Manual Therapy (2003) 8(1), 1 1356-689X/03/$ - see front matter # 2003 Published by Elsevier Science Ltd. doi:10.1054/math.2002.0492
Editorial
Editorials and Scholarly Debate analysis of the work published in this or past issues, we would like you to use the facility of published comment in the letters to editors section. It is likely that others may or may not agree with you and they too could write to the Journal. Few persons have used this section of the journal to date. We encourage you to do so in order that some healthy, challenging and scholarly debate can emerge. Such debate is a sign of a vibrant profession. On another issue, you will notice that another change of content has occurred in this issue of the Journal, following other changes such as the amended name change of the Journal and formalisation of Technical and Measurement Section. The latest change is that there is no longer a bibliography section. The Editorial Board considered that the information carried in this section is freely available to the majority of the readership using the current internet search facilities available worldwide. Your comments on this decision would be welcome as would any suggestion for other modifications of the Journal. We look forward to developing a very active ‘Letters to the Editor’ section of the journal to further foster international debate.
Welcome to volume 8 of the Manual Therapy Journal and the first editorial for the volume. In this editorial we seek to increase the interaction between the Journal and its readers. The editorial offers the editors or invited persons the opportunity to write opinions on current trends in clinical practice, research or other academic topics as well as professional issues pertaining to the practice of manual and musculoskeletal therapy. Editorials raise what we believe to be ‘‘hot topics’’ which relate to the current political climate and new innovations in musculoskeletal therapy research and clinical practice. It is hoped that the editorials are thought provoking, sometimes challenging and perhaps inspiring to some readers. On occasions, editorials can produce counter-irritation in some of the readership, personifying some of your thoughts and feelings about musculoskeletal therapy. What we wish to encourage is further interaction between the Journal and its readership. We very much welcome your comments on Journal content and indeed suggestions for editorials in areas of politics or aspects of clinical practice which you believe require comment. There is a questionnaire about the Journal on the Journal’s web site. However, if you have something to say about the issues raised in editorials or some constructive critical
Ann Moore and Gwen Jull Editors
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Manual Therapy (2003) 8(1), 2–9 1356-689X/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved. doi:10.1054/math.2002.0487
Masterclass
Manipulation of the cervical spine W. A. Hing*, D. A. Reid*, M. Monaghanw *School of Physiotherapy, Faculty of Health Studies, Auckland University of Technology, Auckland, New Zealand, w Physical Medicine Centre, Nelson, New Zealand
SUMMARY. In New Zealand, a new approach to manual therapy of the cervical spine has integrated physiotherapy and osteopathy techniques. The combination of the philosophies of these two professions has added a new dimension to the management of cervical spine pain. Emphasis is placed on issues of safety, such as the degree of cervical rotation and comfort for both the patient and the therapist. This is combined with biomechanical considerations, which have made the teaching and learning of these manipulative techniques less complicated and easily progressed from palpation to mobilization and onto manipulation. Appropriate patient screening and selection identified through thorough subjective and objective assessments are important aspects of this approach and reflective interpretation of all clinical findings is essential. The refinement of cervical joint positioning and an increased anatomical awareness have led to the utilization of new upper cervical high-velocity thrust techniques. Consequently, it is envisaged that an increase in the safety and specificity of cervical manipulative techniques is achieved. r 2003 Elsevier Science Ltd. All rights reserved.
Existing techniques have been modified and are considered easy to learn, as a result of progressing from assessment to treatment and from mobilization to manipulation. The purpose of this paper is to discuss manipulation of the cervical spine, detail the teaching strategies developed for cervical spine manipulation in New Zealand, outline the clinical assessment and provide examples of the procedures in practice.
INTRODUCTION In New Zealand, manipulative physiotherapy of the spine has evolved considerably in recent years. A fresh approach, integrating physiotherapy and osteopathy techniques, has emerged adding a new dimension to the management of cervical spine pain. Michael Monaghan, a physiotherapist, who subsequently trained to be an osteopath, joined the teaching faculty of the New Zealand Manipulative Physiotherapists Association (NZMPA) and this has facilitated the inclusion of this osteopathic approach. In combining these professions’ philosophies, great emphasis has been placed on issues of safety and comfort for both the patient and the therapist (Monaghan, 2001). In addition, there is an increased consideration for the anatomical and biomechanical attributes specific to this region of the cervical spine.
