of Pathology 1980;132(2):133–59. ten Have HAMJ, Euldeink F. Mobility and degenerative changes of the ageing cervical spine. Gerontology 1981;2e`:42–50. Van Roy P, Barbaix E, Clarys JP. Functional anatomy of the cervical spine. In: Spalski M, Gunzburg R, editors. The degenerative cervical spine. Philadelphia, Lippincott: Williams & Wilkins; 2001. p. 3–27. Van Roy P, Van den Bogaerde F, Cattrysse E, Baeyens JP, Verbruggen L, Clarys JP. Effects of ageing and degeneration on regional coupled motion in the cervical spine. Fifteenth Congress of the International Society of Electrophysiology and Kinesiology, Boston, USA, 2004. Werne S. Studies in spontaneous atlas dislocation. Acta Orthopaedica Scandinavica 1957(Suppl 23):1–150. White A, Panjabi M. Clinical biomechanics of the spine. 2nd ed. Philadelphia: Lippincott; 1990. p. 722. Wilke HJ, Krishchak S, Claes LE. Formalin fixation strongly influences biomechanical properties of the spine. Journal of Biomechanics 1996;29(12):1629–31. Wilke HJ, Wenger K, Claes L. Testing criteria for spinal implants: recommendations for the standardization of in-vitro stability testing of spinal implants. European Spine Journal 1998;7(2): 148–54. Woltring HJ. 3-D attitude representation of human joints—a standardization proposal. Journal of Biomechanics 1994;27(12): 1399–414. Woltring HJ, Huiskes R, Delange A, Veldpaus FE. Finite centroid and helical axis estimation from noisy landmark measurements in the study of human joint kinematics. Journal of Biomechanics 1985;18(5):379–89. Worth DR. Movements of the cervical-spine. Journal of Anatomy 1985;142(OCT):227–8.

ARTICLE IN PRESS


Original article

Manual fixation versus locking during upper cervical segmental mobilization. Part 2: An in vitro three-dimensional arthrokinematic analysis of manual axial rotation and lateral bending mobilization of the atlanto-axial joint E. Cattrysse, J.P. Baeyens, J.P. Clarys, P. Van Roy Vrije Universiteit Brussel, Department of Experimental Anatomy (EXAN), Laarbeeklaan 103, B1090 Brussels, Belgium Received 29 November 2005; received in revised form 11 May 2006; accepted 12 July 2006

Abstract Background: Three-dimensional kinematic aspects of coupled motion during manual cervical mobilization have not previously been studied. Using an in vitro 3D-motion analysis method, the kinematic effects of two different segmental techniques for axial rotation and lateral bending mobilization of the upper cervical spine were investigated as a second part of the study (in part one, kinematic effects of flexion-extension mobilization have been investigated). Methods: Axial rotation and lateral bending mobilization of the atlanto-occipital and atlanto-axial segments were analysed in vitro using an electromagnetic tracking device. Local reference frames were defined based on bony reference points that were registered using a 3D-digitizing stylus. Five embalmed and one fresh specimen were analysed. Segmental motion was registered simultaneously in the atlanto-occipital and the atlanto-axial joints during manual mobilization through the full range of axial rotation and lateral bending mobility. The 3D-kinematic aspects during regional mobilization were compared with those during segmental mobilization with manual fixation and during segmental mobilization using a locking technique. Results: During both segmental axial rotation techniques of the atlanto-axial joint, a significant reduction of the coupled lateral bending and flexion-extension motion was observed. The locking technique also induced an increase in the main axial rotation component. During lateral bending mobilization of the atlanto-axial joint, the manual fixation technique reduced the effect on the coupled flexion-extension component significantly. Interpretations: These results suggest that for manual segmental axial rotation and lateral bending mobilization of the upper cervical spine segmental manual fixation or locking may be preferred in different situations depending on the desired effects. This study brings additional information to the data provided by part 1 of this study on the 3D-arthrokinematic effects of flexionextension mobilization. r 2006 Elsevier Ltd. All rights reserved. Keywords: Upper-cervical; In vitro; Axial rotation; Lateral bending; Kinematic analysis; Manual mobilization; Coupled motion

1. Introduction

Corresponding author. Tel.: +32 2 4774423; fax: +32 2 4774421.

E-mail address: [email protected] (E. Cattrysse). 1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.07.016

This paper represents the second part of an in vitro study of three-dimensional (3D) kinematic aspects of manual mobilization of the upper cervical spine. In the first study the effects of flexion-extension mobilization


354

Table 1 Reported range of segmental motion in the upper-cervical spine Method of analysis

Type of motion

Axial rotation

Lateral bending

Penning (1978)

Planar X-rays

Active

C0–C2: 10

Panjabi et al. (1988)

Literature

Act & pass

Amiri et al. (2003)

In vitro stereophotogrametry In vivo electromagnetic tracking device

Passive Active

C0–C1: 01 C1–C2: 701 C0–C1 unilat: 0–5.21 C1–C2 unilat 14.5–701 C0–C1 unilat: 7.21 C1–C2 unilat 38.91 C0–C2: 83.9–84.2

were analysed. This second part presents the results of an analysis of axial rotation and lateral bending manual mobilization techniques. The effects of two different segmental manual mobilization techniques, a manual fixation technique and a locking procedure, were compared to those of regional mobilization techniques. Only limited information is available about 3D segmental coupled motion in the upper cervical spine, and—to the best of the present authors’ knowledge—no information has been published about the 3D aspects of segmental coupled motion during manual mobilization. Very few studies have been performed on the kinematic effects of spinal manipulative therapy at the level of the cervical spine (Triano and Schultz, 1994; Feipel et al., 2000; Klein et al., 2003). These authors have focused on the global range of motion of the cervical spine during high-velocity thrust techniques. In the literature, significant differences in regional cervical range of motion (ROM) have been reported for axial rotation as well as for lateral bending (Penning, 1978; Dvorak et al., 1992; Walmsley et al., 1996; McClure et al., 1998; Chen et al., 1999; Lantz et al., 1999; Castro et al., 2000; Mannion et al., 2000; Ferrario et al., 2002; Sforza et al., 2002; Lantz et al., 2003) with a general tendency towards greater passive than active ranges of motion. Chen et al. (1999) presented a meta analysis. These authors calculated that the ROM for regional axial rotation was 15117231 and 17417181 for active and passive situations, respectively. The authors reported averaged ROM of 861751 of active and 1091751 of passive lateral bending. The results of this meta-analysis also mentioned that the ROM decreases with age. Variations within each measuring technology, however, were as large as, or larger than those between technologies, indicating that the clinical procedures are as important as the accuracy and precision of the technology itself (Chen et al., 1999). Several studies have reported on the segmental ROM of the upper cervical spine (Penning, 1978; Penning and Wilmink, 1987; Panjabi et al., 1988; Van Roy et al., 1997; Van Roy et al., 2001; Amiri et al., 2003). These authors have emphasized that axial rotation mainly takes place in the atlanto-axial joint, while they do not

C0–C1 C1–C2 C0–C1 C1–C2

unilat: 8–401 unilat 0–101 unilat: 5.51 unilat 6.71

provide concurrent information about the amount of axial rotation in the atlanto-occipital joint (Table 1). The present study focused on the differences in the kinematic aspects of coupled motions during manual segmental axial rotation and lateral bending mobilization of the atlanto-axial joint and on the effects on the adjacent atlanto-occipital joint. To do so, a method was used combining an electromagnetic tracking device and a 3D-digitizer (Baeyens et al., 2005; Cattrysse et al., 2005b). 2. Materials and methods 2.1. Specimens One fresh and five embalmed human spinal specimens were used in this study. Each specimen consisted of the occiput and all cervical vertebrae down to the first thoracic vertebra. Specimens were 60 years old or more.1 Room temperature was controlled between 15 and 20 1C and humidity was above 60% to avoid dehydration of the specimens during testing. Methodological problems possibly related to the use of specimens of higher age and the absence of skin and muscular tissues are discussed in part one (Cattrysse et al., 2006). 2.2. Instruments A ‘Flock of Birds’ electromagnetic tracking system (Ascension Technologies Corporation—USA) was used in combination with a 3D digitizing stylus (MicroscribeTM G2X—Immersion Corporation, USA). The accuracy of the instruments has been referenced in part 1 (Cattrysse et al., accepted; Cattrysse et al., 2006). Kinematic data were calculated using ‘Mathcad Professional’ mathematical software (r1986–2000 MathSoft, Inc.). 1 The specimens were gathered at the anatomical laboratory of the Vrije Universiteit Brussel. Most of the anatomical specimens were provided by people who died aged 50–90 years and bequeathed their bodies for scientific purposes. For reasons of confidentiality, no personal history or medical antecedents were available.


355

2.3. Methodology 2.3.1. Test–retest Two specimens—one embalmed and one fresh—were tested twice to investigate the repeatability of the measuring procedure. 2.3.2. Test-procedure Three sensors were rigidly attached to the skull, atlas and axis of the specimens as described in detail in part one of this study (Cattrysse et al., 2006). First the specimens were mobilized regionally by guiding the occiput manually through the full range of axial rotation and lateral bending motion. Subsequently, two different segmental mobilization techniques were performed on the C1–C2 level. In one technique, the axis was manually fixed (Fig. 1), while in the second technique the lower segments were brought in a 3Dlocking position to minimize motion in the adjacent segments (Fig. 2). A locking position is a 3D end range position leading to a bony or capsulo-ligamentous locking of the joint. The positions and orientations of each sensor were continuously registered during all mobilizations. Using the 3D drawing stylus, the spatial coordinates of local anatomical landmarks were digitized to relate the sensor data to the bony segments. A typical registration consisted of at least three cycles of full range motion mobilization of the specimens. The horizontal set-up was chosen to simulate the clinical situation in which optimal muscular relaxation of the patient is provided in supine position. No additional axial preload was applied that would simulate basic muscle tone. The finite helical axis (FHA) (Woltring et al., 1985) was calculated on the basis of the individual sensor data for discrete sampling ranges of motion.2 The derived angles, or finite helical angles, are the result of the decomposition of the rotation vector according to the predefined bone-embedded reference frame. This method together with the calculation algorithm of the FHA (Spoor and Veldpaus, 1980), were used in previous studies (see part 1; (Cattrysse et al., 2005c)). 2.4. Construction of the bone-embedded coordinate system The bone-embedded reference frames used to analyse the 3D kinematics of axial rotation and lateral bending mobilization are identical to those used in part one on 2 The Finite Helical Axis can be described as a momentary axis in space around which an object rotates while at the same time translating along this axis. The FHA is described by its position in space (position vector), its orientation (orientation vector), the rotation around the axis (rotation angle) and the translation along the axis (shift)— Woltring et al., 1985.

Fig. 1. Manual segmental mobilization of the atlanto-axial joint with manual fixation of C2.

Fig. 2. Manual segmental mobilization of the atlanto-axial joint with locking of the cervical spine.

the flexion-extension mobilization. These local reference frames are built on the anatomical data registered by the 3D-digitizing stylus. The local reference frame of the occiput (C0) was related to the connecting line between the most inferior points of the mastoid processes (X-axis). The second axis was constructed from the external occipital protuberance, perpendicularly to the first axis (Z-axis). The third axis was perpendicular to the two others (Yaxis). The reference frame on the atlas (C1) was constructed on the basis of the interconnecting line through the most lateral parts of the transverse processes and a perpendicular line from the anterior tubercle of C1. This local reference frame is represented in Fig. 3. On the axis (C2), the reference frame was similarly constructed, interconnecting the posterior tubercle on


356

transverse processes of C1. The lateral bending component is derived from the decomposition of the rotation vector of the finite helical axis approach, with reference to an axis through the anterior tubercle of the atlas perpendicularly to the flexion-extension axis. The axial rotation component refers to a rotation around an axis that is perpendicular to the other two. This implies that this Y-axis may not coincide with the dens of C2. 3.1. Test–retest

Fig. 3. Local coordinate frame of C1.

the transverse processes for the X-axis and constructing a perpendicular through the most central part of the anterior corpus (Z-axis). For both vertebrae, the Y-axis was constructed perpendicularly to the X and Z-axes. In this study coupled motion components are considered ipsi-lateral, when the sign of the coupled motion is equal to the sign of the main motion component at his maximum peak value. The coupling pattern was labelled as not present when the main or the coupled motion did not exceed one degree. 2.5. Statistical analysis Due to the limited number of specimens included in the test–retest protocol, the results were analysed by calculating the Z-score. Z-scores for the mean retest values below 2 and above +2 were regarded as significantly different from the test-results. The presence of differences between the results of the different mobilizing situations was analysed by a repeated measures ANOVA. Differences in mean ranges of main and coupled motion components were analysed by the student’s t-test (P ¼ 0:05) (see part 1).

3. Results The 3D aspects of manual induced functional anatomic movements—regarded as uni-planar—were analysed in terms of rotational movements around three axes. The rotations of the separate vertebrae around the X-, Y- and Z-axis can be labelled as ‘segmental flexionextension’, ‘segmental axial rotation’ and ‘segmental lateral bending’ respectively, when they are referred to the predefined bone-embedded reference frames. This means that the flexion-extension component of the movement is derived from the finite helical axis component with reference to an axis through the two

Two specimens were tested twice (Table 2), and the results showed no significant differences (Po0:05) for the main motion and the coupled motion components in 28 out of 36 situations. Taking into account the limited number of specimens in the test–retest situation and the small standard deviations, this can be regarded as an acceptable degree of reproducibility. 3.2. Regional versus segmental axial rotation mobilization The repeated measures ANOVA indicated significant differences between the three axial rotation situations: regional mobilization, segmental mobilization with manual fixation and segmental mobilization with locking of the inferior segments (P-values between 0.07 and 0.7) except for the segmental axial rotation component on the C0–C1 level during the lateral bending technique (P ¼ 0:03). Statistical significance of the differences of mean range of motion of the main and coupled motions was indicated by a positive t-test (Po0:05). 3.3. Axial rotation The observed main axial rotation motion in the atlanto-axial joint (C1–C2) ranged from 361 to 551. For the majority of cases, a contra-lateral coupling between the segmental axial rotation and lateral bending components (yk)1 and (yk)2 was observed in all three situations (Fig. 4). The t-test showed significant decreases in the ranges of main and coupled motion components in both segmental mobilization techniques compared to the regional mobilization, except for the axial rotation in the locking technique where a significant increase was observed (Table 3). The coupled lateral bending component ranged from 13 to 211, being largest during the regional mobilization technique. The coupled movements occurring simultaneously in the atlanto-occipital joint (C0–C1) during all three axial rotation mobilization techniques on C0–C1 (Table 3/ Fig. 5) were much smaller (range 2–91). A significant reduction of the main and coupled movement components was observed in both segmental techniques compared to the regional mobilization technique, except

Table 2 test-retest results Regional

C0–C1 axial rotation Mean test+SD test Mean retest Z-score

Y

C0–C1 lat bending Mean test+SD test Mean retest Z-score

Z

10.21

Y 12.15 8.62 0.32

X 1.27

0.86

5.25 1.54 0.63

5.89

*

0.40

9.40 3.16 1.05

5.95

*

X 11.07

Z 5.41 7.20 2.09

8.60 6.40 5.45

4.64

Y

0.91 *

X

*

0.56

7.47

13.86 3.39 2.93

3.58

2.81 2.89 0.08

0.99

3.93 0.65 3.37

0.98

Y 50.38 55.10 0.32

2.90

5.53

0.01 *

Y

3.95 2.59 0.63

2.14

0.99

3.10

Y 2.74 2.02 0.21

3.38

Z 29.10 21.65 1.57 Y 11.96 8.79 4.15

X 4.74

4.26 8.59 1.21

8.80 2.93 0.76

7.72

4.06 0.66 1.55

2.18

* X

2.20 1.74 0.15

2.95

X 2.33

2.63 1.99 0.27

3.59

X 0.76

Z

2.58 2.37 0.07

X 1.54 0.57 0.98

3.94

8.24 7.53 0.18

X

1.77 1.35 58.69

14.81

Z 6.60 0.95 1.02

*

Y

*

5.82 7.31 0.51 X

Z

Z 3.99 3.00 1.77

X 26.26 23.62 0.35

Y 0.07

7.88 3.45 62.72 Y

7.15 5.07 2.30

1.88

4.60 5.51 0.48

Z 25.88

Z

X

4.55 2.57 0.43

Y 45.07 53.07 0.31

Z 3.63 3.54 0.03

3.63

4.28 0.56 0.92

4.02

*Significant ¼ 24Z-score 42.

28.298 30

20

10

0

-10

-20

20

-21.195 -30

(A)

10.832 10

0

40

-22.355 -30

(B)

30.939

20

0

-20

-23.248 -40

(C)

0 0.05

5 5.45

10

10

10

20

20

15

30 t

30 t

20 t

40

40

25

50

50

30

60 57.05

60 51.05

35 31.25

357

0 7.85

Fig. 4. Finite Helical Angles of C1–C2 during atlanto-axial rotation mobilization (specimen 4). (A) during regional mobilization, (B) with manual fixation, (C) with locking, t ¼ time in seconds, (yk)0: Finite Helical Angle with reference to the X-axis, (yk)1: Finite Helical Angle with reference to the Y-axis, (yk)2: Finite Helical Angle with reference to the Z-axis.

ARTICLE IN PRESS

Z 10.10 10.74 0.06

Z 28.18 26.05 1.68


C1–C2 lat bending Mean test+SD test Mean retest Z-score

17.81

-10

Y 54.57 60.14 0.31

Locking

-20

C1–C2 axial rotation Mean test+SD test Mean retest Z-score

Fixation

358

Table 3 Results axial rotation on C1–C2 Axial rotation

Y

Z

Regional

Fixation

Locking

X

Regional

Fixation

Locking

Regional

Fixation

Locking

C1-C2 Mean+SD t-test sign d mean ROM

* 49.944

5.519

* 35.77 0.05 ** 14.18

11.915

9.19

55.13 0.54 ** 3.76

C0-C1

d mean ROM

7.7433

contro 5/6

2.1562

Irregular

* 13.1 0.12 ** 8.16

7.802

contro 5/6

1.04

Mainly no

* 15.64 0.27 ** 5.62

7.043

contro 4/5

8.24

4.51

6.73 0.55 ** 1.39

4.033

2.15

Irregular

9.09

2.89

4.52 0.01

1.74

* 3.72 0.06 ** 4.39

1.405

* 3.88

2.03

1.72

2.67 0.29 ** -0.79

4.49

6.76 0.24 ** 3.30

3.015

2.36 0.56 ** 0.66

3.62 0.67 ** 1.14

-4.83

6.1 0.17 ** -3.25

3.57

5.258 10

5

0

-5

4

3

2

1

0

-1

10

-8.295 -10

(A)

3.512

-0.495

(B)

6.873

5

0

-5

-8.078 -10

(C)

5 5.45

10 10.25

0 4.85

10

10 15

15

20

20 t

20 t

30 t

25

40 25

30

50

35 30.65

30 25.85

60 56.45

Fig. 5. Finite Helical Angles of C0–C1 during atlanto-axial rotation mobilization (specimen 4), (A) during regional mobilization, (B) with manual fixation, (C) with locking, t ¼ time in seconds, (yk)0 : Finite Helical Angle with reference to the X-axis, (yk)1: Finite Helical Angle with reference to the Y-axis, (yk)2: Finite Helical Angle with reference to the Z-axis.

ARTICLE IN PRESS

*: results of fresh specimen significant different from group. t-test: P-values. **: significant on Po0:05. d mean ROM: mean difference in range of motion compared to regional mobilization.


Mean7SD t-test

21.26


0.97

3.22 3.18 0.83

1.39 1.04

no 5/6 5.56 0.96

1.41

4.62 5.42 4.29 0.89

1.20

* 2.88 C0–C1 Mean+SD t-test sign d mean ROM

2.39

4.18 0.94

5.12

1.56 0.00

*: results of fresh specimen significant different from group. t-test: P-values. **: significant on Po0:05. d mean ROM: mean difference in range of motion compared to regional mobilization.

1.91

4.31

ipsi 4/6 3.30 0.46

4.07

5.18

0.32

5.20

* no 5/6 2.56

1.39

* 1.47 0.27

1.51

1.49

* 4.113 3.01 0.03 ** 6.13 5.779 no/5/6 7.234 4.532 no 6/6 8.251 0.89 * 8.736 * 3.2202 4.748 0.53 4.782 5.052 0.52 * 7.0961 C1–C2 Mean+sd t-test sign d mean ROM

Regional

Lateral bending Z

Table 4 Results lateral bending C1–C2

Fixation

Locking

3.5

Regional

Y

6.2647 no 5/6

4. Discussion

3.867 6.15 0.68

5.06 Fixation

Locking

X

The main and coupled movements in the atlanto-axial joint during the lateral bending mobilizations were small (range 2–101). No significant changes could be observed during the two segmental techniques, except for a significant reduction of the coupled flexion-extension component during the manual fixation technique (Table 4). In most cases, no coupling pattern between lateral bending and axial rotation motion components could be recognized. The range of motion of the different movement components in the atlanto-occipital joint during lateral bending mobilization was even smaller than in the atlanto-axial joint (range 1–61), and the t-test showed no significant differences (Po0:05) between the three situations (Table 4). During the regional mobilization technique, the coupling patterns at this level was ipsilateral in 5 out of 6 cases, but no coupling was observed during the segmental mobilizations (Fig. 6).

Regional

Fixation

3.4. Lateral bending

* 9.878 0.37

Locking

for the flexion-extension component ((yk)0) in the fixation technique. In most cases, either no or an irregular coupling pattern was observed.

The in vitro results indicate that the use of segmental axial rotation mobilization techniques on the atlantoaxial segment can significantly influence the coupled lateral bending and flexion-extension motions compared to so-called uni-planar regional mobilization. While manually fixating the axis and also while using a locking technique, the associated flexion-extension component was significantly reduced. Manual segmental mobilization techniques thus reduce the involuntary coupled motion patterns during planar induced movements. Moreover, the locking technique enabled an increase in the main axial rotation motion, while the manual fixation technique restricted this main motion. Small reductions of coupled motions were also observed in the adjacent atlanto-occipital joint. There was also a small but significant (Po0:05) increase of 31 of the main axial rotation motion on this level using the locking technique. However, the absence of significant results for the preceding ANOVA for the axial rotation component during lateral bending at this motion segment indicates that the significant t-test scores were irrelevant. During segmental lateral bending mobilization, no significant effects for main and coupled motions could be observed at the atlanto-axial level compared to the regional mobilization. Only a significant reduction of the coupled flexion-extension component at the atlanto-

359


360

9.537

10

5

0

-3.885

-5 5 5.45

(A) 12.372

10

15

20

25

30

35

t

40 30.65

15

10

5

0

-5 -7.063 -10

(B)

0 0.05

10

20

30 t

40

50 48.65

Fig. 6. Finite Helical Angles during regional atlanto-axial lateral bending mobilization (specimen 3), (A) at C1–C2, (B) at C0–C1, t ¼ time in seconds, (yk)1: Finite Helical Angle with reference to the X-axis, (yk)2 : Finite Helical Angle with reference to the Y-axis, (yk)3: Finite Helical Angle with reference to the Z-axis.

axial joint could be observed during lateral bending using the manual fixation technique. The results of the axial rotation mobilization techniques can be compared to the results of regional versus segmental flexion-extension mobilization on the C0–C1 joint (Cattrysse et al., 2006). The manual fixation technique did not significantly influence the main flexion-extension component in comparison to a regional mobilization. On the other hand, it significantly reduced the coupled axial rotation and lateral bending component at the mobilised motion segment. Equally, a reduction of the coupled motions was observed at the mobilised motion segment during an axial rotation mobilization. However, the main motion—i.e., axial rotation—was also reduced by the manual fixation. The locking technique did not influence the main and coupled motions on the mobilized segment during flexion-extension mobilization. During an axial rotation mobilization, however, a significant decrease of the coupled motion component was observed, but the use of

this technique also induced an increase of the main axial rotation motion. A similar comparison can be made concerning the effect of segmental mobilization techniques on the adjacent upper cervical level. During flexion extension mobilization of the C0–C1 joint, both segmental techniques—manual fixation and locking—could reduce the coupled rotations on the adjacent C1–C2 joint. The locking technique could also reduce the main flexionextension motion in the atlanto-occipital joint. Although the manual fixation as well as the locking technique reduced all movements in the adjacent atlanto-occipital joint during the segmental axial rotation and lateral bending mobilization of the atlantoaxial joint, the coupled flexion-extension component remained unaffected by the manual fixation technique. These results indicate that, when considering the effect of segmental mobilization techniques on coupling patterns, the coupling patterns are influenced by the technique during lateral bending mobilization, but not during axial rotation mobilizations. During the segmental axial rotation mobilizations of the atlanto-axial joint, the pattern of motion coupling between axial rotation and lateral bending remains mainly contralateral. On the other hand, because of a significant reduction of coupled motions, coupling patterns could no longer be distinguished during segmental lateral bending mobilizations. This pattern was mainly ipsilateral during a regional mobilization (Cattrysse et al., 2005a). When the aim of the intervention is to increase the rotation mobilization component on the atlanto-axial joint, the locking technique might be preferred. It has to be taken into account, however, that the coupled lateral bending and flexion-extension components are also reduced. When, however, it is important not to influence the coupled atlanto-occipital flexion-extension component, one should choose the segmental manual fixation technique, given that it reduces the main axial rotation and coupled lateral bending components. The results—although so far restricted to in vitro situations—suggest that specific therapy techniques may lead to specific arthrokinematic effects. This would include the choice of an optimal technique for a specific desired effect.

5. Conclusions This study offers new information about 3D segmental aspects of manual mobilization by focusing on the effects of manually induced segmental axial rotation and lateral bending mobilization. As mentioned previously in part 1 on the effect of segmental flexionextension mobilization of the upper cervical spine, manually induced so-called planar movements, as used


in clinical mobilization techniques reveal three dimensional aspects. Even during functional anatomical flexion–extension mobilization, small coupled movement components occur around the Y (axial rotation) and Z-axes (lateral bending) of a bone-embedded coordinate frame. The results of this in vitro study indicate that manual fixation as well as locking techniques reduce the range of coupled motion components during axial rotation mobilization of the atlanto-axial joint. The locking technique, however, enables an increase in the main motion. The coupling pattern is not influenced by the segmental mobilization technique. The segmental lateral bending mobilization techniques did not induce significant differences in the range of coupled motions or in the arthrokinematic coupling patterns compared to a regional mobilization technique. The fixation technique significantly reduced the coupled flexion-extension motion in the atlanto-axial joint. The results of this in vitro study suggest that when the therapy focus is on the axial rotation component of the mobilization, the locking technique may be the preferred method as it may reduce the ranges of the coupled motions, increase the axial rotation component on the segment itself and significantly reduce all motion in the adjacent atlanto-axial joint. If for any reason it may not be opportune to reduce or influence the flexionextension component on the C1–C2 level, then, the results of this study suggest that the segmental mobilization technique with manual fixation of the axis may be preferable. No major differences were observed between the different lateral bending mobilizations techniques. However, if the therapist intends to reduce the coupled flexion-extension component, the segmental manual fixation technique may be preferred. The results of this in vitro study suggest that it might be important in a therapy situation to choose specific techniques according to the desired effect (Osterbauer et al., 1992; Cattrysse et al., 2006). In-vivo studies will have to confirm this hypothesis.

References Amiri M, Jull G, Bullock-Saxton J. Measuring range of active cervical rotation in a position of full head flexion using the 3D Fastrak measurement system: an intra-tester reliability study. Manual Therapy 2003;8(3):176–9. Baeyens JP, Cattrysse E, Van Roy P, Clarys JP. Measurement of threedimensional intra-articular kinematics: methodological and interpretation problems. Ergonomics 2005;48(11–14):1638–44. Castro WHM, Sautmann A, Schilgen M, Sautmann M. Noninvasive three-dimensional analysis of cervical spine motion in normal subjects in relation to age and sex—an experimental examination. Spine 2000;25(4):443–9. Cattrysse E, Baeyens JP, Clarys JP, Van Roy P. In vitro 3D arthrokineamtic analysis of coupled rotations in the atlanto-axial

361

joint during axial rotation and lateral bending. Second international conference on movement dysfunction; pain and performance: evidence and effect, Edinburgh-UK, 2005a. Cattrysse E, Baeyens JP, Clarys JP, Van Roy P. In vitro 3D arthrokinematic analysis of coupled motions in the Atlanto-axial joint during axial rotation and lateral bending. International society of biomechanics XXth meeting. American Society of Biomechanics 29th meeting, Cleveland state University, Ohio, USA: International Society of Biomechanics, 2005b. Cattrysse E, Baeyens JP, Van Roy P, Van de Wiele O, Roosens T, Clarys JP. Intra-articular kinematics of the upper limb joints: a six degrees of freedom study of coupled motions. Ergonomics 2005c;48(11–14):1657–71. Cattrysse E, Baeyens JP, Clarys JP and Van Roy P. Does manual mobilization influence motion coupling patterns in the atlantoaxial joint? Journal of Electromyography and Kinesiology, accepted for publication. Cattrysse E, Baeyens JP, Clarys JP and Van Roy P. Manual fixation versus locking during upper cervical segmental mobilization. Part 1: An in vitro three-dimensional arthrokinematic analysis of manual flexion-extension mobilization of the atlanto-occipital joint. Manual Therapy, 2006, in press, doi:10.1016/ j.math.2006.07.015. Chen J, Solinger AB, Poncet JF, Lantz CA. Meta-analysis of normative cervical motion. Spine 1999;24(15):1571–8. Dvorak J, Antinnes JA, Panjabi M, Loustalot D, Bonomo M. Age and gender related normal motion of the cervical-spine. Spine 1992;17(10):S393–8. Feipel V, Van Geyt B, Dugailly PM, Lepers Y, Klein P, Rooze M. The use of 3D electrogoniometry to assess kinematics outcome of various manual techniques functional and cervical spine. Archives of Physiology and Biochemistry 2000;108(1–2):205. Ferrario VF, Sforza C, Serrao G, Grassi G, Mossi E. Active range of motion of the head and cervical spine: a three-dimensional investigation in healthy young adults. Journal of Orthopaedic Research 2002;20(1):122–9. Klein P, Broers C, Feipel V, Salvia P, Van Geyt B, Dugailly PM, et al. Global 3D head-trunk kinematics during cervical spine manipulation at different levels. Clinical Biomechanics 2003;18(9):827–31. Lantz CA, Chen J, Buch D. Clinical validity and stability of active and passive cervical range of motion with regard to total and unilateral uniplanar motion. Spine 1999;24(11):1082–9. Lantz CA, Klein G, Chen J, Mannion A, Solinger AB, Dvorak J. A reassessment of normal cervical range of motion. Spine 2003;28(12):1249–57. 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. McClure P, Siegler S, Nobilini R. Three-dimensional flexibility characteristics of the human cervical spine in vivo. Spine 1998;23(2):216–23. Osterbauer PJ, Derickson KL, Peles JD, Deboer KF, Fuhr AW, Winters JM. 3-Dimensional head kinematics and clinical outcome of patients with neck injury treated with spinal manipulative therapy—a pilot-study. Journal of Manipulative and Physiological Therapeutics 1992;15(8):501–11. Panjabi M, Dvorak J, Duranceau J, Yamamoto I, Gerber M, Rauschning W, et al. Three-dimensional movements of the upper cervical-spine. Spine 1988;13(7):726–30. Penning L. Normal movements of cervical-spine. American Journal of Roentgenology 1978;130(2):317–26. Penning L, Wilmink JT. Rotation of the cervical spine. A CT study in normal subjects. Spine 1987;12(8):732–8. Sforza C, Grassi G, Fragnito N, Turci M, Ferrario VF. Threedimensional analysis of active head and cervical spine range of



motion: effect of age in healthy male subjects. Clinical Biomechanics 2002;17(8):611–4. Spoor CW, Veldpaus FE. Rigid body motion calculated from spatial coordinates of markers. Journal of Biomechanics 1980;13(4):391–3. Triano JJ, Schultz AB. Motions of the head and thorax during neck manipulations. Journal of Manipulative and Physiological Therapeutics 1994;17(9):573–83. Van Roy P, Caboor D, De Boelpaep S, Barbaix E, Clarijs JP. Leftright asymmetries and other common anatomical variants of the first cervical vertebra. Manual Therapy 1997;2(1):24–36.

Van Roy P, Barbaix E, Clarys JP. Functional anatomy of the cervical spine. In: Spalski M, Gunzburg R, editors. The degenerative cervical spine. Philadelphia Lippincott: Williams & Wilkins; 2001. p. 3–27. Walmsley RP, Kimber P, Culham E. The effect of initial head position on active cervical axial rotation range of motion in two age populations. Spine 1996;21(21):2435–42. Woltring HJ, Huiskes R, Delange A, Veldpaus FE. Finite centroid and helical axis estimation from noisy landmark measurements in the study of human joint kinematics. Journal of Biomechanics 1985;18(5):379–89.

ARTICLE IN PRESS


Original article

Postural neck pain: An investigation of habitual sitting posture, perception of ‘good’ posture and cervicothoracic kinaesthesia Stephen J. Edmondstona,, Hon Yan Chana, Gorman Chi Wing Ngaia, M. Linda R. Warrena, Jonathan M. Williamsa, Susan Glennona, Kevin Nettoa,b a

School of Physiotherapy, Curtin University of Technology, P.O. Box U1987, Perth, Western Australia 6845, Australia b School of Science and Primary Industries, Charles Darwin University, Darwin, Northern Territory Received 6 February 2006; received in revised form 26 May 2006; accepted 13 July 2006

Abstract Impairments of cervico-cephalic kinaesthesia and habitual forward head posture have been considered important in the aetiology of postural neck pain, yet these factors have not been specifically examined in a homogeneous clinical population. The objective of this study was to compare the habitual sitting posture (HSP), perception of good posture and postural repositioning error (PRE) of the cervico-thoracic (CT) spine in individuals with postural neck pain, with a matched group of asymptomatic subjects. Twenty-one subjects with postural neck pain and 22 asymptomatic control subjects were recruited into the study. An optical motion analysis system was used to measure the HSP and perceived ‘good’ sitting posture. PRE was measured over six trials where the subject attempted to replicate their self-selected ‘good’ posture. There was no difference between the groups in the HSP but significant differences were identified in the perception of ‘good’ posture. Posture repositioning error was higher for the head posture variables than for CT and shoulder girdle variables in both groups. However, there was no significant difference in posture repositioning error between groups for any of the posture measures. The findings suggest that individuals with postural neck pain may have a different perception of ‘good’ posture, but no significant difference in HSP or kinaesthetic sensibility compared with matched asymptomatic subjects. r 2006 Elsevier Ltd. All rights reserved. Keywords: Posture; Pain; Kinaesthesia; Cervico-thoracic

1. Introduction Postural neck pain is usually associated with sustained static loading of the cervical spine and shoulder girdle during occupational or leisure activities (Tittiranonda et al., 1999; May and McKenzie, 2002). Since the prevalence of neck and shoulder girdle pain in office workers using computers may be as high as 31%, identification of the aetiological factors is important in relation to prevention and treatment of this disorder (Bernard et al., 1994; Yu and Wong, 1996). Within this clinical population, elevated levels of muscle activity Corresponding author. Tel.: +61 8 9266 3665; fax: +61 8 9266 3699. E-mail address: [email protected] (S.J. Edmondston).


when sitting, or habitual postures which increase the load on non-contractile tissues have been considered important intrinsic factors contributing to the development of the symptoms (Maigne, 2000; Westgaard et al., 2001; Szeto et al., 2005a, b). Habitual postures of the head and neck vary considerably between individuals within the general population (Raine and Twomey, 1997). Consequently, cross-sectional studies have generally not found differences in habitual posture in subjects with neck pain, compared to those who are pain-free (Griegel-Morris et al., 1992; Refshauge et al., 1995; Grimmer, 1996, 1997). Conversely, case–control studies have shown significant differences in habitual and work postures in individuals with a history of neck pain, compared to asymptomatic subjects (Watson and Trott, 1993; Szeto


S.J. Edmondston et al. / Manual Therapy 12 (2007) 363–371

et al., 2002; Szeto et al., 2005b). The between-group differences in these postural measures have generally been small, raising doubts about their importance in the aetiology of the symptoms. However, it has been suggested that small changes in head position in the sagittal plane can result in a significant increase in the load on supporting structures, and the related level of muscle activity (Harms-Ringdahl et al., 1986; Straker et al., 1997). Consideration of postures in relation to the extremes of range may be important in order to make comparisons between individuals and between groups. To date, there have been few studies which have compared cervicothoracic postures of individuals with postural neck pain, with matched asymptomatic control subjects, or compared end-range referenced postures between these groups. The control of neck posture and movement is dependent on appropriate motor responses to mechanoreceptive input from joints and muscle spindles (Kristjansson, 2005). An impairment of kinaesthetic sense has been found to reduce the accuracy of postural repositioning following movement in patients with whiplash-related neck pain (Heikkila and Astrom, 1996; Heikkila and Wenngren, 1998; Treleaven et al., 2003). This impairment of neck function is more evident in patients with moderate to severe pain (Sterling et al., 2004). In contrast, kinaesthetic deficits have been less clearly identified in patients with non-traumatic neck pain, or patients with less severe whiplash-related pain (Rix and Bagust, 2001; Armstrong et al., 2005; Zito et al., 2006). One factor contributing to the development and maintenance of postural neck pain may be an impairment of kinaesthetic sensibility, such that these individuals may adopt postures which place greater load on the neck. Similarly, the ability to locate and maintain more neutral postures of the head and neck may also be reduced in patients with postural neck pain. Habitual posture, perception of good posture and postural repositioning error (PRE) have not been adequately examined in the clinical subgroup of patients with postural neck pain. The potential role of these factors in the aetiology of postural neck pain may be better determined where there is greater homogeneity within the patient group in relation to age, neck mobility, aetiology and pain-related activity. The objective of this study was to compare the habitual posture, perception of good posture and PRE between individuals with postural neck pain and matched asymptomatic control subjects. 2. Materials and methods 2.1. Study design This study used a cross-sectional observational design to compare habitual sitting posture (HSP), perceived

‘good’ posture and posture repositioning error between individuals with postural neck pain and matched asymptomatic subjects. 2.2. Subjects Twenty-one subjects with postural neck pain and 22 asymptomatic controls were recruited through poster advertising. The inclusion criteria for the postural neck pain group were pain which was aggravated by sustained postural loading and relieved by postural modification, no restriction of cervico-thoracic (CT) mobility, a symptom duration of greater than 3 months and aged between 20 and 45 years. The patients were required to experience neck pain on at least 1 day/week over the previous 3 months. Subjects with any medical condition affecting cervical mobility, neurological symptoms or those who had received formal postural education were excluded. Subjects in the control group were aged between 20 and 45 years and had no current neck pain, and no history of neck pain requiring medical evaluation or physical treatment. They were also required to have full range, pain-free mobility in the cervical spine. The institutional Human Research Ethics Committee granted approval for the study, and all participants provided written informed consent. 2.3. Apparatus To measure the dependent variables, a seven camera, synchronized, three-dimensional optical motion analysis system (PEAK Performance Technologies Inc., Centennial, CO, USA) was used. The cameras were placed in a dual ring setup with four cameras placed at 2 m above the ground in an 8 m diameter ring and three cameras positioned in a 4 m diameter ring overhead. Additionally, a digital video camera was set up orthogonal to the subject to capture qualitative synchronized, real-time footage of the test procedure. Prior to data collection, the motion analysis system was calibrated to a maximum of 5 mm error range. All motion data was collected at 50 Hz and the system was controlled by PEAK Motus 8.2 data acquisition software (PEAK Performance Technologies Inc, Centennial, CO, USA) running on a desktop computer (Intels Pentium 4 CPU 2 GHz.AT/AT compatible). 2.4. Procedure All subjects completed a questionnaire about the history and behaviour of their neck pain to ensure fulfilment of the group inclusion criteria. Pain intensity was measured using a 100 mm visual analogue scale (VAS), and subjects were required to indicate their average pain intensity during the pain-related activity, over the previous week. Subjects were also asked to

ARTICLE IN PRESS S.J. Edmondston et al. / Manual Therapy 12 (2007) 363–371

estimate the duration of the neck pain disorder. Height and weight were measured for all subjects using a stadiometer and electronic personal scale (Camry EB6271). An examination of active cervical range of motion was conducted in order to determine that unidirectional mobility was not restricted or painful in the cardinal planes, consistent with the inclusion criteria. The subject was seated on a 41 cm wooden stool with feet placed flat on the floor and arms resting comfortably on their thighs, and asked to face forward for the duration of the testing. The subject was suitably disrobed to allow skin marker placement. Anatomical landmarks for the reflective markers were located by an experienced physiotherapist, and confirmed by a second investigator. Using double-sided tape, 1.5 cm reflective markers were applied bilaterally over the lateral margin of the orbit, tragus of the ear and postero-lateral acromion, and over the C7 and T4 spinous processes, and the sternal notch. An extra two virtual markers were created using the four markers on the head. The first virtual marker was defined as the vector mid-point between the two anterior (lateral orbit margin) markers with the second virtual marker defined by the vector mid-point of the two posterior (tragus) markers. These virtual markers allowed the creation of an imbedded right-hand Cartesian coordinate system that was used to describe the orientation of the four-marker segments on the head. This system was placed on the second virtual marker and was facilitated by the creation of unit vectors between the various markers of the four-marker segments. A second system was imbedded on the C7 marker and described the angle between C7 and the posterior head. Direction cosines were obtained from both systems and these were used to calculate the values of head tilt (HT) and head protraction (HP) (Fig. 1). During pilot testing, this method of obtaining angular data was shown to be highly reliable (r240.95) when head flexion–extension range of movement obtained from motion analysis was compared to data simultaneously obtained from an electromagnetic tracking device (3-Space Fastrak, Polhemus Navigation Sciences Division, Vermont, USA). 2.5. Range of motion, habitual sitting posture and referenced habitual sitting posture Subjects were familiarized with cervicothoracic protraction and retraction movements using standardized verbal instruction, active-assisted movement and active movement. Each subject then completed three movement trials to the end of available range of CT protraction and retraction. During these movements, subjects were instructed to look forward at the wall in front, and the movement was monitored to ensure localization of movement to the cervicothoracic spine

365

Fig. 1. Stick figure diagram with embedded 3-axis Cartesian coordinate system in head and neck. The postural variable HP is a combination angle that added HT to a neck tilt angle that was defined as the angle between unit vector u of the neck and the global z-axis unit vector in the direction cosine matrix, obtained from a flexion/ extension, lateral flexion and rotation sequence order.

and shoulder girdle. Data was captured over a 15-s period with a one minute interval between trials. The HSP was defined as the position adopted when the subject relaxed following the protraction and retraction movements. The subjects were unaware of the video capture at the time the habitual posture was recorded. For each trial, the range of protraction and retraction movement was obtained and the mean of the three trials was calculated. HSP was analysed from 1 s of data capture during the relaxed period. Using the same data capture, the referenced habitual sitting posture (RefHSP) was obtained. This was calculated by subtracting the values for HSP from the end of range protraction values resulting in an angular measure of distance from end range. A mean RefHSP from the three protraction/retraction range of motion trials was then calculated for each subject. 2.6. Perceived good posture The subject was blindfolded and instructed to move from relaxed sitting into what they perceived to be a good posture (PGP). The investigator provided no feedback or guidance during this movement. Data was captured over a 10-s period, and posture variables were calculated from 1 s of footage between seconds eight and nine of the data capture.