Current New Zealand model Since the early 1970s, the teaching of manual and manipulative therapy in New Zealand has not adhered to any particular philosophy, being an eclectic approach and including aspects of Maitland, Kaltenborn, McKenzie, Mulligan, Cyriax and other philosophies and principles. Courses have been run by special interest groups of the New Zealand Society of Physiotherapists (NZSP) and by New Zealand universities and have met the International Federation of Orthopaedic Manual Therapists’ (IFOMT) educational standards. The physiotherapy-osteopathic approach to treatment and management of the cervical spine instigated in the mid-1980s was in contrast to the older torsional techniques of past medical manipulators performed
W. A. Hing, MSc (Hons), ADP (OMT), Dip MT, Dip Phys, D. A. Reid, PGD (Manip Phys), Dip MT, BSc, Dip Phys, School of Physiotherapy, Faculty of Health Studies, Auckland, New Zealand, M. Monaghan, D.O., Dip MT, Dip Phys, Physical Medicine Centre, Nelson, New Zealand. Correspondence to: WH, School of Physiotherapy, Faculty of Health Studies, Auckland University of Technology, Private Bag 92006, Auckland 1020, New Zealand. Tel.: +64 9 9179999 x7800; Fax: +64 9 9179620; E-mail:
[email protected] 2
Manipulation of the cervical spine 3
at end of range of movement often with traction (Cyriax 1984). Techniques applied in a more controlled, comfortable manner carried out in midphysiological range appeared to be far less traumatic to the spine. In addition, some types of physiotherapy assessment and treatment were traditionally carried out in the prone position. However, a number of patients are incapable of, or have great difficulty in, assuming the prone position, (i.e. pregnant women, patients with thoracic kyphosis, the elderly and obese patients). The integration of osteopathic principles utilizes mainly supine patient positioning. These refined techniques and alternative positions offer a number of advantages that include improved therapist and patient comfort and communication. Techniques may be modified with feedback from the patient who is able to see the therapist which may reduce feelings of anxiety. These simple modifications enables a greater variety of patients to receive effective treatment for cervical pain and restricted range of motion. The therapist comfort has also been enhanced by improvements in the therapist handling and body positioning. The supine position is also preferred for assessment and can lead directly to segmental mobilization techniques and on to manipulative procedures. PATIENT ASSESSMENT Integration of the osteopathic model into physiotherapy assessment of the cervical spine requires the
practitioner to recognize all components of somatic dysfunction (Greenman, 1966; Hartman 1997; Gibbons & Tehan 2000) in the presenting patient. Somatic dysfunction is defined as ‘impaired or altered function related to components of the somatic system such as muscles, ligaments, bone and joints’ (Greenman 1966). The first stage of recognizing a patient with somatic dysfunction is derived from the subjective history. The key findings of the subjective history may be summarized under the following headings: site, stage, severity, stability, nature, irritability, progression, regularity and diagnosis (provisional) of the patient’s symptoms. These findings create the acronym SSSSNIPRD presented in Table 1. A comprehensive subjective examination should also allow the therapist to determine any contraindications to mobilization and manipulation. The second stage is the ability to combine the palpatory and objective examination findings with the subjective information gained from the ‘SSSSNIPRD’ analyses. If what is ‘felt’ is consistent with a diagnosis of somatic dysfunction, then the treatment will follow a logical progression from the assessment. The key features of the objective examination originates from the acronym ‘ARTT’ (Greenman 1966). These features are asymmetry, range of motion, tissue texture changes and tissue tenderness. In the New Zealand model, ARTT has been modified with the addition of relevant pain pattern recognition, now forming the acronym PARTT:
Table 1. SSSSNIPRD Summary Site
3
The area and site of the symptoms are clearly marked on the body chart with symptom details.
Stage
3
Is the problem acute, subacute or chronic?
Severity
3
The level of pain as determined by the patient. Pain intensity is measured with a visual analogue scale.
Stability
3
Is the condition improving, staying the same or worsening?
Nature
3
The patient’s description of their symptoms – may also be used to determine mechanical or inflammatory pain.
Irritability
3
The ease with which the symptoms are provoked, the intensity to which they arise and importantly how quickly they resolve.
Progression and rate
3
How long will the condition take to resolve and how many treatments will be required to achieve this?
Regular or irregular
3
Do the symptoms fit a regular or irregular pattern of presentation? This may include psych-social factors.
Diagnosis – provisional
3
Provisional diagnosis provided by the therapist.
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Manual Therapy (2003) 8(1), 2–9
4 Manual Therapy
function, treatment repetition, grade, amplitude and velocity of the techniques will be determined from a compilation of the SSSSNIPRD analysis and the PARTT findings. Safety aspects
Fig. 1FSegmental blocking. Example of blocking for left rotation. The therapist’s right thumb blocks the spinous process moving to the right.