2.7. Posture repositioning error The subject remained blindfolded and was instructed to relocate the perceived good posture as accurately as possible, commencing from a fully relaxed posture. No further feedback or guidance was provided by the investigator. In order to optimize the accuracy and precision of the posture repositioning test, six repositioning trials were completed for each subject, with a one minute interval between trials (Allison and Fukushima, 2003). Analysis of 1 s of data capture of each trial was conducted and the resultant mean used to determine PRE. The PRE was quantified by 4 dependent variables which represented HT, CT angle, shoulder protraction (ShP) and HP. These measures represent the position of the head, neck and shoulder girdle which were considered the key elements of cervicothoracic posture. 2.8. Posture variables The posture variables used in the analysis of the habitual and perceived good posture, and the posture repositioning error were as follows. 2.8.1. Head tilt (HT) The angle between the unit vector u of the head and the global z-axis unit vector in the direction cosine

matrix, obtained from a flexion/extension, lateral flexion and rotation sequence order (Fig. 2). 2.8.2. Cervico-thoracic angle (CT) This is defined as the angle formed by the intersection of lines connecting the tragus marker and the C7 spinous process marker, and the C7 spinous process marker and the T4 marker (Fig. 2). 2.8.3. Shoulder protraction (ShP) This was formed from a line connecting the posterior lateral acromion marker to the C7 spinous process marker and the unit vector of the Y-axis at the level of the C7 spinous process marker (Fig. 2). 2.8.4. Head protraction (HP) A combination angle that added HT to a neck tilt angle that was defined as the angle between unit vector u of the neck and the global z-axis unit vector in the direction cosine matrix, obtained from a flexion/ extension, lateral flexion and rotation sequence order (Fig. 2). 2.9. Data processing Skin markers were manually identified and automatically digitized. The direct linear transformation (DLT) method was used to obtain three-dimensional coordinates of the markers and these coordinates were smoothed at 4 Hz using a second-order low-pass Butterworth digital filter. These smoothed data were then used to calculate the angles described in the preceding paragraphs. All processing was performed using the PEAK Motus 8.2 analysis software (PEAK Performance Technologies Inc., Centennial, CO, USA). 2.10. Statistical analysis

Fig. 2. Marker placement and angular measurements used to define the postural variables. Head tilt is the angle a–c–b, cervico-thoracic angle is the angle c–d–e, and shoulder protraction is the angle f–d–g.

All statistical analyses were performed using SPSS Version 12.0 software. Descriptive statistics were used to summarize the postural measures and reposition errors for each group. The Shapiro–Wilk test for normality showed all variables were normally distributed except for the CT angle of the RefHSP, and the HT and HP data in the PRE study. For each posture variable, between group comparisons were conducted using independent t-tests where the data sets were normally distributed and Mann–Whitney U-tests where the data sets were not normally distributed. In addition, the Pearson or Spearman correlation analyses were used to examine the linear relationship between pain severity and PRE. The criterion for statistical significance was set at Po0.05.


3. Results The characteristics of the subjects are presented in Table 1. The postural neck pain and control groups were matched for gender, and there was no significant difference between groups in age, weight and height. No significant difference in range of protraction and retraction existed between the groups (Table 2). HSPs were very similar between groups. The biggest differences were in the HT and HP (3.21 and 3.41, respectively) but these differences were not significant (Table 3). Similarly, there was no difference between groups when the habitual postures were referenced to the end-range positions (Table 3). For the perceived good posture, HP was 4.61 greater (t ¼ 2:03; Po0.05), and HT was 4.51 less (t ¼ 2:04; Po0.05) in the pain group. There was no significant between-group difference in CT angle or ShP (Table 4). There were no significant differences between groups in posture repositioning error for all postural variables measured (Fig. 3). In both groups a larger PRE was found for the variables relating to head position

Table 1 Characteristics of the subject groups presented as group mean (SD) and range Pain group (n ¼ 21)

10 12 25.7 (5.95) 20.0–45.0 71.2 (13.63) 48.8–98.7 170.9 (8.64) 158.0–184.0 —

10 11 29.0 (7.36) 20.0–45.0 72.9 (13.52) 46.1–102.2 170.4 (10.79) 150.5–187.5 48.3 (14.81) 25.8–71.9 5.2 (4.28)

—

P

Pain

CT HT HP ShP

16.0 20.0 42.7 11.7

16.0 19.8 40.4 11.8

(4.31) (6.77) (7.25) (3.24)

CT ¼ cervicothoracic, HT ¼ head ShP ¼ shoulder protraction.

tilt,

HP ¼ head

Pain

P

CT

HSP RefHSP

157.0 (6.22) 3.8 (3.0)

158.0 (5.75) 2.8 (4.3)

0.460 0.148

HT

HSP RefHSP

68.0 (7.26) 11.0 (6.59)

64.8 (5.41) 11.8 (7.00)

0.117 0.715

HP

HSP RefHSP

166.6 (6.82) 25.6 (4.47)

170.0 (8.24) 22.9 (6.96)

0.143 0.140

ShP

HSP RefHSP

11.9 (6.33) 4.1 (2.18)

11.7 (4.74) 4.8 (2.51)

0.899 0.311

RefHSP ¼ angular difference between the HSP and the fully protracted posture.

Table 4 Mean (SD) angles for perceived ‘good’ posture P-value

Angle

Control

Pain

CT HT HP ShP

151.5 64.4 165.0 11.8

153.6 59.8 169.6 12.7

(4.91) (7.78) (7.85) (6.08)

CT ¼ cervicothoracic, HT ¼ head ShP ¼ shoulder protraction. *Po0.05.

6 0.67 0.86

P-value (5.82) (7.34) (8.47) (4.63)

Control

tilt,

(5.87) (7.00) (7.25) (5.27)

HP ¼ head

0.21 0.04* 0.04* 0.61 protraction,

7

Table 2 Mean (SD) range of each posture variable which was defined as the difference between the angles recorded in end-range protraction and retraction Control

Angle

0.11

0.5–20.0

Angle

Table 3 Mean (SD) angles for habitual sitting posture (HSP) and referenced habitual sitting posture (RefHSP)

0.99 0.93 0.36 0.90 protraction,

Repositioning Error (Degrees)

Male Female Age (years) Range Weight (kg) Range Height (cm) Range VAS (/100) Range Symptom Duration (years) Range

Control group (n ¼ 22)

367

Control Pain

5 4 3 2 1 0 CT Angle

Head Tilt

Cx Protraction

Sh Protraction

Fig. 3. Posture repositioning error (mean and standard deviation) for each of the posture variables.

(HT and HP). Pain intensity was not significantly correlated with the PRE for any of the posture variables (CT r ¼ 0:03, ShP r ¼ 0:51, HT rs ¼ 0:51 and HP rs ¼ 0:17).



4. Discussion The aetiology of postural neck pain remains uncertain but is generally considered to be associated with poor postural awareness and habitual postures which result in greater load on the supporting structures (Farfan, 2000; Neumann, 2002). Postural neck pain is further defined by the absence of an impairment of CT motion (Grant and McKenzie, 1994). In the present study, there was no difference in the range of CT spine protraction and retraction, or the associated movements of the shoulder girdle in the subjects with postural pain, when compared to the asymptomatic control group. Equality of functional range of motion highlighted the homogeneity of the two groups and confirmed that mobility impairment would not impact on the performance of the testing procedures. Individuals who had received physical treatment for their neck pain were excluded from this study and it is possible that these patients may have had higher pain intensity, and possibly more significant postural change and kinaesthetic deficits. Most of the symptomatic subjects reported a mild to moderate pain intensity and this should be acknowledged in the interpretation of the results. Previous studies examining the relationship between cervicothoracic posture and pain have identified subjects with neck pain retrospectively, or have included heterogeneous groups of subjects with neck pain. These studies have generally found no difference in habitual posture in the subjects with neck pain, or when differences have been significant, the magnitude of difference is small (Griegel-Morris et al., 1992; Watson and Trott, 1993; Refshauge et al., 1995; Grimmer, 1996). In order to promote the homogeneity of the symptomatic group in the present study, subjects with neck pain were included only where pain was predominantly provoked by sustained sitting postures. However, the differences in habitual posture were small compared to the control subjects. The symptomatic group tended to adopt postures with greater HP and upper cervical extension, but these differences were less than 41 compared to the control group. Consistent with this finding, Szeto et al. (2005b) reported a difference of only 3.91 in head flexion angle between subjects with neck pain and asymptomatic control subjects when performing a computer task. These findings suggest that while individuals with postural neck pain may adopt habitual postures with greater HP and upper cervical extension, the differences are small compared to asymptomatic individuals. The posture of the cervicothoracic spine relative to the extremes of range may be considered more relevant to the development of pain than the unreferenced posture. End-range postures increase the load on supporting structures, which over time may lead to the development of tissue sensitization and pain (HarmsRingdahl et al., 1986; White et al., 1991). This issue has

been considered in the lumbar spine, but not in previous studies which have examined cervicothoracic posture (O’Sullivan et al., 2006). However, in the present study there was no significant difference in referenced HSP, for all variables, between the postural pain and control groups. Therefore, the concept of end-range loading as an aetiological factor in the development of postural cervicothoracic pain is not supported by the findings of this study. In both subject groups, the habitual postures were considerably short of the extreme of range where higher levels of passive tissue loading are likely to occur. There is a widely held belief in the value of a ‘good’ posture, and ideal postures have been described for the CT spine which promote optimal patterns of load transfer and muscle activity (White and Sahrmann, 1994; Kendall et al., 2005). A novel concept examined in this study was the perception of a good (or correct) sitting posture. Subjects with postural neck pain perceived the correct posture to be one with significantly more HP and upper cervical extension than the control group. Individuals with postural neck pain may have a different perception about posture and posture correction compared to asymptomatic individuals. Alternatively, some individuals with postural neck pain may have difficulty adopting the intended posture due to an impairment of postural kinaesthetic sense. While impairments of kinaesthetic function have been identified in some studies examining the effects of neck pain, the extent to which these are present within different patient subgroups remains uncertain. The results of this study showed that in individuals with non-traumatic postural neck pain, there were no significant differences in PRE compared to matched, asymptomatic control subjects. In the present study, the magnitude of the PRE was not significantly associated with pain intensity. These findings are consistent with previous studies that have found no significant impairment of kinaesthesia in subjects with non-traumatic neck pain, or with whiplash associated disorder with mild disability (Rix and Bagust, 2001; Armstrong et al., 2005; Zito et al., 2006). In contrast, impairments of cervical kinaesthesia have been identified in individuals with whiplash-related neck pain, particularly where the severity of pain and disability are relatively high (Heikkila and Astrom, 1996; Loudon et al., 1997; Heikkila and Wenngren, 1998; Treleaven et al., 2003; Sterling et al., 2004). The differences between studies may reflect different methods of testing, different pain and disability levels, or differences in pathology underlying the symptoms. However, it is becoming increasingly apparent that impairments of kinaesthetic sense may not be a significant clinical feature of nontraumatic neck pain. In most studies examining spinal kinaesthesia, subjects are required to replicate a posture, or position defined by the investigator. In contrast, the subjects in


the present study were asked to replicate a self-selected posture. The ‘correct’ posture adopted by the subject may reflect an innate postural characteristic or intrinsic movement pattern, which may be relatively easy for the individual to reproduce (Christensen and Nilsson, 1999). An investigator selected posture, or an unfamiliar posture, may have resulted in a greater difference in PRE between groups, however this issue was not examined and would require further investigation. The three-dimensional motion analysis technique used in this study enabled PRE to be examined simultaneously in multiple related body segments. Most previous studies have quantified PRE as one dependent variable, which generally considers the position of the head (Rix and Bagust, 2001; Kristjansson et al., 2003; Armstrong et al., 2005). Evaluation of components of CT posture and movement provides a broader evaluation of posture and kinaesthesia, which may have greater relevance to the clinical setting. While the difference in habitual postures adopted by the symptomatic and control groups were small, it is possible that the level of muscle activity associated the maintenance of the posture may have been different between the groups. Higher levels of neck muscle activity have been identified in office workers with neck pain compared to those who are asymptomatic (Vasseljen and Westgaard, 1995; Westgaard et al., 2001). Alternatively, the patterns of neck and shoulder girdle muscle activity may be influenced by the posture being adopted. The relative levels of activity in the paravertebral and axio-scapula muscles during computer work has been shown to be different in subjects with neck pain compared to asymptomatic subjects (Szeto et al., 2005a). Similarly, changing from a relaxed to a more upright posture has been shown to change the relative levels of activity in the muscles of the cervical spine and shoulder girdle (Fountain et al., 1966; Basler et al., 1997). Consequently, although the differences in the habitual posture between groups were small in the present study, the magnitude and distribution of load on the cervical spine may have been different due to the relative levels of muscle activity required to maintain the posture. A number of factors not considered in this study may be important in the aetiology of postural neck pain. All subjects in this study were employed in sedentary occupations which required prolonged periods of computer and desk-based work. However, the actual time spent performing these activities each day was not controlled for, and may have been different between groups. Previous studies have shown that the prevalence of neck pain among people involved in sustained loading activities is related to the daily work hours (Waersted and Westgaard, 1991; Ariens et al., 2001b; Wergeland et al., 2003). Furthermore, the postures observed in a laboratory setting may not reflect those

369

adopted in the work setting, or changes in posture over time. However, it has been reported that differences between work and habitual postures tend to be small, and consistent between symptomatic and asymptomatic subjects (Szeto et al., 2002). Similarly, the individual variation in work posture over a 1 h duration is generally small during computer-based tasks (Szeto et al., 2005b). Finally, a range of psychosocial factors have been linked to the development of neck pain and the transition to chronicity (Linton, 2000). These include job stress, low job satisfaction, depression, low job control and poor general health (Torp et al., 2001; Ariens et al., 2001a; Korhonen et al., 2003; Ostergren et al., 2005). Evaluation of these factors was considered beyond the scope of this study but their potential contribution to the development of postural neck pain must be acknowledged.

5. Conclusions The findings of this study suggest that postural neck pain is not associated with habitual postures or kinaesthetic sensibility which are different from those of matched asymptomatic subjects. A significant difference in the perception of good posture was evident in individuals with postural neck pain compared to the asymptomatic group, but the magnitude of the difference was relatively small. Future studies examining the aetiology of postural neck pain should focus on physical factors influencing loading of the cervical spine, such as patterns of muscle activity, and work-related factors such as job demand and daily workload.

Acknowledgements The authors acknowledge with appreciation the technical assistance provided in this study by Mr. Paul Davey, Research Assistant. The statistical advice of Dr. Ritu Gupta, Department of Mathematics & Statistics, Curtin University of Technology is also acknowledged. References Allison G, Fukushima S. Estimating three dimensional spinal repositioning error: the impact of range, posture and number of trials. Spine 2003;28:2510–6. Ariens G, van Mechelen W, Bongers P, Bouter L, van der Wal G. Psychosocial risk factors for neck pain: a systematic review. American Journal of Industrial Medicine 2001a;39:180–93. Ariens GAM, Bongers PM, Douwes M, Miedema MC, Hoogendoorn WE, van der Wal G, et al. Are neck flexion, neck rotation, and sitting at work risk factors for neck pain? Results of a prospective cohort study. Occupational and Environmental Medicine 2001b;58:200–7.



Armstrong BS, McNair PJ, Williams M. Head and neck position sense in whiplash patients and healthy individuals and the effect of the cranio-cervical flexion action. Clinical Biomechanics 2005;20: 675–84. Basler HD, Keller S, Herda C. Good postural habits: a pilot investigation using EMG scanning of the paraspinals. Applied Psychophysiology and Biofeedback 1997;22:171–82. Bernard B, Sauter S, Fine L, Petersen M, Hales T. Job task and psychosocial risk factors for work-related musculoskeletal disorders among newspaper workers. Scandinavian Journal of Environmental Health 1994;20:417–26. Christensen HW, Nilsson N. The ability to reproduce the neutral zero position of the head. Journal of Manipulative and Physiological Therapeutics 1999;22:26–8. Farfan HF. The thoracic spine and the tired neck syndrome. In: Giles LGF, Singer KP, editors. Clinical anatomy and management of thoracic spine pain. Oxford: Butterworth-Heinemann; 2000. p. 171–6 [Chapter 11]. Fountain FP, Minear WL, Allison RD. Function of Longus Colli and Longissimus Cervicis muscles in man. Archives of Physical Medicine and Rehabilitation 1966;47:665–9. Grant RN, McKenzie RA. Mechanical diagnosis and therapy for the cervical and thoracic spine. In: Grant R, editor. Physical therapy for the cervical and thoracic spine. 2nd ed. Edinburgh: Churchill Livingstone; 1994. p. 359–78 [Chapter 17]. Griegel-Morris P, Larson K, Mueller-Klaus K, Oatis CA. Incidence of common postural abnormalities in the cervical, shoulder, and thoracic regions and their association with pain in two age groups of healthy subjects. Physical Therapy 1992;72:425–9. Grimmer K. The relationship between cervical resting posture and neck pain. Physiotherapy 1996;82:45–52. Grimmer K. An investigation of poor cervical resting posture. Australian Journal of Physiotherapy 1997;43:7–16. Harms-Ringdahl K, Ekholm J, Schuldt K, Nemeth G, Arborelius UP. Load moments and myoelectric activity when the cervical spine is held in full flexion and extension. Ergonomics 1986;29:1539–52. Heikkila H, Astrom P. Cervicocephalic kinesthetic sensibility in patients with whiplash injury. Scandinavian Journal of Rehabilitation Medicine 1996;28:133–8. Heikkila H, Wenngren B. Cervicocephalic kinesthetic sensibility, active range of cervical motion, and oculomotor function in patients with whiplash injury. Archives of Physical Medicine and Rehabilitation 1998;79:1089–94. Kendall FP, McCreary EK, Provance P, Rodgers M, Romani W. Testing and function with posture and pain, 5th ed. Baltimore: Lippincott Williams & Williams; 2005. Korhonen T, Ketola R, Toivonen R, Luukkonen R, Hakkanen M, Viikari-Juntura E. Work related and individual predictors for incident neck pain among office employees working with video display units. Occupational and Environmental Medicine 2003;60:475–82. Kristjansson E. The cervical spine and proprioception. In: Boyling J, Jull G, editors. Grieve’s modern manual therapy: the vertebral column. 3rd ed. Edinburgh: Churchill Livingstone; 2005. p. 243–56 [Chapter 18]. Kristjansson E, Dall’Alba P, Jull G. A study of five cervicocephalic relocation tests in three different subject groups. Clinical Rehabilitation 2003;17:768–74. Linton SJ. A review of psychological risk factors in back and neck pain. Spine 2000;25:1148–56. Loudon J, Ruhl M, Field E. Ability to reproduce head position after whiplash injury. Spine 1997;22:865–8. Maigne J-Y. Cervicothoracic and thoracolumbar spinal pain syndromes. In: Giles LGF, Singer KP, editors. Clinical anatomy and management of thoracic spine pain. Oxford: Butterworth-Heinemann; 2000. p. 157–69 [Chapter 10].

May S, McKenzie RA. Mechanical diagnosis and therapy for the cervical and thoracic spine. In: Grant R, editor. Physical therapy of the cervical and thoracic spine. 3rd ed. London: Churchill Livingstone; 2002. p. 355–73. Neumann DA. Kinesiology of the musculoskeletal system. St. Louis: Mosby Inc.; 2002 [Chapter 10, p. 341]. Ostergren P-O, Hanson BS, Balogh I, Ektor-Andersen J, Isacsson A, Orbaek P, for the Malmo Shoulder Neck Study Group, et al. Incidence of shoulder and neck pain in a working population: effect modification between mechanical and psychosocial exposures at work? Results from a one year follow up of the Malmo shoulder and neck study cohort. Journal of Epidemiology and Community Health 2005;59:721–8. O’Sullivan PB, Mitchell T, Bulich P, Waller R, Holte J. The relationship between posture and back muscle endurance in industrial workers with flexion-related low back pain. Manual Therapy 2006; in press. Raine S, Twomey L. Head and shoulder posture variations in 160 asymptomatic women and men. Archives of Physical Medicine and Rehabilitation 1997;78:1215–23. Refshauge K, Bolst L, Goodsell M. The relationship between cervicothoracic posture and the presence of pain. Journal of Manual and Manipulative Therapy 1995;3:21–4. Rix G, Bagust J. Cervicocephalic kinesthetic sensibility in patients with chronic, nontraumatic cervical spine pain. Archives of Physical Meicine and Rehabilitation 2001;82:911–9. Sterling M, Jull G, Vicenzino B, Kenardy J. Characterization of acute whiplash-associated disorders. Spine 2004;29:182–8. Straker L, Jones KJ, Miller J. A comparison of the postures assumed when using laptop computers and DT computers. Applied Ergonomics 1997;28:263–9. Szeto G, Straker L, Raine S. A field comparison of neck and shoulder postures in symptomatic and asymptomatic office workers. Applied Ergonomics 2002;33:75–84. Szeto G, Straker L, O’Sullivan P. A comparison of symptomatic and asymptomatic office workers performing monotonous keyboard work—1: neck and shoulder kinematics. Manual Therapy 2005a;10:281–91. Szeto G, Straker L, O’Sullivan P. A comparison of symptomatic and asymptomatic office workers performing monotonous keyboard work—2: neck and shoulder kinematics. Manual Therapy 2005b;10:270–80. Tittiranonda P, Burastero S, Rempel D. Risk factors for musculoskeletal disorders among computer workers. Occupational Medicine: State of the Art Reviews 1999;14:17–38. Torp S, Riise T, Moen B. The impact of psychosocial work factors on musculoskeletal pain: a prospective study. Journal of Occupational and Environmental Medicine 2001;43:120–6. Treleaven J, Jull GA, Sterling M. Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error. Journal of Rehabilitation Medicine 2003;35:36–43. Vasseljen O, Westgaard RH. A case–control study of trapezius muscle activity in office and manual workers with shoulder and neck pain and symptom-free controls. International Archives of Occupational and Environmental Health 1995;67:11–8. Waersted M, Westgaard RH. Working hours as a risk factor in the development of musculoskeletal complaints. Ergonomics 1991;34: 265–76. Watson DH, Trott PH. Cervical headache: an investigation of natural head posture and upper cervical flexor muscle performance. Cephalalgia 1993;13:272–84. Wergeland EL, Veiersted B, Ingre M, Olsson B, Akerstedt T, Bjornskau T, et al. A shorter workday as a means of reducing the occurrence of musculoskeletal disorders. Scandinavian Journal of Work, Environment and Health 2003;29:27–34.

ARTICLE IN PRESS S.J. Edmondston et al. / Manual Therapy 12 (2007) 363–371 Westgaard R, Vasseljen O, Holte K. Trapezius muscle activity as a risk indicator for shoulder and neck pain in female service workers with low biomechanical exposure. Ergonomics 2001;44: 339–54. White SG, Sahrmann SA. A movement system balance approach to management of musculoskeletal pain. In: Grant R, editor. Physical therapy for the cervical and thoracic spine. 2nd ed. Edinburgh: Churchill Livingstone; 1994. p. 339–57 [Chapter 16].

371

White DM, Taiwo YO, Coderre TJ, Levine JD. Delayed activation of nociceptors: correlation with delayed pain sensations induced by sustained stimuli. Journal of Neurophysiology 1991;66:729–34. Yu IT, Wong TW. Musculoskeletal problems among VDU workers in a Hong Kong bank. Occupational Medicine (London) 1996;46:275–80. Zito G, Jull G, Story I. Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache. Manual Therapy 2006;11:118–29.

ARTICLE IN PRESS


Original article

The use of surface electromyography as a tool in differentiating temporomandibular disorders from neck disorders Virgilio F. Ferrario, Gianluca M. Tartaglia, Francesca E. Luraghi, Chiarella Sforza Dipartimento di Morfologia Umana, Via Mangiagalli 31, I-20133 Milano, Italy Received 4 July 2005; received in revised form 6 March 2006; accepted 3 July 2006

Abstract The aim of this study was to assess the electromyographic characteristics of the masticatory muscles (masseter and temporalis) of patients with either ‘‘temporomandibular joint disorder’’ or ‘‘neck pain’’. Surface electromyography of the right and left masseter and temporalis muscles was performed during maximum teeth clenching in 38 patients aged 21–67 years who had either (a) temporomandibular joint disorder (24 patients); (b) ‘‘neck pain’’ (13 patients). Ninety-five control, healthy subjects were also examined. During clenching, standardized total muscle activities (electromyographic potentials over time) were significantly different in the three groups: 75 mV/mV s % in the temporomandibular joint disorder patients, 124 mV/mV s % in the neck pain patients, and 95 mV/mV s % in the control subjects (analysis of variance, Po0:001). The temporomandibular joint disorder patients also had significantly (Po0:001) more asymmetric muscle potentials (78%) than either neck pain patients (87%) or control subjects (92%). A linear discriminant function analysis allowed a significant separation between the two patient groups, with a single patient error of 18.2%. Surface electromyographic analysis during clenching allowed to differentiate between patients with a temporomandibular joint disorder and patients with a neck pain problem. r 2006 Elsevier Ltd. All rights reserved. Keywords: Temporomandibular disorders; Head pain; Neck pain; Electromyography

1. Introduction Pain, either in the face, head or neck, is the almost universal complaint of the patients seeking dental care. On some occasions, the origin of this pain remains uncertain, even after the execution of all the conventional clinical and instrumental diagnostic procedures. Diagnosis is therefore of a generic ‘‘cranio-faciocervical’’ dysfunction, and therapeutic procedures are focused only on the solution of the symptom, namely pain relief (Ash and Ramfjord, 1995; DeVocht et al., 2003). Some of these cranio-facio-cervical dysfunctions could be categorized as temporomandibular disorders Corresponding author. Tel.: +39 02 503 15407; fax: +39 02 503 15387. E-mail address: [email protected] (V.F. Ferrario).


(TMD). TMD is a complex disease, and its nature is not completely understood yet (Ash and Ramfjord, 1995; Visser et al., 1995; De Wijer et al., 1996; Gross et al., 1996; Liu et al., 1999; Alcantara et al., 2002; Landulpho et al., 2004). A large number of TMD patients report pain in the masticatory muscles, and present symptoms and signs of muscular alteration (Visser et al., 1995; De Wijer et al., 1996; Sato et al., 1998; Liu et al., 1999; Pinho et al., 2000; John et al., 2003; Suvinen et al., 2003; Landulpho et al., 2004). Among the several treatments used in the TMD patients, occlusal splints, a conservative and reversible therapy, can reduce pain in most cases (Nemcovsky et al., 1992; Ash and Ramfjord, 1995; Ferrario et al., 2002; Landulpho et al., 2004). In contrast, in other patients the occlusal splints are not beneficial, and pain remains a major problem. These patients often present cervical pain as their main complaint. Indeed, significant associations between neck

ARTICLE IN PRESS V.F. Ferrario et al. / Manual Therapy 12 (2007) 372–379

pain and temporomandibular joint (TMJ) dysfunction have been demonstrated (Ciancaglini et al., 1999; Alcantara et al., 2002; Visscher et al., 2002), with some overlap between ‘‘stomatognathic’’ and cervical symptoms in both TMJ and neck disorders (De Wijer et al., 1996). The stomatognathic apparatus comprises all the head and upper cervical structures pertaining to the digestive apparatus, including the oral cavity, teeth with supporting bones and gengivae, the tongue, salivatory glands, the pharynx, the masticatory muscles and TMJ. Cervical muscles are also involved in TMJ dysfunctions, and patients can exhibit a more flexed head position than normal individuals of the same age and sex (Lee et al., 1995), even if non-significant differences have also been reported (Visscher et al., 2002). In healthy individuals mandibular and neck muscles act coordinately in an integrated structure, and alterations in one part can derange also the other one (Eriksson et al., 2004). The assessment of the electromyographic (EMG) characteristics of cervical and head muscles may allow a deeper insight into this coupling in both health and disease (Pinho et al., 2000; Ferrario et al., 2002; Suvinen et al., 2003). Previous investigations analysed masticatory function in patients with TMJ alterations, and found EMG a useful diagnostic tool (Sato et al., 1998; Pinho et al., 2000; Landulpho et al., 2004). EMG has also provided valuable information in patients with chronic neck pain (Falla, 2004). On no occasion was stomatognathic function of patients with TMJ alterations compared to that of patients with cervical pain as the principal symptom. In the present study, the EMG characteristics of two groups of patients with either TMJ alteration or neck pain have been analysed. The null hypothesis was that the subjects in the two analysed groups had no differences in the EMG characteristics of their masseter and temporalis muscles during standardized teeth clenching. Patient data were also compared to those collected in healthy young subjects with a good occlusion, a group used to provide an external reference of normality.

2. Materials and methods 2.1. Patients One hundred and thirty-three subjects aged 18–67 years were examined. Thirty-eight were patients referring to a dental clinic for the treatment of craniocervical pain, who reported subjective symptoms of pain in the orofacial and neck regions. After physical and radiographic examination of the neck and stomatognathic apparatus (De Wijer et al., 1996; Bogduk, 1999) and considering the subjective information gathered during

373

the clinical history, the patients were subdivided into two non-overlapping groups: (a) ‘‘TMJ disorder’’ (17 women and seven men, age range 21–66 years, mean 35, SD 14); (b) ‘‘neck pain’’ (11 women and three men, age range 30–67 years, mean 48, SD 17). Physical examination included palpation of the masticatory and neck muscles, palpation of the TMJ, examination of the oral cavity with teeth and supporting structures, assessment of the TMJ and neck movements. The TMJ disorder patients had internal derangement with or without reductions, capsulitis, synovitis, masticatory muscle myalgia with articular dysfunction, arthrosis, arthritis with or without arthralgia. Pain (either in the TMJ area or over the masticatory muscles, both spontaneous and during palpation) ranged from moderate to severe, with limited active mouth opening and mandible laterodeviations on mouth opening. In all patients pain duration was inferior to 6 months. Clicking and other TMJ sounds were also detected. In contrast, the ‘‘neck pain’’ patients had craniocervical pain without TMJ dysfunction (Ash and Ramfjord, 1995; De Wijer et al., 1996; Bogduk, 1999; Visscher et al., 2002). The neck pain patients reported a generalized neck pain (moderate to severe in intensity, exacerbated by palpation), which was indicative of myalgia, together with a limitation in the amplitude of the active head and neck movements. Anamnesis was negative for whiplash injuries; pain duration was inferior to 6 months. Radiographic examination of the cervical spine was negative for anatomical alterations. The patients entered the study consecutively, but all patients who fall in both categories were excluded, and replaced by other subjects. None of them had systemic diseases involving the locomotor apparatus, vestibular or neurological problems, or anatomical alterations of the cervical spine. All patients had a complete dentition, with at least 24 elements (all natural teeth or partial fixed prostheses), with no crossbite. They had no periodontal problems, or acute inflammatory oral diseases. Ninety-five control subjects (28 women and 67 men, age range 18–22 years, mean 20, SD 2) were also examined. All of them had a complete natural dentition (28 teeth at least), no crossbite, and were free from periodontal problems and acute inflammatory oral diseases. Exclusion criteria in the control group were past or present signs or symptoms of TMD (muscular or TMJ pain, TMJ noises, limitations on mouth opening, mandible laterodeviations on mouth opening), neck problems (including whiplash injuries), systemic diseases. These subjects were used to provide an external reference of normality, with healthy occlusal conditions. All the procedures were non-invasive, and performed with minimal disturbance to the subjects. The subjects were previously informed about all the adopted procedures, and they all signed an informed consent form approved by the local ethic committee.


V.F. Ferrario et al. / Manual Therapy 12 (2007) 372–379

2.2. EMG recordings and measurements 2.2.1. Instrumentation The masseter and anterior temporalis muscles of both sides (left and right) were examined. Disposable silver/ silver chloride bipolar surface electrodes with a diameter of 10 mm and an interelectrode distance of 2171 mm (Duo-Trode; Myo-Tronics Inc., Seattle, WA, USA) were used, while a disposable reference electrode was applied to the forehead. Bipolar surface electrodes were positioned on the muscular bellies parallel to muscular fibres as previously described (Ferrario et al., 2002): temporalis anterior: vertically along the anterior margin of the muscle (about on the coronal suture); masseter: parallel to the muscular fibres, with the upper pole of the electrode at the intersection between the tragus-labial commissura and the exocanthion-gonion lines. To reduce skin impedance, the skin was carefully cleaned prior to electrode placement, and recordings were performed 5– 6 min later, allowing the conductive paste to adequately moisten the skin surface. EMG activity was recorded using a computerized instrument (Freely, De Go¨tzen srl; Legnano, Milano, Italy). The analogue EMG signal was amplified (gain 150, bandwidth 0–10 KHz, peak-to-peak input range from 0 to 2000 mV) using a differential amplifier with a high common mode rejection ratio (CMRR ¼ 105 dB in the range 0–60 Hz, input impedance 10 GO), digitized (12 b resolution, 2230 Hz A/D sampling frequency), and digitally filtered (high-pass filter set at 30 Hz, low-pass filter set at 400 Hz, band-stop for common 50–60 Hz noise). The signals were averaged over 25 ms, with muscle activity assessed as the root mean square (r.m.s.) of the amplitude (unit: mV). EMG signals were recorded for further analysis.

2.2.2. Standardization recording (clenching on cotton rolls) At first, a standardization recording was performed. This would provide reference EMG values for a subsequent normalization. Two 10-mm thick cotton rolls were positioned on the mandibular second premolar/ first molars of each patient, and a 5-s maximum voluntary clench (MVC) was recorded. For each of the four analysed muscles (right and left masseter and temporalis), the mean EMG potential (r.m.s. of the amplitude) was set at 100%, and all EMG potentials obtained during MVC directly performed on the occlusal surfaces (see below) were expressed as a percentage of this value (unit: mV/ mV 100). During all recordings, the patients sat with their head unsupported and were asked to maintain a natural erect position. They were invited to clench their teeth as hard as possible.

2.2.3. MVC directly on occlusal surfaces EMG activity was recorded during a 5-s MVC test in intercuspal position: the patient was invited to clench as hard as possible with the maxillary and mandibular teeth in maximum contact, and to maintain the same level of contraction for all the recording. For each patient, the best (those with the most constant r.m.s. EMG signal) 3 s of the MVC test were then automatically selected by the EMG software, and the EMG potential were normalized as detailed before (EMG amplitude on occlusal surfaces divided for the mean EMG amplitude of the normalization record on the cotton rolls). Subsequently, the mean (left and right masseter and temporalis) total muscle activities were computed as the areas of the standardized EMG potentials (normalized r.m.s. amplitude) over time (unit: mV/mV s %) (Ferrario et al., 2004). Muscle activity has already been used as a global index of the masticatory muscle work performed during both dynamic and static tasks (Ferrario et al., 2004, 2006). The EMG waves of paired muscles were compared by computing a percentage overlapping coefficient (POC, unit: %) (Ferrario et al., 2000). POC is an index of the symmetric distribution of the muscular activity as determined by occlusion; it is computed by superimposing the left and right side normalized EMG amplitudes of a muscle (masseter or temporalis) over time: the area of superimposition is assessed as a percentage of the total EMG amplitudes. The index ranges between 0% and 100%: when two paired muscles contract with perfect symmetry, a POC of 100% is obtained (EMG amplitudes completely superimposed). Mean (masseter and temporalis) POCs were obtained for each patient. Considering the direction in the lateral plane of the muscular fibres relative to the cranium (fixed bone) and the mandible (mobile bone), the two muscles assessed in the current study act in an opposite direction: the superficial part of the masseter muscle goes craniocaudally and anterior-to-posterior, while the temporalis anterior goes cranio-caudally and posterior-to-anterior. A muscular couple is therefore generated when the contralateral masseter and temporalis muscles (for instance, right temporalis and left masseter) contract (Ferrario et al., 2000). If only one muscular couple is activated, unbalanced by a similar contraction of the other muscular couple, a potential lateral displacing component acting on the mandible might occur. The Torque coefficient (TC, unit %) (Ferrario et al., 2000) is calculated by superimposing the right temporalis plus left masseter normalized EMG amplitudes over the left temporalis plus right masseter normalized EMG amplitudes: the area of superimposition is assessed as a percentage of the total EMG amplitudes. TC ranges between 0% (complete presence of lateral displacing force) to 100% (no lateral displacing force).


Reproducibility of surface EMG measurements of the same muscles has already been tested in our laboratory by repeated analyses of seven subjects chosen at random (Ferrario et al., 2006). For all EMG variables the intraclass correlation coefficients were larger than 0.63, showing a good accuracy of the measurements, without random errors (paired Student’s t test, P40:05). 2.3. Data analysis Descriptive statistics were computed for the control group, and for each of the two patient groups. Age and sex distribution in the three groups were compared by one-way analysis of variance (age), followed by post-hoc tests (Tukey’s honestly significant difference), and w-square test (sex distribution). Subsequently, the EMG variables (POC, TC and activity) were compared among the three groups by using a generalized linear model (GLM) that used age, sex, and the age sex interaction as factors in an analysis of variance. The model could separate the effects of age and sex from those of the actual differences in the EMG variables among the three groups. The statistical package SAS was used. A linear discriminant analysis was run between the two patient groups using the individual values of muscle activity and POC. The discriminant function analysis (Lison, 1961; Walker and Kowalski, 1974) allows to differentiate between two populations by the calculation of a function L ¼ Lx x þ Ly y, where x and y are two independent variables measured in the populations, and Lx, Ly, are the relevant discriminant coefficients. The analysis also supplies a threshold value L0 for the discrimination between the two populations, together with the probability error for the classification of a new single individual according to L0. The threshold L0 is chosen to minimize the number of mis-classified individuals. The significance of the discriminant analysis was calculated with an analysis of variance (Lison, 1961). Significance was set at 5% (Pp0:05) for all statistical tests.