Pain: The pain pattern will have been established in the history taking. This will now be tested against active movement and later passive segmental assessmentFboth physiological and accessory. Asymmetry: This needs to be related to function as, on its own, it is not relevant. An example in the cervical spine is an acute locking at C2-3 held in flexion and rotation away from the site of pain (wry neck). Functional movements would confirm this with an asymmetrical presentation. Asymmetry is not as common in the cervical spine as it is in the lumbar region. Range of movement changes: This clinical sign is the most useful, as it relates directly to the function of the cervical spine. It most often defines the direction of movement loss and, by pattern, may give a clue to the joint level. Diagnosis may be further clarified by simple active movement and segmental blocking (Figure 1). Special note is made of any referred symptoms on the active tests, whether somatic or radicular. These responses are correlated to the history findings. Passive intersegmental assessment may add information to the active tests by way of: (a) level confirmation, (b) quality of motion and (c) reactivity of tissues to movement. Tissue tension and texture changes: Information on the state of the soft tissues may also be gauged in sitting or supine lying, before assessing the active movements. The osteopathic concept places particular emphasis on this aspect of examination. Once the subjective and objective assessments are complete, confirming the presence of somatic dysManual Therapy (2003) 8(1), 2–9
With respect to the cervical spine, the osteopathic approach allows the clinician to gain information from a series of assessment procedures that test the movements of the small joints in a logical, sequential and graded sequence. These methods allow interpretation of ‘end feel’ and PARTTs. The nature and progression of the sequence allow the therapist to gain information on both joint motion and ligamentous integrity. Grading scales designed by Maitland et al. (2001) and Kaltenborn (1989) are still used to guide the therapist and can be used as an objective measure of the patient’s progress. However, in the osteopathic model, there is considerable emphasis placed on the physical assessment of the joint ‘barrier’ (Greenman 1966; Hartman 1997) and end feel. In this sense, treatment will either be short of the barrier (for a more painful problem) or into the barrier (for a more joint stiffness problem). As the patient’s signs and symptoms improve, the amount of force used to engage the barrier can be progressed. Recent literature (Thiel et al. 1994; Kuether et al. 1997) has documented that full cervical rotation and traction are the most provocative positions for vertebral artery compromise. Given that the older style of high-velocity manipulative techniques utilize end physiological range, often with a traction component, the potential for vertebral artery damage from a technical perspective was evident (Reid & Hing 2001). These factors have led to a potential reduction in the amount of manual therapy used in the cervical spine as a consequence of the potential dangers to the vertebral artery (Gibbons & Tehan 2001; Clubb 2002). The newly implemented Musculoskeletal Physiotherapy Australia (MPA) Vertebrobasilar Insufficiency (VBI) guidelines have addressed these issues with a greater emphasis on the subjective examination and the clinical reasoning process rather than the objective testing (Grant 1996; Magarey et al. 2000). Although there has been a considerable amount of evidence related to the reliability and validity of objective vertebral artery testing (Karnik et al. 1987; Refshauge 1994; Cote et al. 1996), there has been little evaluation of the physiotherapy techniques used in the cervical spine area (Reid & Hing 2001). Once the findings of the assessments have been established and a high velocity thrust (HVT) technique in the cervical spine indicated, then the type of techniques used are often termed ‘combined leverage, spinal # 2003 Elsevier Science Ltd. All rights reserved.
Manipulation of the cervical spine 5
Fig. 2FShort lever PAIVM upslope. (A) Skeletal view showing hand and finger positioning; (B) patient view with additional cervical rotation to view finger positioning. The sensor finger (a) and the motive finger (b) are marked.
manipulative thrust techniques’ (McCarthy 2001). Using the leverage of the head and those joints not included in the HVT, forces can be directed to the target joints. Thus, there is little stress on the rest of the neck and the elimination of full physiological cervical spine locking positions. In this way, the amount of cervical rotation will be minimized which has been shown to reduce the amount of stress and kinking of the vertebral artery (Haynes et al. 2002). This approach also provides a logical progression with a continuum, from palpation to mobilization then manipulation, particularly with the patient positioned in supine lying, a balance that is not achievable if palpation and mobilization are carried out in the prone position. Indications for manipulation There are a number of clinical indications that are useful in guiding therapists in the use of an HVT technique (Gibbons & Tehan 2000, 2001; McCarthy 2001): K
K
K
K
K
As a first option in acute cases, for example, if a patient is seen soon after an incident and muscle guarding is not extensive. This option is suitable if there are only two biomechanically linked directions of movement loss. If the problem is mechanical in nature and fits with a biomechanical pattern that is regular and recognizable (see Table 1, SSSSNIPRD analysis). There are no contraindications to manipulation and ligament integrity and the absence of VBI signs has been confirmed. Where the joint end feel is firm (not springy or empty) and is consistent with the clinical barrier identified during the mobilization techniques. The patient has been responding favourably through a progression of mobilization procedures, but has not progressed any further than expected.
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The next section of this paper details some of the techniques used in the New Zealand approach to cervical spine mobilization and manipulation. Commonly used manual therapy terms, utilized in the New Zealand physiotherapy and osteopathic manipulative approach, are described in Table 2. TECHNIQUES Passive intervertebral joint testing Localized passive movement has been traditionally utilized by physiotherapists and manual therapy professionals for many years. One of the most wellknown paradigms of passive movement spinal treatment is the Maitland Concept (Maitland et al. 2001). Passive spinal joint assessment consists of both passive accessory intervertebral movement (PAIVMs) and passive physiological intervertebral movement (PPIVMs). Passive accessory intervertebral movement (PAIVMS) So-called short lever techniques (Table 2) are useful for the assessment of joint glide and treatment of acute presentations and elderly patients. With all assessment and treatment using the ‘new’ approach, the patient is positioned in supine with the head supported by a pillow, while the therapist is positioned standing at the top of the plinth. Figure 2 illustrates the hand contact points and finger placement on a skeletal view (Fig. 2A) and on a patient (Fig. 2B). The therapist’s left hand is the ‘sensor’ while his right is the motive hand. The ‘sensor’ index finger (a) is placed on the articular pillar of the vertebral level to be tested (Fig. 2A). This finger senses the movement of the segment up or down the facet joint plane. The motive hand is placed with the hypothenar region contacting the occiput. By overlapping the sensing finger with the Manual Therapy (2003) 8(1), 2–9
6 Manual Therapy Table 2. Commonly used terms Term
Description
Sensing hand
This is the hand that is in direct contact with the joint to be tested. It may cover adjacent joint margins or adjacent bony point. A thorough knowledge of the anatomical landmarks is required to isolate these points.
Motive hand
This is the hand that creates the motion. It may be on another part of the head or neck or may be over the sensing hand. It is important to maintain the separate functions of these hands to increase the sensitivity of the information you are trying to gather.
Contact hand
This is the hand during a mobilising technique that is in direct contact with the joint to be mobilised.
Supportive hand
This hand supports the head during the mobilising movement and adds a counter pressure to the mobilising hand.
Short lever movements
These are testing movements or mobilisations that are in direct contact with the segments to be moved. The sensing finger and motive hand will create the movement together. They will generate accessory movement in the joint. They are useful for testing, acute spines and elderly spines that need minimal leverage and have limited physiological motion. Also applicable for hypermobile necks.
Long lever movements
These are testing and treating movements that utilise the locking of two or more cervical segments to create a lever. These are often helpful when assessing physiological movements and make the movement more specific to a particular spinal level. Combinations of rotation and side bending of the spine are utilised to achieve locking of the cervical joints.
Cradle hold
Refers to techniques where both hands cradle the head, using the soft parts of the hypothenar eminance. This allows the fingertips to remain free to palpate specific levels or create other movements. These are commonly used for long lever movements.
Chin hold
This is an alternative grip of the head where the therapist’s non-contact arm is placed along the side of the face with either a small amount of contact with the chin or none at all. This grip is used for manipulation where the therapist may have small hands making the cradle hold difficult, or for heavier heads and necks.
Upslope movement
Movements of the facet joints in the mid to lower cervical spine that occur during contra-lateral rotation or contra-lateral side bending.
Downslope movement
Movements of the facet joints in the mid to lower cervical spine that occur during ipsilateral side-bending, rotation and extention.
Fig. 3FLong lever PPIVM F mid-cervical rotation upslope to the right.
index finger of the motive hand (b), the desired movement is created, either cranially (upslope) or caudally (downslope), along the facet joint plane. If the sensing finger is over the spinous process then a central postero-anterior motion is tested. With practice, this becomes a comfortable and efficient assessment procedure (Monaghan 2001). Other directions are achieved as a modification of the above. Passive physiological intervertebral movement (PPIVMs) These mobilizations employ the principles of using a long lever (Table 2). That is, the head and neck are utilized in such a way as to create locking of the joints Manual Therapy (2003) 8(1), 2–9
Fig. 4FDownslope mobilization of the mid-cervical spine (arrow indicates direction of mobilization).
above the one to be tested. The patient position is in supine with their head supported on a pillow, while the therapist stands at the top of the plinth. Figure 3 illustrates a long lever PPIVM upslope, where the middle finger of the left sensing hand is placed over the spinous process of the level to be tested, while the index finger is over the articular pillar. These fingers move the segment up the facet plane (often referred to as upslope or flexion of the facet joint) to test, in this case, right rotation. The direction of movement should be 451 in an upwards direction to the opposite eye. The motive hand (right) cradles the side of the head over the zygomatic arch. This hand also keeps the head in # 2003 Elsevier Science Ltd. All rights reserved.
Manipulation of the cervical spine 7
some side flexion (in this case to the left). Both hands move together, to create right rotation, with the left hand predominantly sensing and the right hand being supportive. Mobilization techniques Mobilization requires the sensing hand to firm up and act as a fulcrum, while the motive hand directs the cervical spine up to the end range or clinical barrier. At this point a graded, rhythmic mobilization may be carried out. Figure 4 illustrates a long lever downslope. This technique may also be referred to as side bending or an extension mobilization. It is used to restore a loss of rotation and extension to the side of movement. The sensing hand can assist in the mobilization, but its prime function is to sense change at the level being treated. This feedback is essential to give control and safety to the technique. Manipulation techniques The sequence of palpation, mobilization and finally to manipulation, is easily learned, logical, and readily accepted by students. Other systems of manipulation may not flow as above, and the endpoint at which the thrust is applied is often poorly located, being either too tight, leading to a painful jarring, or too loose, leading to a wide amplitude thrust which may compromise safety. The use of a segmental approach also removes the emphasis from manipulation and leaves it as a natural treatment progression from mobilization. The palpation determines the quality of movement and provides information toward the decision process of treatment selection. Progressing to an HVT follows the previously described principles of mobilization, with the sensing hand firmed up and engaging the articular pillar and spinous process,
Fig. 5FCradle hold upslope on the right, HVT mid-cervical spine (arrow indicates direction of thrust). # 2003 Elsevier Science Ltd. All rights reserved.