375

tials were approximately one-fourth smaller when clenching in intercuspal position (directly on the occlusal surfaces) than on the cotton rolls (Fig. 1). In the neck pain patient group, the MVC in intercuspal position was made with larger muscle potentials than the MVC on the cotton rolls, and the mean standardized muscular activity was larger than 100% (namely, 124 mV/mV s %) (see Table 1). In the control subjects, clenching on the cotton rolls or clenching in intercuspal position was performed with similar muscular activities (standardized muscular work 95 mV/mV s %). The mean activities of the three groups were significantly different (P ¼ 0:002) as assessed by the GLM analysis of variance. The model found that the effects of sex (P ¼ 0:656), age (P ¼ 0:237), and the sex age interaction (P ¼ 0:092) were all not significant, while the effect of group was highly significant (Po0:001). Significant differences among the three groups were found also for muscular symmetry (POC index, mean of temporalis anterior and masseter muscles, Po0:001 at the analysis of variance) and torque (TC index, Po0:001): on average, the control subjects were the most symmetric and those with the larger absence of torque, while the TMJ disorder patients were the least symmetric and those with the larger presence of torque. The significant effects of group (Po0:001) remained for both variables even when the factors sex (P ¼ 0:981 for POC, P ¼ 0:589 for TC, both not significant), age (P ¼ 0:004 for POC, P ¼ 0:005 for TC, both significant), and the age sex interaction (P ¼ 0:008 for POC, significant; P ¼ 0:945 for TC, not significant), were factored out by the GLM analysis of variance. The linear discriminant analysis performed between the two patient groups was highly significant (F ¼ 28, 2;35 degrees of freedom, Po0:001). Using the function L ¼ 0:1002 POC þ 0:0478 muscular activity, and the threshold value L0 ¼ 13:173 for the discrimination, a single, new patient could be allocated either to the TMJ disorder patients or neck pain patients with an

3. Results On average, the control group was significantly younger than the two patient groups (analysis of variance, Po0:001). The post hoc tests found significant differences among all three groups. Also, the sex distribution among the three groups was significantly different (w-square test, Po0:001). To take into consideration these differences, the EMG variables were subsequently compared among the three groups using a GLM analysis of variance. The TMJ disorder patients had a standardized muscular activity (four muscles pooled) during MVC of 75 mV/mV s %, that is, their muscular electric poten-

Fig. 1. Activity standardized, symmetry (POC) and torque (TC) indices in patients with TMJ alteration, neck pain, and control subjects (mean+1 SD). Po0:001 (GLM analysis of variance).


376

Table 1 Maximum voluntary teeth clenching in ‘‘TMJ disorders’’ and ‘‘neck pain’’ patients and control subjects (mean and standard deviation) Unit Number Age

Year

Activity standardized

mV/mV s %

Symmetry (POC)

%

Torque (TC)

%

TMJ

Neck pain

Control

24 35.25a 14.06 74.96 22.08 77.75 11.21 84.89 10.36

14 47.67b 16.71 124.00 36.97 86.86 3.34 91.25 1.60

91 20.01c 2.00 94.68 19.44 91.53 2.48 94.80 1.14

P

Sex

Age

Interaction

Group

0.002

0.656

0.237

0.092

0.001

0.001

0.981

0.004

0.008

0.001

0.001

0.589

0.005

0.945

0.001

0.001

P, probability value: Age, one-way analysis of variance (2;125 degrees of freedom), means with different superscript (a, b, c) differ at post-hoc test (Tukey’s honestly significant difference); EMG variables, GLM analysis of variance factored out for sex, age, sex age interaction, actual group difference.

error of 18.2%. In the present 38 patients, sensitivity of the discrimination was 0.86, with a 0.92 specificity.

4. Discussion Surface EMG of masticatory muscles is currently a part of the quantitative assessment of patients in dentistry. Among the jaw elevator muscles, the masseter and temporalis muscles are those most often assessed in clinical evaluations because they are the most superficial, and they are the only accessible to surface EMG examination. In contrast, the medial and lateral pterygoid muscles can be evaluated only with needle EMG. Indeed, in the assessment of stomatognathic dysfunction and several head disorders, the analysis of masseter and temporalis muscles can provide quantitative functional data with minimal discomfort to the patient and without invasive or dangerous procedures (Visser et al., 1995; Sato et al., 1998; Liu et al., 1999; Burnett et al., 2000; Pinho et al., 2000; Ferrario et al., 2002, 2004; Suvinen et al, 2003; Landulpho et al., 2004). Unfortunately, as underlined by several researchers, this simple, low cost, and fast exam also has many limitations that must be carefully considered and eventually removed (De Luca, 1997). For instance, technical artifacts (the instrumental noise), the thickness of the skin fat layer, crosstalk from different muscles. Therefore, a correct EMG assessment should be performed only with standardized (normalized) potentials, thus removing most of biological and technical noise (De Luca, 1997). In the current study, to reduce patient variability, the EMG protocol comprised a normalization record (a MVC on cotton rolls performed just before the recording of the actual test, i.e. with the same electrodes, cables, and EMG apparatus, and on the same cutaneous area) that should limit biologic and technical noise (De Luca, 1997; Burnett et al., 2000). Indeed, the height of the cotton roll might slightly modify the vertical

dimension (and consequently the length of muscular fibres and the interelectrode distance), but, when clenched, it becomes so thin to make the effect negligible. The resulting standardized EMG potentials should therefore be determined only by the muscular contraction as it correlates to the occlusal surfaces (Ferrario et al., 2000, 2002). Standardized EMG potentials can allow the measurement of the actual impact of morphology on stomatognathic function (Visser et al., 1995; Sato et al., 1998; Liu et al., 1999; Burnett et al., 2000; Pinho et al., 2000; Ferrario et al., 2002, 2006; Landulpho et al., 2004). From the standardized electric potentials produced by the single masticatory muscles, the muscular activity (integrated value in time) can be calculated to assess the actual effort made by the muscles (Sato et al., 1998; Burnett et al., 2000; Ferrario et al., 2004, 2006). Several previous investigations analysed the EMG characteristic of patients with TMJ alterations. The masticatory muscles of symptomatic TMD patients were more hypertonic at rest, less efficient and become more easily fatigued when compared to those of healthy subjects matched for sex and age (Liu et al., 1999; Pinho et al., 2000). Overall, the contraction of masticatory muscles elicited reduced electric potentials (Visser et al., 1995; Sato et al., 1998; Pinho et al., 2000), the masticatory efficiency was lessened, and the maximum bite force was significantly reduced (Sato et al., 1999). In the current study, bite force was not measured, but EMG activity during MVC may be considered as a useful approximation (Fogle and Glaros, 1995; van Kampen et al., 2002). Chronic musculoskeletal disorders of the head and neck are often without specific anatomical modifications that can be used for an objective differential diagnosis (Bogduk, 1999; Visscher et al., 2002), and functional assessments may provide useful information (Falla, 2004). A recent investigation found that patients with craniomandibular disorders and patients with cervical spine disorders had no differences in their head posture


(Visscher et al., 2002). In contrast, no EMG data on dental patients with cervical pain as the principal symptom have been reported so far. In the two groups of patients analysed in the present study, the mean standardized muscular activity during the MVC test was significantly different from that found in healthy controls. In the TMJ disorder patients, MVC on cotton rolls (the standardization recording) was made with significantly larger EMG potentials than MVC performed directly on the occlusal surfaces. Also, the standardized activity of the masseter and temporalis muscles of these patients was significantly unbalanced, both between sides (asymmetry) and muscular couples (torque). Asymmetric normalized muscular activity and unbalanced muscular couples might potentially dislocate the mandible on one side, and produce more force on one dental hemiarch and TMJ than on the contralateral structures (Ferrario and Sforza, 1994). Asymmetry (sides) and instability (muscular couples) in normalized muscular activity often result from a functionally unstable occlusion when the maxillary and mandibular teeth contact during clenching and swallowing (Ferrario et al., 1999). According to literature references (Ferrario et al., 2000), and in comparison to the analysed control subjects, TMJ disorder patients had a functionally unstable occlusion (Landulpho et al., 2004). Clenching on the cotton rolls reduced the proprioceptive inputs from this unstable occlusion, and allowed the patients to contract more efficiently their masticatory muscles. Even if the actual role of occlusion in the development of signs and symptoms in patients with TMD is still controversial, in some patients altered occlusal conditions may be a factor in triggering abnormal muscular activity (Ferrario et al., 2002). In contrast, in the neck pain patients the cotton rolls inhibited the muscular contraction, and a larger activity was found in intercuspal position. A possible explanation of this inhibition may be that the cotton rolls introduced a further alteration, which incremented the actual non-occlusal and non-TMJ problem. Indeed, their POC and TC coefficients, even significantly lower than that calculated in the control subjects, were inside normal ranges (larger than 85% for the POC index, and larger than 90% for the TC index, Ferrario et al., 2006). To make the discrimination between the two patient groups as simple as possible, a linear discriminant analysis was performed. This analysis not only allows the recognition of differences between two populations using a linear combination of variables (two in the current investigation) (Walker and Kowalski, 1974), but it also supplies the probability error for the classification of a new single individual where the same variables are measured (Lison, 1961). The surface EMG assessment of masseter and temporalis muscles during standardized teeth clenching and the calculation of muscular activity

377

and index POC allows to allocate the new patient either to the TMJ disorder group or neck pain group with an error of 18.2%, i.e. the number of mis-classified individuals would be less than 2 out of 10. Also, sensitivity and specificity of the test, as assessed from the current group of patients, were good. It has to be mentioned that the analysed individuals represent a convenience sample, and the extrapolation of the present results to a wider population should be done with caution. Furthermore, the control group was younger than the two patient groups, and the male: female ratio was different. The GLM analysis of variance used to compare the EMG variables of the three groups took these differences into consideration, and found significant effects of age for POC and TC indices, and a significant age sex interaction for POC. In contrast, the effect of sex was never significant. Even considering these effects, the differences in EMG indices remained highly significant among the three groups. Indeed, the use of standardized potentials should reduce inter-subject variability (De Luca, 1997; Burnett et al., 2000; Ferrario et al., 2000). Literature reports on the effects of sex and age on EMG variables are scanty. In accord with the current findings, no significant sex-related differences in normalized EMG potentials recorded during MVC were reported by Ferrario et al. (2000, 2006) for young healthy subjects. In subjects with a good occlusion, aging seems to have minor effects on the normalized EMG indices: in control subjects aged 53 years on average, a recent study reported a mean standardized activity of 104.9 mV/mV s % (SD 28.9) mean POC of 87% (SD 0.9) and mean TC of 90.8% (SD 0.4) (Ferrario et al., 2004). In contrast, Ueda et al. (2002) found that the masticatory muscles were more fatigable in women than in men, and some effect of age was found on muscle recruitment during incisal biting at different bite forces by Fogle and Glaros (1995). Indeed, in view of the different experimental settings and analysed variables, it is difficult to make conclusive assertions on this problem.

5. Conclusion Surface EMG of the right and left masseter and temporalis anterior muscles, performed with a welldefined protocol, provided standardized data that were used for a quantitative assessment of two patient groups. The test was simple, low cost, fast and noninvasive, it provoked no discomfort to the patients and it had no side effects. A discriminant analysis of the standardized data obtained from the EMG test allowed a possible differentiation between patients with a TMJ disorder and patients with a neck pain problem. The two groups


V.F. Ferrario et al. / Manual Therapy 12 (2007) 372–379

of patients need different treatments, and a quick decision between the two diagnoses may allow a prompt solution of their disturbance. Patients with a low standardized muscular activity and a reduced right–left muscular symmetry during MVC had more probably a TMJ disorder, and the first, immediate step of their treatment included the preparation of a stabilization splint (Ferrario et al., 2002). Indeed, among the several treatments used in the TMD patients, occlusal splints are believed to be beneficial in a large part of cases: they are a conservative and reversible therapy, and can reduce pain in most cases (Nemcovsky et al., 1992; Ash and Ramfjord, 1995; Ferrario et al., 2002). In contrast, patients with a high standardized muscular activity and a nearly normal right–left muscular symmetry during MVC had most likely a neck problem, and an occlusal splint will probably be not beneficial for them. Their assessment should be performed in collaboration with a physiotherapist and/ or a chiropractor, and a manual treatment together with an appropriate exercise programme may be beneficial (Alcantara et al., 2002; DeVocht et al., 2003; Falla, 2004). An occlusal splint may be used only to avoid the biomechanical influences of occlusal stress on the neck.

Acknowledgements The precious statistical assistance of Mr. Bruno Lovecchio, B.Sc, and the expert secretarial assistance of Ms Cinzia Lozio are gratefully acknowledged.

References Alcantara J, Plaugher G, Klemp DD, Salem C. Chiropractic care of a patient with temporomandibular disorder and atlas subluxation. Journal of Manipulative and Physiological Therapeutics 2002;25:63–70. Ash MM, Ramfjord S. Occlusion, 4th Ed. Philadelphia: WB Saunders Co; 1995. p. 233–4. Bogduk N. The neck. Baillie`re’s of Clinical Rheumatology 1999;13:261–85. Burnett CA, Fartash L, Murray B, Lamey P-J. Masseter and temporalis muscle EMG levels and bite force in migraineurs. Headache 2000;40:813–7. Ciancaglini R, Testa M, Radaelli G. Association of neck pain with symptoms of temporomandibular dysfunction in the general adult population. Scandinavian Journal of Rehabilitation Medicine 1999;31:17–22. De Luca CJ. The use of surface electromyography in biomechanics. Journal of Applied Biomechanics 1997;13:135–63. DeVocht JW, Long CR, Zeitler DL, Schaeffer W. Chiropractic treatment of temporomandibular disorders using the activator adjusting instrument: a prospective case series. Journal of Manipulative and Physiological Therapeutics 2003;26:421–5. De Wijer A, Steenks MH, Bosnian F, Helders PJM, Faber J. Symptoms of the stomatognathic system in temporomandibular and cervical spine disorders. Journal of Oral Rehabilitation 1996;23:733–41.

Eriksson P-O, Zafar H, Haggman-Henrikson B. Deranged jaw–neck motor control in whiplash-associated disorders. European Journal of Oral Sciences 2004;112:25–32. Falla D. Unravelling the complexity of muscle impairment in chronic neck pain. Manual Therapy 2004;9:125–33. Ferrario VF, Sforza C. Biomechanical model of the human mandible in unilateral clench: distribution of the TMJ reaction forces between the working and balancing side. Journal of Prosthetic Dentistry 1994;72:169–76. Ferrario VF, Sforza C, Serrao G, Colombo A, Schmitz JH. The effects of a single intercuspal interference on EMG characteristics of human masticatory muscles during maximal voluntary teeth clenching. Cranio-Journal of Craniomandibular Practice 1999;17:184–8. Ferrario VF, Sforza C, Colombo A, Ciusa V. An electromyographic investigation of masticatory muscles symmetry in normo-occlusion subjects. Journal of Oral Rehabilitation 2000;27:33–40. Ferrario VF, Sforza C, Tartaglia GM, Dellavia C. Immediate effect of a stabilization splint on masticatory muscle activity in temporomandibular disorder patients. Journal of Oral Rehabilitation 2002;29:810–5. Ferrario VF, Tartaglia GM, Maglione M, Simion M, Sforza C. Neuromuscular coordination of masticatory muscles in subjects with two types of implant supported prostheses. Clinical Oral Implants Research 2004;15:219–25. Ferrario VF, Tartaglia GM, Galletta A, Grassi GP, Sforza C. The influence of occlusion on jaw and neck muscle activity: a surface EMG study in healthy young adults. Journal of Oral Rehabilitation 2006;33:341–8. Fogle LL, Glaros AG. Contributions of facial morphology, age, and gender to EMG activity under biting and resting conditions: a canonical correlation analysis. Journal of Dental Research 1995;74:1496–500. Gross AR, Haines T, Thomson MA, Goldsmith C, Mcintosh J. Diagnostic tests for temporomandibular disorders: an assessment of the methodologic quality of research reviews. Manual Therapy 1996;1:250–7. John MT, Miglioretti DL, LeResche L, Von Korff M, Critchlow CW. Widespread pain as a risk factor for dysfunctional temporomandibular disorder pain. Pain 2003;102:257–63. Landulpho AB, E Silva WAB, E Silva FA, Vitti M. Electromyographic evaluation of masseter and anterior temporalis muscles in patients with temporomandibular disorders following interocclusal appliance treatment. Journal of Oral Rehabilitation 2004;31:95–8. Lee WY, Okeson JP, Lindroth J. The relationship between forward head posture and temporomandibular disorders. Journal of Orofacial Pain 1995;9:161–7. Lison L. Statistica applicata alla biologia sperimentale. Milano, Italy: CEA; 1961. p. 313–29. Liu ZJ, Yamagata K, Kasahara Y, Ito G. Electromyographic examination of jaw muscles in relation to symptoms and occlusion of patients with temporomandibular joint disorders. Journal of Oral Rehabilitation 1999;26:33–47. Nemcovsky CE, Gazit E, Serfati V, Gross M. A comparative study of three therapeutic modalities in a temporomandibular disorder (TMD) population. Journal of Craniomandibular Practice 1992;10:148–55. Pinho JC, Caldas FM, Mora MJ, Santana-Penin U. Electromyographic activity in patients with temporomandibular disorders. Journal of Oral Rehabilitation 2000;27:985–90. Sato S, Ohta M, Goto S, Kawamura H, Motegi K. Electromyography during chewing movement in patients with anterior disc displacement of the temporomandibular joint. International Journal of Oral and Maxillofacial Surgery 1998;27:274–7. Sato S, Ohta M, Sawatari M, Kawamura H, Motegi K. Occlusal contact area, occlusal pressure, bite force, and masticatory

ARTICLE IN PRESS V.F. Ferrario et al. / Manual Therapy 12 (2007) 372–379 efficiency in patients with anterior disc displacement of the temporomandibular joint. Journal of Oral Rehabilitation 1999;26:906–11. Suvinen TI, Reade PC, Kononen M, Kemppainen P. Vertical jaw separation and masseter muscle electromyographic activity: a comparative study between asymptomatic controls & patients with temporomandibular pain & dysfunction. Journal of Oral Rehabilitation 2003;30:765–72. Ueda HM, Kato M, Saifuddin M, Tabe H, Yamaguchi K, Tanne K. Differences in the fatigue of masticatory and neck muscles between male and female. Journal of Oral Rehabilitation 2002;29:575–82.

379

van Kampen FMC, van der Bilt A, Cune MS, Bosman F. The influence of various attachment types in mandibular implantretained overdentures on maximum bite force and EMG. Journal of Dental Research 2002;81:170–3. Visscher CM, De Boer W, Lobbezoo F, Habets LLMH. Is there a relationship between head posture and craniomandibular pain? Journal of Oral Rehabilitation 2002;29:1030–6. Visser A, Kroon GW, Naeije M, Hansson TL. EMG differences between weak and strong myogenous CMD patients and healthy controls. Journal of Oral Rehabilitation 1995;22:429–34. Walker GF, Kowalski CJ. Computer aided diagnosis of craniofacial abnormalities. Medinfo 1974;74:553–7.

ARTICLE IN PRESS


Technical and measurement report

Wireless orientation sensors: Their suitability to measure head movement for neck pain assessment Jan M. Jasiewicza,, Julia Treleavenb, Peter Condiea, Gwendolen Jullb a

Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland 4059, Australia b Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Australia Received 12 January 2006; received in revised form 22 June 2006; accepted 10 July 2006

Abstract The purpose of this study was to verify the performance and suitability of new generation 3D wireless orientations sensors to measure cervical range of movement against a criterion standard instrument, an electromagnetic motion analysis system (FastrakPolhemus). The wireless orientation sensor (InertiaCube 3) consists of 9 motion-sensing elements: 3 accelerometers, 3 angular velocity rate transducers and 3 magnetometers. Measurements of cervical range of motion in each primary plane, left-lateral flexion, flexion and left rotation were directly compared from both systems in 10 normal asymptomatic subjects. Results showed very high cross-correlations (.99–.97) and low average root mean square errors (0.7–2.51). We conclude that orientation sensors are a valid, accurate and suitable device for obtaining cervical joint ranges of motion in the primary plane of movement. r 2006 Elsevier Ltd. All rights reserved. Keywords: Head movement; Inertial sensors; Neck pain; Whiplash

1. Introduction Assessment of head position with respect to both range of motion and cervical joint position sense are important elements in the assessment of patients with neck pain (American Medical Association (AMA), 1993; Jull et al., 2004). Restricted cervical motion and greater cervical joint position error have been demonstrated in subjects with neck pain of both idiopathic and traumatic origin (Revel et al., 1991; Heikkila and Astrom, 1996; Heikkila and Wenngren, 1998; Dall’alba et al., 2001; Dumas et al., 2001; Treleaven et al., 2003; Kristjansson et al., 2004). Reduced cervical range of motion has also been found to be a useful indicator of physical disability in neck pain (Dall’alba et al., 2001) and one of the predictors of a poorer outcome following a whiplash injury (Sterling et al., 2003; Sterling, 2004). Corresponding author. Tel.: +61 7 3864 5821; fax: +61 7 3864 3390. E-mail address: [email protected] (J.M. Jasiewicz).


Frequently, the instrumentation used to measure cervical motion has been a non-invasive electromagnetic device (3-Space Fastrak, Polhemus, Colchester, VT, USA; Flock of Birds, Ascension Technology, Burlington, VT, USA) that tracks the position of sensors in three dimensions (Dall’alba et al., 2001; Dumas et al., 2001; Treleaven et al., 2003; Kristjansson et al., 2004; Sterling, 2004) and has been shown to be accurate (Pearcy and Hindle, 1989). To measure cervical motion, usually one tracking unit is placed on a lightweight adjustable headband centred on the forehead of the subject while a second tracking unit is placed over the C7 spinous process. Head position in the primary plane of movement and the two associated movement planes is calculated relative to a global origin. In the sagittal plane, extension is considered the primary movement while simultaneous lateral flexion and rotation are the associated movements. However, in recent studies only the primary plane has been used as the outcome measure as few differences in the associated movement planes

ARTICLE IN PRESS J.M. Jasiewicz et al. / Manual Therapy 12 (2007) 380–385

have been demonstrated between neck pain and control subjects (Dall’alba et al., 2001; Treleaven et al., 2003). While Fastrak and other similar devices have made a significant contribution in non-invasive techniques to accurately and reliably measure cervical movement and positioning over the last 10–15 years (Trott et al., 1996), such instrumentation has some limitations. Some secondary instruments such as electromyography (EMG) may affect the accuracy of tracking because such devices may distort the magnetic field lines of the transmitter source. More importantly tracking accuracy is reduced as a function distance from the electromagnetic source. Advances in micro-mechanical and wireless technologies have stimulated the development of miniature motion sensing systems incorporating accelerometers, magnetometers and rate gyroscopes. Such devices have important advantages: 1. One, the capacity to determine absolute orientation and track movement in three dimensions. 2. Minimizing electronic and integration drift in conjunction with Kalman filters. 3. Ability to access data from each transducer making it possible to obtain additional parameters, such as linear accelerations, velocities and displacements (Jasiewicz et al., in press). 4. They are self-contained and portable, relatively inexpensive and can be used with other devices such as EMG and force transducers. As a result they are being increasingly used for motion analysis for a variety of applications (Tong and Granat, 1999; Aminian et al., 2002; Mayagoitia et al., 2002; Lee et al., 2003; Zhu and Zhou, 2004; Simcox et al., 2005; Jasiewicz et al., in press). As a considerable bank of data for cervical motion for both asymptomatic and neck pain subjects (Trott et al., 1996; Dall’alba et al., 2001) has been built based on the Fastrak system it would be beneficial to determine whether the wireless motion sensors give comparable results. Therefore aim of this study was to determine the accuracy of new generation of wireless orientation sensors for the kinematic analysis of cervical head movement compared to the same measurement obtained from a Fastrak device.

381

gyroscope (712001/s), a uniaxial accelerometer (74 g) and a magnetometer. Static accuracy is 0.251 in pitch and roll and 11 in yaw, while dynamic accuracy is between 0.5X2.51 RMS depending on type of movement. Orientation is reported as Euler angles (yaw, pitch and roll). The terms yaw, pitch and roll, originally derived from aeronautical nomenclature, describe the orientation and movement of an object in space. The best analogy is to imagine an aircraft where yaw relates to the movement of aircraft’s nose rotating from side to side about its vertical axis, roll is the when the aircraft banks about an axis along the length of the fuselage while pitch is when the aircraft’s nose moves up or down (climbs or dives) about an axis across the fuselage. If the sensor axes (yaw, pitch and roll) are aligned with the anatomical axes of the head, for example, when the yaw axis is aligned with the head’s left and right rotation axis then yaw will measure left and right head movements (saying ‘‘no’’). Orientation data were collected using a custom developed Labview program (version 7.1 National Instruments, Austin, TX, USA) using a laptop running windows XP. 2.2. Fastrak The 3-Space Fastrak (Polhemus, Colchester, VT, USA) is a six degree of freedom (x, y, z, yaw, pitch and roll) electromagnetic tracking device that senses the position and orientation of one or multiple receiver units within a generated magnetic field. The Fastrak’s static accuracy is to within 70.21 (Pearcy and Hindle, 1989) but diminishes as the distance from the transmitter increases. The update rate is 60 samples per second for 2 tracking units. As the Fastrak is frequently used in neck pain research (Dall’alba et al., 2001; Dumas et al., 2001; Sterling et al., 2003; Treleaven et al., 2003; Kristjansson et al., 2004), it was considered as the criterion standard. 2.3. Subjects Ten University of Queensland volunteers from the School of Physiotherapy (mean age 33.479.9 SD, range 20–51 years) with no previous history of neck injury participated in this study. All subjects provided informed consent prior to participating in the study. The study received ethical approval from the University of Queensland Ethics Committee.

2. Methods 2.4. Protocol 2.1. Orientation sensor system The sensors (IC3) used in this study are wireless three degree of freedom orientation sensors (Intersense, Bedford, MA, USA). Each sensor contains 3 integrated sensing elements in each orthogonal axis: a rate

To compare head range of motion measured simultaneously by the Fastrak and the orientation sensors, each Fastrak tracking unit was ‘‘piggybacked’’ on top of the orientation sensor. The body axes of both the orientation sensors and Fastrak tracking units were aligned.


382

ment conditions started from the same initial position; looking straight ahead (head mid-line coincident with the trunk mid-line) and level. Both systems collected data simultaneously at 60 Hz.

One piggybacked sensor (orientation sensor+Fastrak tracking unit) was placed on a lightweight adjustable headband centred on the forehead of the subject. A second orientation-Fastrak tracking unit was placed over the C7 spinous process using double-sided tape. The Fastrak electromagnetic transmitter was placed in a box attached to the back of a wooden chair. The Fastrak was connected to a PC. The orientation sensors communicated via a 2.4 GHz wireless link using a receiver connected to a USB (universal serial bus) port of an IBM-compatible laptop. Subjects were required to sit in a wooden chair with their head level. Prior to the beginning of the trial, the heading (yaw) of the sensor was reset to 01. This ensured that the yaw axes of both sensors were aligned to the Fastrak’s coordinate system. Subjects performed three head rotation repetitions (maximum left rotation in yaw plane), three repetitions of maximum flexion (pitch plane, head/chin down), and three repetitions of lateral flexion (roll plane, tilting head to the left). Extension, right rotation and lateral flexion were not examined because including these conditions would have decreased the statistical power of our analyses given that 10 subjects were tested. All move-

2.5. Data processing and analysis The purpose of the three movement conditions (flexion, (L) lateral flexion and (L) rotation) was to measure the maximum range of head movement in each primary plane. The rotation order calculations for both systems were identical. A different rotation order will result in a different final orientation. In addition, the Fastrak orientations are relative to the transmitter axes, while for the IC3 sensor orientation is relative to gravity and 01 heading. To compare the results of both tracking devices, the alignment of both sensor axis systems must be identical. Head movement in the primary plane and its two associated planes (secondary planes) were collected for each condition. For example, in the pitch plane, flexion was the primary movement and any simultaneous lateral flexion and rotation were the associated movements in

Table 1 Summary statistics including ranges of motion, mean error, error range and variance for the IC3 and Fastrak orientation sensors Direction

Primary axis

Head mounted sensors Flexion Pitch Lateral flexion Roll Rotation Yaw C7/Trunk mounted sensors Flexion Pitch Lateral flexion Roll Rotation Yaw

FastTrak (FST)

IC3

Mean error (FST-IC3)

Error range

Mean

Mean

Std

Mean

Std

Min

63.11 42.31 75.01

78.61 77.71 79.61

63.21 40.11 75.01

78.01 76.91 710.71

0.21 2.21 0.81

70.81 70.81 71.31

1.11 0.31 3.91

1.31 4.31 1.81

6.91 7.01 37.21

6.41 7.11 7.91

73.41 75.41 75.31

7.01 6.71 9.81

74.11 75.21 77.01

0.01 0.41 1.91

70.61 70.31 70.71

3.11 0.11 5.71

5.21 1.21 0.91

2.81 0.11 3.51

Std

Variance

Max

Table 2 Summary of root mean square errors (including standard deviations) and cross-correlations between the Fastrak and IC3 sensors. All crosscorrelations were significant Movement

Primary plane

RMSE

Cross-correlation

Head mounted sensors Flexion Lateral flexion Rotation

Pitch Roll Yaw

2.11 (71.11) 2.51 (70.91) 2.31 (70.91)

0.98 0.97 0.97

C7/Trunk mounted sensors Flexion Lateral flexion Rotation

Pitch Roll Yaw

1.21 (70.51) 0.71 (70.71) 0.91 (70.51)

0.98 0.99 0.98


Orientation Angle (deg)

50

Fastrak-Head IC3-Head

30

Fastrak-C7 IC3-C7

RMSE= 3.7°

5 6 Time (s)

7

383

Primary plane orientations were cross-correlated and root means square errors (RMSE) were calculated. Means, mean errors (Fastrak-IC3), variances and error ranges (min–max) for the maximum ranges were obtained from both system for both head and C7/trunk mounted sensors. Means were compared using a fourfactor 2 2 3 3 (device sensor location rotation plane repetition) repeated measures ANOVA. The overall significance level was set a .05. A Tukey’s post-hoc test was used to pinpoint any significant interactions.

RMSE= 1.8°

10 -10 -30 -50 -70 0

1

2

3

(A)

8

9

10

3. Results

RMSE= 0.0°

10 Orientation Angle (deg)

4

0 -10 -20 -30 RMSE= 2.1° -40 -50 0

1

2

(B)

3 4 Time (s)

6

7

6

7

RMSE= 3.4°

50 Orientation Angle (deg)

5

30 10 -10 -30

RMSE= 0.8°

-50 0 (C)

1

2

3 4 Time (s)

5

Fig. 1. Example Fastrak and IC3 motion data for one subject (subject 2). The RMSE values between the Fastrak and IC3 sensors are shown for the head and trunk. The three graphs represent the following primary plane movement conditions: (A) head flexion movement (as in the ‘‘yes’’ gesture), (B) left lateral flexion (as in the ‘‘ear to shoulder’’ gesture) and (C) head rotation (as in the ‘‘no’’ gesture).

the other two planes. The parameter of interest is the motion in the primary plane because this is the major outcome measure used for neck injuries (Dall’alba et al., 2001; Treleaven et al., 2003).

The values for cervical range of motion in the primary plane for the three movements (left lateral flexion, flexion and left rotation) showed good agreement between the IC3 sensors, positioned on the head and C7 (Table 1). The analysis of variance showed no significant differences in the mean error (difference between the Fastrak and IC3 sensor) for all three-movement tasks for both sensor locations. RMSE values, summarized in Table 2, revealed differences in relation to the location of the sensors. The head RMSE ranged from 2.11 to 2.51 while the C7/ sensor values ranged from 0.71 to 1.21. We note that, while the RMSE values for the head sensor were larger than those for C7, the head sensor moved over a larger range than the C7 sensor (approximately 601 and 7.01, respectively) so proportionally the head sensor error was lower. The cross-correlations were high ranging between 0.99 and 0.97 (Table 2). Fig. 1 shows the direct comparison of movement of the head and C7 sensor in the primary plane (Fig. 1A pitch/flexion; B roll/left lateral flexion and C yaw/ rotation for one subject. It illustrates the close correspondence between both measurement systems. Of note are the very low root means square errors ranging from 0.01 to 3.71 for both head and trunk data.

4. Discussion The results suggest that the orientation sensors (IC3) are an accurate device for measuring head motion and assessing cervical range of motion in the primary plane. The IC3 sensors exhibited high cross-correlations and low root mean errors. The data for the primary range of motion in each direction are similar to those reported in previous studies using the Fastrak device (Trott, et al., 1996; Dall’alba et al., 2001). However, when comparing results from other studies it is important to ensure that the methodology for calculating orientations use the


J.M. Jasiewicz et al. / Manual Therapy 12 (2007) 380–385

identical rotation order otherwise the results will not be equivalent. It is possible that the IC3 may have interfered with the Fastrak receiver, because the IC3 housing could distort the electromagnetic waves. However, because the IC3’s were placed with the receivers, which were some distance away from the transmitter the amplitude of the reflected waves, are small and therefore quite weak. Also, the data from both systems were so closely matched suggesting that any interference effects may have been negligible. Orientation sensors are becoming more prevalent for biomechanical and motion analysis, both for research (Tong and Granat, 1999; Aminian et al., 2002; Mayagoitia et al., 2002; Lee et al., 2003; Zhu and Zhou, 2004; Simcox et al., 2005; Jasiewicz et al., in press) and in the clinical environment (Li et al., 2006) especially for dynamic visual acuity and gaze stabilization tests (Neurocom, Clackamas, OR, USA). Orientation sensors have several distinct advantages. First, they are portable, highly accurate and easy to use. Second, they are comparatively cost effective and versatile. Third, they do not suffer from diminished accuracy as a function distance. Fourth, the sensors can be used in conjunction and synchronized with EMG systems or other analogue devices. There are some inherent limitations of orientation sensors. For example, they do not accurately measure linear translations, unlike Fastrak, which is a true six degree of freedom system (6-DoF). It is possible to estimate linear translations if the linear acceleration signals are double integrated from a known starting position but the accuracy is not comparable to that of true 6-DoF systems. However, if linear translations are a minor component of the total movement then orientation sensors are particularly well suited for clinical assessment of cervical range of motion in neck pain. Such sensors widen the possibilities for developing new quantitative assessment techniques for the diagnosis and treatment of neck pain and whiplash injury. Further research is needed to determine the accuracy and validity of the sensor in neck pain and whiplash patients and future studies of these populations are being planned.

5. Conclusions In conclusion, this study demonstrated that wireless inertial sensors are comparable, in terms of accuracy to a Fastrak motion analysis system for measuring head movement. They appear to be a suitable clinical measurement system particularly for the primary range of motion for neck pain assessment, although some caution needs to be exercised in comparing results from

previous studies as the results can differ due different methods employed in calculating orientation and joint angles.

References American Medical Association (AMA). Guides to the evaluation of permanent impairment, 4th ed. Chicago, IL: American Medical Association. Aminian K, Najafi B, Bu¨la C, Leyvarz P-F, Robert Ph. Spatiotemporal parameters of gait measured by ambulatory system using miniature gyroscopes. Journal of Biomechanics 2002;35:689–99. Dall’alba P, Sterling M, Trelaeven J, Jull G. Cervical range of motion discriminates between asymptomatic and whiplash subjects. Spine 2001;26(19):2090–4. Dumas JP, Arsenault AB, Boudreaux G, Magnoux E, Lepage Y, Bellavance A, et al. Physical impairments in cervicogenic headache: traumatic vs. nontraumatic onset. Cephalalgia 2001;21(9):884–93. Heikkila H, Astrom PG. Cervicocephalic kinesthetic sensibility in patients with whiplash injury. Scandinavian Journal of Rehabilitation Medicine 1996;28(3):133–8. Heikkila HV, Wenngren BI. Cervicocephalic kinesthetic sensibility, active range of cervical motion, and oculomotor function in patients with whiplash injury. Archives of Physical Medicine and Rehabilitation 1998;79(9):1089–94. Jasiewicz JM, Allum JHJ, Middleton JW, Barriskill A, Condie P, Purcell B, et al. Gait event detection using linear accelerometers or angular velocity transducers in able-bodied and spinal cord injured individuals Gait & Posture, in press. Jull G, Falla D, Treleaven J, Sterling M, O’Leary S. A therapeutic exercise approach for cervical disorders. In: Boyling J, Jull G, editors. Grieve’s modern manual therapy: the vertebral column. Edinburgh: Churchill Livingstone; 2004. p. 451–70 (Chapter 3). Kristjansson E, Hardardottir L, Asmundardottir M, Gudmundson K. A new clinical test for cervicocephalic kinesthetic sensibility: ‘‘the fly’’. Archives of Physical Medicine and Rehabilitation 2004;85(3): 490–5. Lee RYW, Laprade J, Fung EHK. A real–time gyroscopic system for three-dimensional measurement of lumbar spine motion. Medical Engineering & Physics 2003;25(10):817–24. Li RC, Jasiewicz JM, Middleton J, Condie P, Barriskill A, Hebnes H, et al. The development, validity, and reliability of a manual muscle testing device with integrated limb position sensors. Archives of Physical Medicine and Rehabilitation 2006;87:411–7. Mayagoitia RE, Nene AV, Veltink PH. Accelerometer and rate gyroscope measurement of kinematics: an inexpensive alternative to optical motion analysis. Journal of Biomechanics 2002;35: 537–42. Pearcy M, Hindle R. New method for the non-invasive threedimensional measurement of human back movement. Clinical Biomechanics 1989;4:73–9. Revel M, Andre-Deshays C, Minguet M. Cervicocephalic kinesthetic sensibility in patients with cervical pain. Archives of Physical Medicine and Rehabilitation 1991;72:288–91. Simcox S, Parker S, Davis GM, Smith RW, Middleton JW. Performance of orientation sensors for use with a functional electrical stimulation mobility system. Journal of Biomechanics 2005;38:1185–90. Sterling M. A proposed new classification system for whiplash associated disorders—implications for assessment and management. Manual Therapy 2004;9(2):60–70. Sterling M, Jull G, Vicenzino B, Kenardy J, Darnell R. Development of motor system dysfunction following whiplash injury Pain 2003;103(1–2):65–73.

ARTICLE IN PRESS J.M. Jasiewicz et al. / Manual Therapy 12 (2007) 380–385 Tong K, Granat MH. A practical gait analysis system using gyroscopes. Medical Engineering & Physics 1999;21:87–94. Treleaven J, Jull G, Sterling M. Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error. Journal of Rehabilitation Medicine 2003;35(1):36–43.

385

Trott P, Pearcy M, Ruston SA, Fulton I, Brien C. Three dimensional analysis of active cervical motion: the effect of age and gender. Clinical Biomechanics 1996;11(4):201–6. Zhu R, Zhou Z. A real-time articulated human motion tracking using tri-axis inertial/magnetic sensors package. IEEE Transactions on Neural Systems and Rehabilitation Engineering 2004;12(2):295–302.

ARTICLE IN PRESS


Technical & measurement report

Clinical measurement of posterior shoulder flexibility$ John D. Borstada,1, Krista M. Mathiowetzb,1, Laura E. Mindayc,1, Bhakti Prabhu1, Daisy E. Christophersond,1, Paula M. Ludewige, a Physical Therapy Division, The Ohio State University, Columbus, OH, USA Sister Kenny Sports and Physical Therapy, Allina Hospitals and Clinics, Minneapolis, MN, USA c Crow Wing Special Education Cooperative, Glencoe, MN, USA d Healthsouth, Denver, CO, USA e Program in Physical Therapy, University of Minnesota, Mayo Mail Code 388, 420 Delaware Street SE, Minneapolis, MN 55455, USA b

Received 28 January 2005; received in revised form 12 May 2006; accepted 10 July 2006

Abstract The objectives of this study were to determine both the intra-rater reliability and the smallest real difference necessary to detect meaningful clinical changes over an 8–12 week period for three clinical measures of posterior shoulder flexibility. Posterior shoulder tightness has been associated with abnormal humeral head translations that narrow the subacromial space and contribute to impingement. Posterior shoulder stretching to normalize joint kinematics is often used when treating individuals with subacromial impingement. Currently there is no measurement of posterior shoulder flexibility that has been demonstrated to be reliable or responsive in patients over a treatment interval. Construction workers with overhead work exposure were recruited to an impingement group (n ¼ 37), and an asymptomatic group (n ¼ 22). Three flexibility measurements were taken on each subject at baseline and 8–12 weeks later by the same physical therapist. Intra-rater reliability was determined using intra-class correlation coefficients (ICCs) and standard errors of measurement (SEM). The smallest real difference value (SRD) determined the smallest detectable intervention-related measurement change over time. ICCs for the three measurements ranged from poor (0.40) to good (0.79). The SEM and SRD values reflected high test–retest variability in all three measurements. None of the three measures were proven to be highly stable indicators of posterior shoulder flexibility over this time period, nor were they able to detect small changes over this interval due to the high trial to trial variance in a non-intervention sample. Caution should be used when interpreting these clinical measurements over prolonged time periods. r 2006 Elsevier Ltd. All rights reserved. Keywords: Shoulder impingement; Range of motion measurement; Posterior capsule

1. Introduction $

This research was supported in part by the Center to Protect Worker’s Rights, the Public Health Service and the University of Iowa under Public Health Service Grant no. U60/CCU317202. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the Center to Protect Worker’s Rights, the Public Health Service, or the University of Iowa. Corresponding author. Tel.: +1 612 626 0420; fax: +1 612 625 7192. E-mail address: [email protected] (P.M. Ludewig). 1 At the time of the study, these authors were graduate students, University of Minnesota Program in Physical Therapy or Rehabilitation Science, Department of Physical Medicine and Rehabilitation, Minneapolis, MN, USA. 1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.07.014

Posterior glenohumeral capsular tightness has been theorized to contribute to shoulder impingement syndrome (Bang and Deyle, 2000). In vitro tightening of the posterior capsule has resulted in increased anterior and superior humeral head translations on the glenoid (Harryman et al., 1990), which are believed to decrease the available subacromial space during upper extremity elevation (Deutsch et al., 1996; Ludewig and Cook, 2002). Tightness in the posterior shoulder has been associated with a loss of glenohumeral internal rotation

ARTICLE IN PRESS J.D. Borstad et al. / Manual Therapy 12 (2007) 386–389

range of motion (ROM) (Cohen and Williams, 1998; Tyler et al., 1999), and decreased glenohumeral internal rotation ROM has been identified in subjects with impingement syndrome (Warner et al., 1990). This ROM loss is believed indicative of posterior shoulder tightness because tension in the posterior capsule has limited glenohumeral internal rotation ROM in cadaver models (Terry et al., 1991). Based on these findings, stretching and soft tissue mobilization of the posterior shoulder tissues are often included in rehabilitation of individuals with subacromial impingement. To determine the necessity and effectiveness of these interventions, a reliable and responsive clinical measure of posterior capsule flexibility is necessary. The purpose of this study was to compare three measurements used to quantify posterior shoulder flexibility.