while the motive hand cradles the occiput, directing the cervical spine to the end range or clinical barrier. The graded, rhythmic mobilization is simply progressed to a manipulative thrust that follows the desired direction (Monaghan 2001). There are two general approaches that can be considered when mobilizing and manipulating the cervical spine, direct and indirect. Direct techniques Techniques consist of the applied glide or thrust parallel to the facet joint plane. This can be referred to as a direct technique applied to that joint and is referred to as ‘upslope’ or ‘downslope’ techniques depending on the direction of the thrust. For example, consider a C4–5 segment presenting with a loss of left rotation due to a restriction of the right C4 facet gliding upwards (or cranially) on C5. A thrust is given on right C4 in an upslope (cranial) direction parallel to the facet plane (Fig. 5). In the scenario of a clinical loss of side bend of the right C5, a thrust is given on the right C4 in a downward (caudal) direction, parallel to the facet plane which is called a downslope technique (Fig. 4). If a cavitation occurs, in both the described techniques, it would occur beneath the contact hand. Indirect gapping technique This technique involves the direction of glide at right angles to the facet joint plane. It is referred to as an indirect technique. In this instance, the HVT is given on one side of the cervical spine with the aim of gapping the same level on the opposite side, an example being a thrust against the left C4–5 to ‘affect’ the right C4–5 joint. The indirect technique appears to improve all movements and appears to be a popular choice in circumstances such as an acute case of sudden onset of neck pain, as an initial treatment, as a progression or where the contact point is too tender.
Fig. 6FIndirect HVT gapping of the left C0–1 (arrow indicates direction of thrust). Manual Therapy (2003) 8(1), 2–9
8 Manual Therapy
Fig. 7FDirect HVT of C1–2Fupslope or rotation technique to the right (arrow indicates direction of thrust).
Cradle hold – chin hold The cradle hold technique (Figs. 4 and 5) follows directly from the long lever palpation, mobilization sequence and is an excellent starting point in learning cervical manipulation. Clinically, the cradle hold may be more appropriate for patients who have had a previously bad experience with a vigorous chin hold manipulation. Its only negative feature is its application in the lower cervical spine, by those therapists with small hands. The thumb on the contact point side of the neck needs to be utilized to contact the mandible to maintain control. Thus, those therapists with small hands are at a disadvantage. The chin hold grip (Figs. 6 and 7) is a potentially stronger hold, which requires practice to avoid pulling on the chin, rather then generating speed through the contact point.
UPPER CERVICAL HVT TECHNIQUES This section outlines specific manipulative techniques in the cervical spine. Particular emphasis is on the upper cervical spine, as this is the area of greatest potential danger for VBI. Each of the following upper cervical HVT techniques can be applied either using the cradle hold or chin hold and direct or indirect principles. A description of an indirect HVT to the left C0–1 segment and a direct HVT to the left C1–2 joint follow. Indirect C0–1 chin hold gapping technique To apply an HVT to the left C0–1 joint the patient is positioned in supine lying. Contact is established with the therapist’s right index finger placed posterior to the transverse process of C1 enabling the web space to cover the lower earlobe and support the head. The occiput is cradled in the therapist’s left forearm with the head rotated a few degrees to the left. Side bending of the occiput to the right follows. This has the effect of both closing the right C0–1 joint and Manual Therapy (2003) 8(1), 2–9
opening the left C0–1. To gap the left C0–1 joint (Fig. 6), the right hand must produce a force in a direction towards the opposite side of the client’s mouth, which is in the line of the C1 joint. Slight translation toward the side to be gapped (in this case to the left) to ‘lock’ the segment may be applied if required. The thrust is given via the right hand directed to the left mastoid region with 80% of the force given with the right hand and 20% countered with the left supporting forearm on the side of the face. Minimal side flexion may also be induced with the support forearm when warranted. Of note in using this technique is minimal rotation in the set up and no rotation in the thrust. These two features make this procedure both safe and comfortable. Once the indirect technique is mastered then HVT at the C0–1 segment is a very useful addition to one’s selection of treatment options. Direct C1–2 chin hold upslope technique One of the more difficult segments to manipulate with safety and comfort is C1–2. At this spinal level, it is imperative to seek end range by use of the coupled movements of side bending and rotation. Take, for example, a loss of rotation to the right due to dysfunction at the left C1–2 facet. To perform an HVT to the left C1–2, contact must be on the left C1– 2 facet. The therapist’s left index finger is placed on the arch of the atlas and the right forearm supports the occiput (Fig. 7). The occiput is side bent to the left, which effects right rotation at C1–2. This is followed by further rotation of the C1–2 joint until the end range for that segment is determined. This should be approximately half of the normal available physiological cervical rotation. The thrust is given via the left hand in an upslope direction towards the lower aspect of the right orbit and there is no added occipital rotation (Fig. 7). This procedure ensures that rotation at the C1–2 joint is still achieved, but the amount of physiological rotation is reduced. Again, the amount of force used is 80% with the left contact hand and 20% with the support hand and forearm. Importantly, as with the previous C0–1 technique described, the support hand is more of a counter pressure rather than an assistor.