2. Methods 2.1. Subjects Subjects were recruited from construction trades that require daily overhead work. Volunteers were required to be at least 18 years of age and have at minimum a 1year work history in their trade. Symptomatic individuals reporting at least 1 week of shoulder pain were considered. Asymptomatic individuals with similar overhead work exposure but no shoulder pain were recruited as a control group. All subjects signed an informed consent agreement upon entry into the study. Symptomatic subjects were required to demonstrate at least two positive impingement tests (Ure et al., 1993; Magee, 1997) as well as two of the following clinical findings for inclusion: (1) a painful arc, (2) pain upon palpation of the rotator cuff or biceps tendons or, (3) pain with resisted glenohumeral motions (Magee, 1997). Exclusion criteria included a history of trauma, fracture, dislocation or surgical procedure, less than 1301 elevation of the arm, symptom provocation with cervical screening, gross shoulder instability, positive thoracic outlet tests (Magee, 1997), or current treatment for a shoulder condition. Asymptomatic volunteers were required to have a negative clinical assessment. Twenty-two asymptomatic and 37 symptomatic subjects met the inclusion criteria for the study.

387

A sidelying adduction measure was taken with a 60inch metal carpenter’s square. Measurements were made by one of two physical therapists, each with a minimum of 6.5 years clinical experience. Internal rotation was measured in supine, with an assistant preventing scapular movement. Degrees of rotation were recorded at the end of passive motion (Warner et al., 1990; Ludewig and Cook, 2002). Horizontal adduction was measured in supine and degrees of rotation were recorded at the palpable onset of scapular motion away from the plinth (Warner et al., 1990; Ludewig and Cook, 2002). Sidelying adduction positioned subjects with the top shoulder directly above the lower shoulder before the humerus was passively taken into horizontal adduction. The limit of posterior shoulder flexibility was considered the onset of scapula movement or humerus rotation out of neutral (Tyler et al., 1999). The distance in centimeters from the top of the plinth to the medial epicondyle was measured by an assistant using the carpenter’s square. The same therapist measured the same subject once at baseline (test), and once after 8–12 weeks (retest), a time period selected to represent the interval over which a treatment intervention and a meaningful clinical change might occur. Each subject was assigned alternately to a therapist on entry into the study to ensure that each therapist measured half of the subjects. All symptomatic subjects continued to be symptomatic at the time of retesting. 2.3. Data analysis A two-way ANOVA with factors of subject and trial was used to calculate intra-rater intra-class correlation coefficients (ICCs) (Portney and Watkins, 2000) and confidence intervals. Test–retest measurement stability was examined by calculating the standard error of measurement (SEM) as the square root of the within subjects mean square error (Fleiss, 1986; Beckerman et al., 2001). The smallest real difference (SRD) indicates the ability of a measurement to detect a change in the variable of interest for a single subject by establishing a 95% error interval (Beckerman et al., 2001). The interval is based on the amount of measurement error determined by the SEM, the difference of the two variances, and the critical limits of a sampling distribution (1.96 O2 SEM).

2.2. Procedures Measurements were taken from the involved (symptomatic) or dominant (asymptomatic) shoulder only. For subjects with bilateral shoulder pain meeting symptomatic inclusion/exclusion criteria, their dominant shoulder was tested. A goniometer measured internal rotation and supine horizontal adduction ROM.

3. Results There were no significant differences (P40.05) between groups on demographic variables (Table 1). Table 2 reports the ICC values for intra-rater reliability, and the stability of the measures indicated by the SEM

ARTICLE IN PRESS J.D. Borstad et al. / Manual Therapy 12 (2007) 386–389

388 Table 1 Demographic data Variable

Symptomatic Asymptomatic

Age (yr) 47.8711.6 Height (cm) 177.577.2 Weight (kg) 92.1716.9 Percent time working overhead (daily) 36.3726.5 Years in the trade 23.2711.4

51.0711.7 180.977.3 90.3710.8 30.6721.2 23.8713.9

Values represent means and standard deviations.

Table 2 Intrarater reliability (ICC and 95% confidence interval) and test–retest measurement stability (SEM and SRD) Measurement

Group Symptomatic

Asymptomatic

Sidelying horizontal adduction ICC 0.40 (0.09–0.64) SEM 4.3 cm SRD 11.8 cm

0.63 (0.29–0.83) 3.7 cm 10.3 cm

Supine horizontal adduction ICC 0.79 (0.63–0.89) SEM 4.21 SRD 11.51

0.74 (0.47–0.88) 4.51 12.41

Supine internal rotation ICC 0.67 (0.45–0.82) SEM 6.81 SRD 18.91

0.79 (0.55–0.91) 5.61 15.51

ICC ¼ Intraclass correlation coefficients (ICC (3,1)). SEM ¼ standard error of measurement ( ¼ square root of mean square error calculated from one-way ANOVA) (Fleiss, 1986). SRD ¼ smallest real difference ( ¼ 1.96 O2 standard error of measurement) (Beckerman et al., 2001).

and SRD. The sidelying adduction measure was least reliable for both groups and lowest in the symptomatic group, while the stability of the measures was comparable between groups for all three measures.

4. Discussion None of the three measures were determined to be highly reliable or able to detect small clinical changes when used at least 8 weeks apart by the same rater. Lower intra-rater reliability values were demonstrated in symptomatic subjects, with relatively high variability within subjects for all measurements. The results indicate that these measurements may not be adequately stable for a single rater to detect within subject treatment effects beyond 5 days as has been previously reported (Tyler et al., 2000). Tyler et al. (1999) reported ICC values for intra-tester reliability in healthy subjects for the sidelying measure-

ment technique at 0.92–0.95. The smaller ICC value in our analysis (0.63) may be explained by two factors. First, the examiners in the present analysis may not have been as skilful at the measurement as those who developed the test. Consistent subject positioning requirements have been described as crucial for a reliable measurement (Tyler et al., 2000), and those who have performed the test more frequently may be more reliable due to practice effects. Second, the longer time between measurements may have influenced the stability of the measures. However, it is believed that the 8–12 weeks between measurements more closely resembles the time over which clinical change would be expected and assessed. ICC values were generally lower in the symptomatic group which is of particular interest because this group represents a clinical impingement population. The lower measurement values may be influenced by an inability to relax, guarding against pain onset, or pain elicited by the measurement. Past analyses measured only asymptomatic subjects (Riddle et al., 1987; Tyler et al., 1999) but a measurement tested to be reliable on healthy individuals may not be reliable on a symptomatic clinical population. The SEM of 4.3 cm for the sidelying measurement in the symptomatic group indicates that an individual’s true measurement is 78.4 cm from their measured value (1.96 SEM). Similarly, the SRD value for this measure indicates that a test–retest difference score of at least 11.8 cm would be needed to demonstrate true change for an individual subject due to an intervention. Estimating humeral length at 28 cm, this 11.8 cm measurement change would result from an angular change at the glenohumeral joint of approximately 251. Subject trunk rotation would alter the distal humeral distance from the table and be incorrectly interpreted as a change in the true measurement, illustrating the critical requirement for subject positioning with the sidelying measurement. Angular SEM values ranged from 4.21 to 6.81 (Table 2) and indicate that a wide range of values can be considered normal measurement variability within an individual. SRD calculations for supine horizontal adduction and supine internal rotation in the symptomatic group also indicate that significant angular changes in ROM (approximately 121 and 191, respectively) would be needed to be interpreted as a true change in posterior shoulder flexibility for a subject following an 8–12 weeks intervention. It is possible that the high SRD values represent true clinical change occurring in posterior shoulder flexibility for some subjects. However, none of the subjects received an intervention, and the mean values were similar within groups at pre- and post-test (Table 3). Although mean values at post-test appear slightly lower for several of the measures, these differences were

ARTICLE IN PRESS J.D. Borstad et al. / Manual Therapy 12 (2007) 386–389 Table 3 Means (standard deviation) and ranges of measurements by group Measurement

Asymptomatic group

Symptomatic group

Mean (SD)

Mean (SD)

Low–high

Sidelying horizontal adduction (cm) Pre-test 28.9 (5.7) 15.9–39.4 15.9–36.2 Post-test 26.1 (4.8)

31.8 (6.4) 31.2 (4.5)

16.8–45.1 17.8–38.1

Supine horizontal adduction (deg) Pre-test 30.0 (9.1) 10–42 Post-test 27.8 (7.7) 12–43

26.5 (9.0) 24.3 (8.0)

8–45 9–42

Supine internal rotation (deg) Pre-test 50.5 (12.2) 23–77 Post-test 48.4 (11.6) 30–78

46.3 (12.4) 45.4 (11.8)

25–71 23–65

Low–high

Low–high indicates the range of scores from lowest to highest. Significant change from pre-test average.

generally not statistically significant (Table 3). These mean changes were also small (21) relative to the reliability of the measures. If true change had occurred for an individual, it must be attributed to another variable such as time, work conditions, or daily activities. Based on the mean years of work exposure relative to the time frame of the study, none of these variables appear likely to be responsible. Also, as the subjects’ average time since original onset of pain was 5 years, we believe their symptoms were stable. Rather, we believe consistency in positioning, alignment of measurement devices, application of manual forces, detection of scapular motion, and detection of end range are more challenging when measurements do not occur within the same day or on consecutive days, and that these factors are primarily related to the limited stability of the measures. The supine measures have not been directly validated for the measurement of posterior capsule flexibility, although reduced supine horizontal adduction ROM has been moderately associated with humeral anterior/posterior translations (Ludewig and Cook, 2002). Construct validity for the sidelying test was demonstrated based on its correlation with limitations of internal rotation ROM in collegiate baseball pitchers (Tyler et al., 1999). As the loss of internal rotation has not been directly linked to posterior capsule tightness, however, validating the sidelying test based on this association is less than ideal.

5. Conclusion Clinical measures demonstrated to be highly reliable on a healthy population over short periods may not be clinically useful on subjects with pathology tested over longer intervals. It may be necessary to use replicate measures, a cluster of tests, a modification of one of these techniques, or an entirely new validated test to

389

reliably assess posterior shoulder flexibility in a clinical population over treatment intervals.

Acknowledgments This research was supported in part by the Center to Protect Worker’s Rights, the Public Health Service and the University of Iowa under Public Health Service Grant no. U60/CCU317202. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the Center to Protect Worker’s Rights, the Public Health Service, or the University of Iowa. References Bang MD, Deyle GD. Comparison of supervised exercises with and without manual therapy for patients with shoulder impingement syndrome. Journal of Orthopaedic and Sports Physical Therapy 2000;30:126–37. Beckerman H, Roebroeck ME, Lankhorst GJ, Becher JG, Bexemer PD, Verbeek ALM. Smallest real difference, a link between reproducibility and responsiveness. Quality of Life Research 2001;10:571–8. Cohen RB, Williams GR. Impingement syndrome and rotator cuff disease as repetitive motion disorders. Clinical Orthopaedics and Related Research 1998;351:95–101. Deutsch A, Altchek DW, Schwartz E, Otis JC, Warren RF. Radiologic measurement of superior displacement of the humeral head in the impingement syndrome. Journal of Shoulder and Elbow Surgery 1996;5:186–93. Fleiss J. Reliability of measurement. In: Fleiss J, editor. The design and analysis of clinical experiments. New York: Wiley; 1986. Harryman DT, Sidles JA, Clark JM, McQuade KJ, Gibb TD, Matsen FA. Translation of the humeral head on the glenoid with passive glenohumeral motion. Journal of Bone and Joint Surgery 1990;72A(9):1334–43. Ludewig PM, Cook TM. Translations of the humerus in persons with impingement syndrome. Journal of Orthopaedic and Sports Physical Therapy 2002;32(6):248–59. Magee DJ. Orthopedic Physical Assessment. 3rd ed. Philadelphia, PA: WB Saunders; 1997. Portney LG, Watkins MP. Foundations of clinical research. 2nd ed. Upper Saddle River, NJ: Prentice-Hall; 2000. p. 560–7. Riddle DL, Rothstein JM, Lamb RL. Goniometric reliability in a clinical setting. Physical Therapy 1987;67(5):668–73. Terry GC, Hammon D, France P, Norwood LA. The stabilizing function of passive shoulder restraints. American Journal of Sports Medicine 1991;19(1):26–34. Tyler TF, Roy T, Nicholas SJ, Gleim GW. Reliability and validity of a new method of measuring posterior shoulder tightness. Journal of Orthopaedic and Sports Physical Therapy 1999;29(5):262–74. Tyler TF, Nicholas SJ, Roy T, Gleim GW. Quantification of posterior capsule tightness and motion loss in patients with shoulder impingement. American Journal of Sports Medicine 2000;28: 668–73. Ure BM, Tiling T, Kirchner R, Rixen D. The value of clinical shoulder examination in comparison with arthroscopy: a prospective study. Ungallchirurg 1993;96:382–6. Warner JJP, Micheli LJ, Arslanian LE, Kennedy J, Kennedy R. Patterns of flexibility, laxity, and strength in normal shoulders and shoulders with impingement. American Journal of Sports Medicine 1990;18(4):366–75.

ARTICLE IN PRESS


Case report

Acute neck pain: Cervical spine range of motion and position sense prior to and after joint mobilization Peter J. McNaira,, Pierre Porterob,c, Christophe Chiquetc, Grant Mawstona, Francois Lavastec a

Physical Rehabilitation Research Centre, Division of Rehabilitation and Occupation Studies, Auckland University of Technology, Private Bag 92006, Auckland, New Zealand b Institut de Myologie, GH Pitie´-Salpeˆtrie`re, Paris, France c Laboratoire de Biomećanique UMR CNRS 8005, Ecole Nationale Supe´rieure d‘Arts et Me´tiers, Paris, France Received 21 March 2006; received in revised form 28 July 2006; accepted 21 August 2006

Abstract Despite the relatively high prevalence of cervical spine pain, the efficacy of treatment procedures is limited. In the current study, range of motion and proprioception was assessed prior to and after specific cervical spine mobilisation techniques. A 44-year-old male office worker presented with a history of cervical pain of 1 day duration. He had woken with pain, stiffness and a loss of range of motion. Examination findings indicated pain to be at C5–6 on the left side. Measurement of maximal three-dimensional cervical motion was undertaken using a Zebris system. A position matching task tested the individual’s ability to actively reposition their head and neck. The treatment undertaken involved grade III down-slope mobilisations on the left side at C5–6 and C6–7 in supine lying. This technique was then progressed by placing the subject in an upright sitting position, and sustained natural apophyseal glides were performed at C6. Immediately following the treatment, the patient reported a considerable decrease in pain, less difficulty in movement and reduced stiffness. Motion analyses showed the most marked percentage improvements in range of motion after treatment were in flexion (55%), extension (35%), left rotation (56%), and left lateral flexion (22%). Ipsilateral lateral flexion with axial rotation was also notably improved following treatment. No change in proprioceptive ability was found following the treatment. The findings showed that the application of standardised specific mobilisation techniques led to substantial improvements in the range of motion and the restitution of normal coupled motion. r 2006 Elsevier Ltd. All rights reserved. Keywords: Neck pain; Manual therapy; Cervical spine; Range of motion

1. Introduction Neck pain is a relatively common problem with 67% of all individuals suffering neck pain at some stage of their life (Cote et al., 1998). Generally, acute mild neck sprains are resolved within 1 month (Sterling et al., 2003). However, the incidence rate reported over 1 year Corresponding author. Tel.: +64 9 9219999x7143; fax: +64 9 9219620. E-mail address: [email protected] (P.J. McNair).


is estimated to surpass 30%, and chronic pain prevalence approaches 14% (Bovim et al., 1994). In western countries, neck/shoulder pain is reported as one of the major causes of long-term sick leave (Rempel et al., 1992) with considerable associated direct and indirect costs for care (Borghouts et al., 1999). Together with pain, a common feature of neck disorders is reduced cervical range of motion (ROM) (Dall’Alba et al., 2001; Sterling et al., 2003; Armstrong et al., 2005). Furthermore, some studies (Heikkila and Astrom, 1996; Heikkila and Wenngren, 1998; Sterling

ARTICLE IN PRESS P.J. McNair et al. / Manual Therapy 12 (2007) 390–394

2. Presentation A 44-year-old male office worker presented with a history of cervical pain of one day duration. In the morning, he had woken with pain, stiffness and a loss of range of motion. The patient reported pain on the left side in the mid-region of the cervical spine with minor radiation to the mid belly of the left trapezius muscle. The pain had not changed in intensity or location at the time of testing. On a visual analogue scale, his average pain level was 5.5/10 and his worst pain was 6/10. The patient complained of difficulty rotating (6/10) and looking up or down (6/10). He rated stiffness at 4.5/10. The patient had no previous recent history of cervical problems and was otherwise in good health. On examination by a physiotherapist with post graduate qualifications in manipulative physiotherapy, reproduction of pain was primarily on rotation to the left and extension. In lying, down-slope accessory movements to the C5-6 level on the left side (posterior glide of the inferior articular facet of C5 on the superior articular facet of C6) reproduced pain. There were no signs of neurological problems. Measurement of cervical motion was undertaken using a Zebris CMS 70P system. This system uses ultrasound signals which are transmitted from emitters

attached to the segment of interest to receivers attached to a fixed point in space. Using triangulation techniques and the time delay between signals, the coordinates of the segment of interest are calculated. The sampling rate of the system is 15 Hz. The information provided by the receivers is transmitted to a computer based data acquisition and analysis system for subsequent calculation of segment angles. The validity and reliability of the system in the cervical spine has been established by Dvir and Prushansky (2000). In the current study, emitters were positioned and the system calibrated as described by Dvir and Prushansky (2000). One triad was attached on the head and the second was attached to the upper lateral aspect of the arm. The receivers were positioned laterally on the right of the subject at a distance of one metre. The subject was seated and assumed a relaxed posture with feet located parallel on the ground and hands resting freely on the thighs. The subject was blindfolded and instructed to close their eyes, and throughout testing standardised commands were used by the researcher for each task. No feedback with regard to performance was given during any of the tests. With the attachments in place, the neutral position was defined as the anatomical position of the head (vertically upright without rotation), subjectively determined by each subject, and calculated across three trials. Six trials were performed within the three planes of motion, and the order of motion was randomised. All motion was performed at a self-determined pace. The pre-treatment values for flexion–extension, rotation and lateral flexion can be observed in Fig. 1. The position matching task was based on previous studies that investigated spinal position sense (Swinkels and Dolan, 1998; McNair and Heine, 1999). The task tested an individual’s ability to actively reposition their Range of Motion (degrees) R. Lateral Flexion L. Lateral Flexion Movement

et al., 2003), although not all (Rix and Bagust, 2001) report that position sense is affected in subjects with neck disorders. Despite the relatively high prevalence of these disorders, the efficacy of treatment procedures is limited. Joint mobilizations for cervical pain are a commonly used approach but controversy still remains regarding their effectiveness. Indeed, recent reviews (Bronfort et al., 2004; Gross et al., 2002, 2004) concerning the efficacy of manual therapy for mechanically based neck disorders and acute neck pain show that there is inconclusive or no evidence to support their use in the short term. Serendipitous circumstances led to the current study being undertaken. At the time that a research project involving the measurement of position sense together with range of motion measures in cervical spine was being undertaken at the Physical Rehabilitation Research Centre, a potential control subject developed acute neck pain. The subject agreed to come to the laboratory, be tested in the above measures, and undertake treatment for the disorder, and thereafter further retesting. The use of 3-D kinematic analyses to assess neck range of motion and position sense is not typically able to be undertaken in the clinical environment, and hence this situation provided an unusual opportunity to quantify range of motion and position sense prior to and after specific mobilization techniques.

391

R. Rotation L. Rotation Extension Flexion 0

20

40

60

80

Post Treatment (deg) Pre Treatment (deg) Fig. 1. Ranges of motion prior to and after treatment. Data are mean values.


392

undertaken in supine lying (Hing et al., 2003). At both levels, 3 sets of 20 mobilizations were undertaken. The patient reported that this procedure reduced pain. This technique was then progressed by placing the subject in an upright sitting position, and a sustained natural apophyseal glide (SNAG) technique (Mulligan, 2004) was utilized. This involved application of an anterior and superior glide (10 repetitions) to the C6 articular pillar on the left with the patient in slight left side bending. The progression from lying to sitting was chosen because the latter was deemed a more functional posture. The patient was treated on the one occasion only.

head and neck. The patient was blindfolded and seated with the head in a neutral position. He was then asked to move his head into either rotation or flexion–extension. At an arbitrary point in the mid range of motion, the patient was asked to stop, hold the head steady and think about their position. This position was referred to as the ‘‘target position’’. After 5 s, the patient returned to the starting position and then attempted to match the target position. Two trials were undertaken in each direction of motion. The mean of these trials was used in subsequent analyses. Using the angles collected for the target and matched positions during each trial, the mean absolute error was calculated (McNair and Heine, 1999). The absolute error for right and left rotation was 41 and 21, respectively. For flexion and extension, the absolute errors were 21 and 11, respectively.

4. Results Immediately following treatment, the patient had a decrease in pain. The average pain level was 2/10 and the worst pain was 2.5/10. In respect to difficulty rotating and looking up or down, these values were now 2 and 1.5, respectively. Stiffness was rated at 1/10.

3. Treatment The treatment undertaken involved grade III downslope mobilizations on the left side at C5-6 and C6-7 50 40

Axial rot Lat flex Flex/ext

30 Left

Angle (°)

20 10 0 -10 -20

Right

-30 -40 -50 0

5

10

15

20

25

30

35

40

45

35

40

45

Time (sec)

(A) 80

Axial rot Lat flex Flex/ext

60 Left Angle (°)

40 20 0 -20

Right

-40 -60 0 (B)

5

10

15

20

25

30

Time (sec)

Fig. 2. Left and right axial rotation together with the coupled movements of lateral flexion and flexion/extension: (A) pre treatment; and (B) posttreatment.


The most notable percentage improvements in range of motion after treatment were in flexion (55%), extension (35%), left rotation (56%), and left lateral flexion (22%) (see Fig. 1). It was also apparent that during axial rotation, coupled movement (ipsilateral lateral flexion) was different. Prior to treatment the lateral flexion did not have a clear pattern of motion occurring with left and right rotation, particularly to the left side. After treatment, the pattern of ipsilateral lateral flexion with rotation was much more observable (see Figs. 2A and B). For position sense, the absolute error for right and left rotation was unchanged at 41 and 31. For flexion and extension, the absolute errors were unchanged at 21 and 11, respectively. Two days after the testing, the patient indicated that he had no problems with pain, range of motion and stiffness.

5. Discussion The onset of the patient’s problem was not unusual. A recent study by Gordon et al. (2002) reported that up to one-third of young adults wake with neck pain or stiffness each week. Based on normative measurements of range of motion (Dvir and Prushansky, 2000), the per cent decrease for the patient in the current study prior to treatment was 30% for flexion, 28% for extension, 28% and 37% for right and left rotation, respectively, and 45% and 36% for right and left lateral bending, respectively. In the literature, reduced range of motion has been noted in subjects with chronic neck problems. For instance, Armstrong et al. (2005) reported that range of motion was significantly decreased (10–30%) in all directions except lateral bending in patients who had a Quebec Task Force Classification of grade II whiplash. Few papers have reported range of motion for patients with acute neck sprain. However, Sterling et al. (2003) reported ranges of motion deficits up to 20% in patients who had suffered a mild whiplash injury within a month of testing. In subjects with minor neck pain, Lee et al. (2005) reported rotation to be decreased between 1% and 4% with repeated testing. In the current study, following treatment, range of motion was considerably increased in all directions of movement. Other than lateral flexion, the post-treatment values were similar to other studies reporting normative data for range of motion. For instance, using the same equipment as the current study, Dvir and Prushansky (2000) reported ranges of motion for subjects who were primarily women without pathology to be 601, 601, 671, 711 and 421 for flexion, extension, R+L rotation and lateral flexion, respectively. Using inclinometers to measure ROM in males, Nyland and Johnson (2004) also reported very similar values to Dvir and Prushansky (2000) for all directions of motion.

393

The choice of treatment technique was based on the principles outlined by Hing et al. (2003). Pain was on the left side only and range of motion deficits were most apparent in both left rotation and side bending, together with flexion and extension. As ipsilateral rotation and side bending are coupled (Bogduk and Mercer, 2000) in the mid to lower cervical spine, a down-slope mobilization technique to the left was performed. This technique was followed immediately by a SNAG technique in which the patient performed active motion while the therapist sustained a facet joint glide (Mulligan, 2004). Absolute error values for position sense (1–41) were unchanged after treatment and similar to subjects without pathology reported upon by Armstrong et al. (2005). Sterling et al. (2003) reported similar error values in sub-acute whiplash patients with mild symptoms. These authors noted that subjects with more severe symptoms after whiplash had increased position sense deficits. Interestingly, in subjects with minor neck pain, Lee et al. (2005) noted improved ability in movement discrimination tests. In summary, a unique opportunity allowed the assessment of motion and position sense in an individual with acute idiopathic neck pain. Range of motion was notably decreased in most directions of motion while position sense was within normal limits. The application of standardised specific mobilization techniques led to substantial improvements in range of motion and the restitution of normal coupled motion. References Armstrong B, McNair P, Williams M. Head and neck position sense in whiplash patients and healthy individuals and the effect of the craniocervical flexion action. Clinical Biomechanics 2005;20:675–84. Bogduk N, Mercer S. Biomechanics of the cervical spine. I: normal kinematics. Clinical Biomechanics 2000;15:633–48. Borghouts J, Koes B, Bouter L. Cost-of-illness in neck pain in the Netherlands in 1996. Pain 1999;80:629–36. Bovim G, Schrader H, Sand T. Neck pain in the general population. Spine 1994;19(12):1307–9. Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine Journal 2004;4(3):335–56. Cote P, Cassidy J, Carroll L. The Saskatchewan health and back pain survey. The prevalence of neck pain and related disability in Saskatchewan adults. Spine 1998;23:1689–98. Dall’Alba PT, Sterling MM, Treleaven JM, Edwards SL, Jull GA. Cervical range of motion discriminates between asymptomatic persons and those with whiplash. Spine 2001;26:2090–4. Dvir Z, Prushansky T. Reproducibility and instrument validity of a new ultrasonography-based system for measuring cervical spine kinematics. Clinical Biomechanics 2000;15(9):658–64. Gordon S, Trott P, Grimmer K. Waking cervical pain and stiffness, headache, scapular or arm pain: gender and age effects. Australian Journal of Physiotherapy 2002;48:9–15. Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, et al. Cervical Overview Group. A Cochrane review of manipulation and mobilization for mechanical neck disorders. Spine 2004;29(14):1541–8.


P.J. McNair et al. / Manual Therapy 12 (2007) 390–394

Gross AR, Kay TM, Kennedy C, Gasner D, Hurley L, Yardley K, et al. Clinical practice guideline on the use of manipulation or mobilization in the treatment of adults with mechanical neck disorders. Manual Therapy 2002;7(4):193–205. Heikkila H, Astrom PG. Cervicocephalic kinesthetic sensibility in patients with whiplash injury. Scandinavian Journal Rehabilitation Medicine 1996;28:133–8. Heikkila HV, Wenngren BI. Cervicocephalic kinesthetic sensibility, active range of cervical motion, and oculomotor function in patients with whiplash injury. Archives of Physical Medicine and Rehabilitation 1998;79:1089–94. Hing W, Reid D, Monaghan M. Manipulation of the cervical spine. Manual Therapy 2003;8:2–9. Lee H, Nicholson L, Adams R, Bae S. Proprioception and rotation sensitisation associated with sub-clinical neck pain. Spine 2005;30:60–7. McNair P, Heine P. Trunk proprioception: enhancement through lumbar bracing. Archives of Physical Medicine and Rehabilitation 1999;80:96–9.

Mulligan B. Manual therapy, 5th ed. New Zealand: APN Print Ltd; 2004. Nyland J, Johnson D. Collegiate football players display more acute cervical spine mobility then high school football players. Journal of Athletic Training 2004;39(2):146–50. Rempel D, Harrison R, Barnhart S. Work related cumulative trauma disorders of the upper extremity. Journal of the American Medical Association 1992;267(6):838–42. Rix GD, Bagust J. Cervicocephalic kinesthetic sensibility in patients with chronic, nontraumatic cervical spine pain. Archives of Physical Medicine and Rehabilitation 2001;82:911–9. Sterling M, Jull G, Vincenzino B, Kenardy J, Darnell R. Development of motor system dysfunction following whiplash injury. Pain 2003;103:65–73. Swinkels A, Dolan P. Regional assessment of joint position sense in the spine. Spine 1998;23:590–7.

Manual Therapy (2007) 12(4), 395

Diary of events

2nd World Congress on Manual Therapy and Sport Rehabilitation, The Spine II, in Roma Italy 6th–8th of March 2009 www.newmaster.it

First international Fascia Research Congress Basic Science and Implication for Conventional and Complementary Health Care 4–5 October 2007 The Conference Center, Harvard Medical School Boston MA http://www.fascia2007.com

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]

5th International Course on the Hand October 21–25, 2007 Target audience: colleagues of the following disciplines; physical medicine and rehabilitation, plastic- and hand surgery, physical- and occupational therapy and other health care professionals, interested in the topic of the hand Lectures include: Prof. Dr. S.E.R Hovius, Ton A.R. Schreuders PT, PhD and G. Van Strein MSc Accreditation applied for at the EACCME (Accreditation Council) of the European Union of Medical Specialists (UEMS) More information and registration: website: www.vitalmedbodrum.com E-mail: [email protected]

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 IFOMT Congress, Rotterdam 8th–13th June 2008 The Scientific Committee wishes to invite abstract submissions for Platform and Poster Presentations. Instructions are now online and available at www.ifomt2008.nl

395

ARTICLE IN PRESS

Manual Therapy 12 (2007) e1 www.elsevier.com/locate/math

Book review Clinical Application of Neuromuscular Techniques. Practical Case Study Exercises, L. Chaitow, J. DeLany. Elsevier, Churchill Livingstone, New York, NY (2005). 289pp., Price £21.99, ISBN: 0443100004 Clinical Application of Neuromuscular Techniques, Practical Case Study Exercises by Leon Chaitow and Judith DeLany provides a collection of 34 patient cases authored by 19 different ‘‘Neuromuscular Therapists’’ presenting a wide range of clinical presentations. Cases are systematically presented under the headings of Profile, Health or Family History, Presenting Complaint(s), Significant Contributing Factors, Clinical Evidence and Previous Treatment, Questions for Reader, Examination, Clinical Impression and Treatment or Action Suggested, and Key Points with some cases also including sections on Further Reading, References and Websites Worth a Visit. Interspersed through most cases are additional Boxes with supportive academic content pertaining to aspects of the case and very good Red Flag Boxes highlighting clinical features that warrant immediate concern and medical consultation. The intention of this book is to assist readers’ integration of neuromuscular techniques and complementary medicine (e.g. diet) into their practice. This is achieved through inclusion of posture, lifestyle, biomechanical and psychosocial considerations through all cases with corresponding management suggestions. Consistent with the book’s focus, physical impairment of muscle, typically in the form of trigger points, but also with respect to posture, habits of movement, muscle length and to some respect motor control, are thoroughly considered. While joint impairment is included, this is

doi:10.1016/j.math.2007.05.007

considerably more superficial in both assessment and management with a notable lack of contemporary content and referencing. The case authors’ clinical reasoning is essentially a summary of management suggestions, not explicitly linked to supporting or negating evidence, with no discussion of recommended outcome measures to monitor or thoughts on progression of treatment. While listing of management options in this manner is very useful, case reasoning could be developed and articulated better. An interesting, but also frustrating feature of this book is its extensive use of highlighting key words in red throughout its cases. Highlighted words can then be looked up in the index of the two companion books ‘‘Clinical Application of Neuromuscular Techniques, Volumes 1 and 2’’ for definition and explanation. Many of the words highlighted refer to assessment or management procedures that are somewhat specialised to ‘‘Neuromuscular Therapists’’ and their philosophy of practice making the cases less accessible to manual therapists without this background. Musculoskeletal physiotherapy does not feature very positively with the majority of the cases either highlighting the poor results of previous physiotherapy management received or making recommendations for osteopathic, chiropractic but not physiotherapy referral. As such I anticipate this book is likely to be of greatest interest to ‘‘Neuromuscular Therapists’’.

M.A. Jones School of Health sciences, University of South Australian, North Terrace, Adelaide, SA 5000, Australia E-mail address: [email protected]

ARTICLE IN PRESS


Book review The Biomechanics of Back Pain, M. Adams, N. Bogduk, K. Burton, P. Dolan. Elsevier Churchill Livingstone (2006). 316pp., £32.99, ISBN: 0443100683 This is an excellent book on anatomy and biomechanics of the lumbosacral spine, its elements, joints and surrounding stabilizing apparatus in normal and in pathologic conditions. Broad attention is placed on biology and metabolism. Growth, ageing and degeneration are considered with remarkable relativity. Traumatology is relatively briefly discussed. The treatment chapters clearly are not the emphasis of this book: they briefly contain general guidelines but no specific techniques. The chapter on surgical methods gives clear indications for different types of surgery in different pathologies. Many fusion techniques are extensively discussed and compared. Recent vertebroplasty techniques are not included, presumably because, at present, only very few follow up studies and no RCT’s are available on these techniques.

doi:10.1016/j.math.2007.05.005

All the illustrations are in black and white. The majority are excellent schematic drawings, including well known drawings from other publications by Prof. Bogduk. Six pages of beautiful colour plates are kept outside the body of text. These pictures would certainly be better placed in the appropriate chapters of the book, or at least reference to these pictures should be included in the body of different chapters. This book is a very useful reminder of concrete anatomy and biomechanics related lumbosacral problems, allowing professionals to refresh anatomy and biomechanics without spending hours trying to extract essential information from general textbooks. It also gives an update of the most recent conclusions from RCT’ s, reviews and guidelines.

E. Barbaix Anatomist RijksUniversiteit Gent, Belgium E-mail address: [email protected]

ARTICLE IN PRESS


Book review Rehabilitation of the Spine. A Practitioners Manual, C. Liebenson. 2nd ed. Elsevier/Churchill Livingstone, New York (2007). £99.95, 972pp., ISBN: 0781729971 With over 900 pages and 39 chapters, the size of this text is a reminder of the diversity of opinion, and methods of management, of spinal pain disorders. The author, Craig Liebenson has written or co-authored 14 chapters, and the remainder have been written by invited contributors. Much of the text is focused on the lumbar spine with relatively less attention given to cervical spine pain. Surprisingly, not one chapter is devoted to disorders of the thoracic spine and their management. The introductory chapters provide an overview of some fundamental concepts in spinal pain including the anatomical sources of pain, mechanisms of injury, pain physiology and the biopsychosocial model. These chapters are well written and supported by relevant literature. The chapters on assessment were somewhat disappointing as the focus was on the diagnostic triage of spinal pain, including screening for psychosocial ‘yellow flags’. The only chapter on physical examination from a physical therapy perspective was in relation to muscle imbalance, and the remaining 3 chapters in this section reviewed physical performance testing. What appears to be missing here is an overview of the clinical examination process for patients with spinal pain, and the clinical reasoning process, which would guide the interpretation of the information obtained. The absence of this information makes the application of the following chapters on physical treatment difficult to interpret. This would be particularly the case for students of the physical therapy professions, or clinicians looking for a stronger framework to support their approach to patient management. In the next section of the text there are 9 chapters which describe ‘acute care management’ which include treatment approaches such as massage, muscle release

doi:10.1016/j.math.2007.05.003

techniques, rehabilitation of breathing patterns, the McKenzie method, neural mobilisation and joint manipulation. Specifically how these treatment methods relate to the management of acute pain is not stated, and it seems that a number would be equally or better suited to the management of non-acute conditions. The following 10 chapters on ‘recovery care management’ mostly present various approaches to trunk muscle strengthening around the ‘stabilisation’ theme. While there is a lot of information presented and some useful ideas for exercise prescription, these chapters are somewhat repetitive, and again, in many cases do not provide a good framework in relation to the types of patient presentation where these approaches may be most useful. Equally disappointing were the chapters on ‘integrated management’ which surprisingly presented similar material to the preceding chapters, and with case studies linked to anatomical diagnoses such as ‘facet syndrome’ and ‘discogenic radiculopathy’. This approach was clearly inconsistent with the introductory chapters, which highlight the problems with anatomical diagnoses, and emphasise a broader approach to the evaluation of ‘non-specific’ spinal pain. For clinicians with a sound approach to clinical reasoning and treatment prescription, this text may provide a range of new ideas or treatment techniques, which could be integrated into patient management. However, for the inexperienced clinician or manual therapy student the range of treatment approaches presented may be somewhat overwhelming, and of less value in relation to the common problem of deciding which approach to treatment is likely to be most useful.

S.J. Edmondston School of Physiotheraphy, Curtin University of Technology, P.O. Box U1987, Perth, WA 6845, Australia E-mail address: [email protected]

ARTICLE IN PRESS


Book review Physiotherapeutic Management of Lumbar Spine Pathology, first ed. D. MacDonald, R. Jemmett. Novont Health, Edmonton AB, USA (2005), $44.95, 199pp., ISBN: 9024234344 I was pleased to be asked to review this book as I am always on the lookout for books that underpin and extend my clinical practice using an up to date evidence base. However, the title was a little misleading as rather than a concise text on spinal pathology, it focused on the area of segmental dysfunction. Nevertheless, I found it an easy book to read and as the authors’ state, it is a ‘‘useful reference tool for evidence based management of patients with segmental dysfunction’’. The first three chapters deal with an overview of relevant anatomy, biomechanics and spinal pathology including motor control dysfunction with an up to date reference list. The subsequent chapters deal with the

doi:10.1016/j.math.2007.05.002

assessment and management of segmental dysfunction and the clinical reasoning behind this. These chapters are reinforced by clear photos demonstrating points and techniques. Chapter seven consists of 10 case studies that the authors have taken from their clinical practice with the aim of bringing together the information presented in their text. The final chapter consists of invited peer review commentaries, which is uncommon in texts, but provides a balanced view of the text as a whole. Overall, the authors have produced a concise and useful reference of lumbar dysfunction which is of interest to both clinicians and students. Lyndsay Alexander Robert Gordon University, Health Sciences, Abderdeen, Scotland, UK E-mail address: [email protected]

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 4, Pages 241-358 (November 2006)

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

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 13, Issue 4, Pages 277-372 (August 2008)

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

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 10, Issue 1, Pages 1-92 (February 2005)

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

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 11, Issue 1, Pages 1-90 (February 2006)

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 9, Issue 3, Pages 123-182 (August 2004)

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 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 4, Pages 241-358 (November 2006)

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

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 13, Issue 4, Pages 277-372 (August 2008)

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

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 10, Issue 1, Pages 1-92 (February 2005)

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

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 11, Issue 1, Pages 1-90 (February 2006)

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 9, Issue 3, Pages 123-182 (August 2004)

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

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

Recommend Documents