CONCLUSION With the combination of osteopathy and physiotherapy, the new approach adopted in New Zealand focuses on a number of features. Appropriate patient selection is achieved through a thorough patient assessment, consisting of both subjective (SSSNIPRD) and objective (PARTT) components and analyses, and having a sound knowledge of contraindications to cervical manipulation. By refining the manual assessment and manipulative techniques, taking into # 2003 Elsevier Science Ltd. All rights reserved.
Manipulation of the cervical spine 9
consideration both the patient and therapist position and a knowledge of anatomy and biomechanics in the cervical region, it is envisaged that an increase in the safety and specificity of cervical manipulative techniques is achieved. References Clubb D 2002 Cervical manipulation and vertebral artery injury: A literature review. The Journal of Manual and Manipulative Therapy 10(1), 11–16 Cote P, Kreitz BG, Cassidy JD, Thiel H 1996 The validity of the extension–rotation test as a clinical screening procedure before neck manipulation: A secondary analysis. Journal of Manipulative and Physiological Therapeutics 19(3), 159–163 Cyriax J 1984 Textbook of Orthopaedic Medicine 11th edn. Balliere Tindall, London Gibbons P, Tehan P 2000 Manipulation of the Spine, Thorax and Pelvis: An Osteopathic Perspective, 1st edn. Churchill Livingstone, Edinburgh Gibbons P, Tehan P 2001 Spinal manipulation: Indications, risks and benefits. Journal of Bodywork and Movement Therapies 5(2), 110–119 Grant R 1996 Vertebral artery testingFThe Australian Physiotherapy Association protocol after 6 years. Manual Therapy 1, 149–153 Greenman PE 1966 Principles of Manual Medicine, 2nd edn. Wilkins and Wilkins, Baltimore Hartman L 1997 Handbook of Osteopathic Technique, 3rd edn. Chapman & Hall, London Haynes MJ, Cala LA, Melsom A, Mastaglia FL, Milne N, McGeachie JK 2002 Vertebral arteries and cervical rotation:
# 2003 Elsevier Science Ltd. All rights reserved.
Modeling and magnetic resonance angiography studies. Journal of Manipulative and Physiological Therapeutics 25, 370–383 Kaltenborn FM 1989 Manual Mobilisation of the Extremity Joints. 4th edn. Olaf Norlis Bokhandel, Oslo Karnik R, Stollberger C, Ammerer H, Perneczky G, Slany J, Brenner H 1987 Validity of continous-wave Doppler sonography of the vertebrobasilar system. Angiology 38, 556–561 Kuether TA, Nesbit Clark W, Barnwell S 1997 Rotational vertebral artery occlusion: A mechanism of vertebrobasilar insufficiency. Neurosurgery 41(2), 427–432 Magarey M, Rebbeck T, Coughlan B, Rivett D 2000 APA premanipulative testing protocol for the cervical spineFresearched and renewed. Part 2FRevised clinical guidelines. Australian Physiotherapy Association, Australia Maitland GD, Hengeveld E, Banks K, English K 2001 Maitland Vertebral Manipulation, 6th edn. Churchill Livingston, Edinburgh McCarthy C J 2001 Spinal manipulative thrust technique using combined movement theory. Manual Therapy 6(4), 197–204 Monaghan M 2001 Spinal Manipulation: A Manual for Physiotherapists. The Copy Press Ltd., Nelson, New Zealand Refshauge KM 1994 Rotation: A valid premanipulative test: does it predict safe manipulation? Journal of Manipulative and Physiological Therapeutics 17(1), 15–19 Reid DA, Hing WA 2001 AJP Forum: Pre-manipulative testing of the cervical spine. Australian Journal of Physiotherapy 47, 163–167 Thiel H, Wallace K, Donat J, Yong-Hing K 1994 Effect of various head and neck positions on vertebral artery blood flow. Clinical Biomechanics 9, 105–110
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Manual Therapy (2003) 8(1), 10–20 1356-689X/03/$ - see front matter # 2003 Elsevier Science Ltd. All rights reserved. doi:10.1054/math.2002.0480
Review article
Evidence for exercise therapy in mechanical neck disorders H. Sarig-Bahat Department of Physical Therapy, University of Haifa, Haifa, Israel
SUMMARY. In spite of neck disorders being so common in the population, little evidence supporting effective interventions has been identified. The objective of this systematic review was to determine if various exercise methods are effective in treating the different mechanical neck disorders occurring in adults. Sixteen trials were included: nine randomized controlled trials (RCTs) and seven randomized comparative trials (CTs). The average PEDro score indicated moderate methodological quality. PEDro results showed the subject- and therapist-blinding criteria to be inappropriate. Findings revealed relatively strong evidence supporting the effectiveness of proprioceptive exercises and dynamic resisted strengthening exercises of the neck–shoulder musculature for chronic or frequent neck disorders. Moderate evidence was found to support early mobilizing exercises in acute whiplash patients. The evidence identified could not support the effectiveness of group exercise, neck schools or single sessions of extension–retraction exercises. Clinicians are encouraged to incorporate these findings into their practice when planning the management of mechanical neck disorders. There is great need for well-designed RCTs to further investigate the topic and perhaps evaluate exercise effectiveness in relation to more specific disorders, e.g., discogenic vs facet joint originated disorder. r 2003 Elsevier Science Ltd. All rights reserved. active participation of the patient in treatment, which may play an important psychological role, by transferring responsibility for wellbeing to the patient. Exercise therapy incorporates a large variety of methods such as mobilizing exercises, stretching, isometric/static or dynamic strengthening, endurance training and proprioceptive exercises. The various exercise types are commonly applied according to the clinician’s perception of their benefits, reasoned by various theories, but seldom based on evidence. In this age of increasing accountability, health fund and compensation demands, there are increasing expectations of evidence-based treatment. Thus the objectives of this review were to present existing evidence for the use of exercise therapy in the management of mechanical neck disorder, and to determine which exercise methods are effective in treating the various mechanical neck disorders.
BACKGROUND Modern lifestyle seems to be changing the prevalence of cervical compared to lumbar disorders. In North America (Saskatchewan, Canada) lifetime prevalence of neck pain is 66.7% (Coˆte´ et al. 1998). The reason for this may lie in the increasing time spent on office and computer work. Also, a significant proportion of mechanical neck disorders consist of whiplashassociated disorders (WAD). Substantial proportions of the population are affected for up to 2 years postinjury: 44% of those involved in a rear-end collision complained of neck stiffness at 6 months after injury (Brison et al. 2000). In spite of neck disorders being so common in the population, little evidence supporting effective interventions has been identified (Gross et al. 2001). Exercise therapy is one commonly used treatment modality for mechanical neck disorders. It demands
METHOD
Received: 8 November 2001 Revised: 12 June 2002 Accepted: 25 July 2002
Search strategy Five databases were searched: AMED, CINAHL, EMBASE, SportsDiscus and PEDro. Keywords used: neck or cervical and exercise, combined with trial or RCT.
Hilla Sarig-Bahat B.P.T, M Phys (Manip), MAPA, MMPA, Manipulative Physiotherapist, Department of Physical Therapy, University of Haifa, Mount Carmel, Haifa 31905, Israel. Correspondence to: HS-B. E-mail:
[email protected] 10
Exercise therapy for neck disorders 11 Table 1. An example search from CINAHL No. 1 2 3
Critical appraisal method
Search history
Results
[(neck or cervical) and exercise] and (limit to abstracts) (RCT or trial) and (limit to abstracts) 1&2
127 4768 12
The search was limited to studies published between January 1985 and October 2001, in the English or Hebrew language. An example of the search process and the results is presented in Table 1.
Inclusion and exclusion criteria Population Studies whose participants were human adults over 18 years of age, with mechanical neck disorder, were included in this review. Mechanical neck disorders correspond to diagnostic categories 1 and 2 (neck pain with or without referral to proximal extremity) of the classification system proposed by the Quebec Task Force on Spinal Disorders (Spitzer et al. 1987). These disorders include conditions with muscle, joint, ligament, disc, or degenerative involvement (e.g., myofascial pain syndrome, spondylosis, whiplash injuries, etc.). Studies that include subjects with neck disorders with definite neurological deficit, and those that include subjects with neck pain caused by other pathological entities such as diffuse connective tissue diseases, rheumatic syndromes, metabolic and endocrine diseases, neurological diseases, neoplasms, fractures or dislocation were excluded. Study design Randomized controlled trials (RCTs) and nonrandomized controlled trials (NRCTs) were accepted for inclusion in this review. RCTs and NRCTs had to compare at least two interventions (i.e. at least one exercise intervention compared with control or placebo, or a comparison of two or more interventions, exercise being one of them). Other study designs such as cohort studies or case series were excluded. Intervention Various types of active exercise were accepted: stretching, strengthening, endurance or aerobic training, postural correction, neuromuscular control and movement awareness. Exercise described as phasic, isometric, isotonic or isokinetic also fulfilled this inclusion criterion. Any passive intervention such as manual therapy, manipulative therapy and electrotherapy were excluded. Exercise used in combination with other passive interventions was also excluded. # 2003 Elsevier Science Ltd. All rights reserved.
The PEDro scale was used to evaluate the methodological quality of all trials identified. It has been developed by physiotherapists, for quality evaluation of physiotherapy trials and has been endorsed by the Cochrane Collaboration, the Australian Physiotherapy Association, and the School of Physiotherapy at the University of Sydney. Nine criteria are based on the Delphi list (Verhagen et al. 1998) established by expert consensus. Two criteria not on the Delphi list (adequacy of follow-up and between-group statistical comparison) have been added to the PEDro scale. The scale has been partially validated: randomization, concealed allocation, blinding and adequacy of follow-up were empirically validated (Moher et al. 1999). The other items have face validity but, however, are yet to be empirically validated (Moseley et al. 2002). Moseley et al. (1999) have shown acceptable inter-rater reliability of the PEDro scale. Quality evaluation blinding has been achieved using the rates published on the web site (http:// ptwww.cchs.usyd.edu.au/pedro) as an additional independent reviewer to the author. The author informed PEDro of any discrepancy found. A PEDro score was calculated by adding up all ‘yes’ answers from the 11 criteria. The first criterion (eligibility) was included in the total score (unlike the original scoring instructions), as it assesses external validity of the study, i.e. population selection could be biased if inclusion/exclusion criteria are not well defined.
Evidence weighting The evidence weighting system was based on that of Linton and van Tulder (2001) who defined four levels of evidence: Level AFStrong evidence: consistent findings from multiple RCTs. Level BFModerate evidence: one RCT or consistent findings from multiple NRCTs. Level CFLimited evidence: only one NRCT. Level DFNo evidence: no RCTs or NRCTs. As no NRCTs were identified in this review, level C became irrelevant and therefore only three levels remained: Strong, moderate and no evidence.
RESULTS Sixteen RCTs were included in this systematic review. The average PEDro score was 671.31 (54%). Scores ranged from 4 to 9, with only one trial achieving 9 (Bronfort et al. 2001), and no trial achieving 8. PEDro scores are presented in Table 2 in a descending fashion. Manual Therapy (2003) 8(1), 10–20
12 Manual Therapy Table 2. RCTs PEDro scores Criteria Author Bronfort et al. (2001) Kamwendo & Linton (1991) Vasseljen et al. (1995) Friedrich et al. (1996) Rosenfeld et al. (2000) Taimela et al. (2000) Jordan et al. (1998) Takala et al. (1994) Levoska and KeinanenKiukaanniemi (1993) McKinney (1989) So¨derlund et al. (2000) Wailing et al. (2000) Randlov et al. (1998) Revel et al. (1994) Hanten et al. (1997) Fitz-Ritson (1995)
A B C D E F G H I J K T Y Y Y Y N N Y Y Y Y Y 9 Y Y N Y N N N Y Y Y Y 7 Y Y Y Y Y N Y
Y Y Y Y Y Y Y
N N Y N N N N
Y Y Y Y Y Y Y
N N N N N N N
N N N N N N N
N Y N Y N Y N
Y Y Y Y Y Y Y
Y N N N N N N
Y Y Y Y Y Y Y
Y Y Y Y Y Y Y
7 7 7 7 6 6 6
Y Y Y Y Y N N
Y Y Y Y Y Y Y
Y N N N N N Y
Y Y Y Y Y Y N
N N N N N N N
N N N N N N N
N N N N N N N
N N N N N N Y
N N N N N N N
Y Y Y Y Y Y N
Y Y Y Y Y Y Y
6 5 5 5 5 4 4
Mean
6
Standard deviation
1.31
Key: A: Eligibility, B: Random allocation, C: Concealed allocation, D: Baseline comparability, E: Blind subjects, F: Method-blind therapists, G: Blind assessors, H: Adequate follow-up, I: Intention to treat analysis, J: Between-group comparisons, K: Point estimates and variability, T: Total (out of 11), Y: Yes, N: No.
Fig. 1FPercentage of rated RCTs that satisfied each criterion of the PEDro scale.
Criteria E (blind subjects) and F (method-blind therapists) were never fulfilled. Figure 1 presents the frequency distribution for each criterion. Collected trials were subdivided according to population type: whiplash-associated disorders (WAD), chronic neck pain and others. The main parameters of each trial i.e. participants, intervention type, outcome measures and results are summarised in Tables 3–7. These tables are organized into two main categories, i.e. whiplash and chronic, and subdivided according to the type of exercise (group, proprioceptive, strengthening etc.). Four RCTs studied WAD: McKinney (1989) conducted a well-designed RCT (6 PEDro score) which showed early mobilization exercises to be effective in reducing pain and encouraging recovery in acute whiplash patients. Rosenfeld et al. (2000) also provided supportive evidence for the use of Manual Therapy (2003) 8(1), 10–20
active exercises in treatment of acute whiplash patients. In this relatively good quality (7 PEDro score) RCT, best results were gained when exercise therapy, comprising frequent active movements, was administered early (within 96 h) rather than after 2 weeks. So¨derlund et al. (2000) compared two exercise programmes given to acute whiplash patients. His basic program included active neck–shoulder training, relaxation and general advice. An additional isometric extension exercise given to the second group was found to have no benefit over the basic programme. All subjects showed significant improvement in physical measures; however, effectiveness of this exercise programme could have been strengthened by a comparison to a placebo/control group. Unlike the three studies above, Fitz-Ritson (1995) studied Phasic exercises for eye–neck–arm coordination. These proprioceptive exercises had a greater effect on pain reduction, than chiropractic treatment with strengthening exercises. In the Whiplash category, this trial scored lowest for quality (4). Fitz-Ritson considered the chiropractic and exercise group as a control group, based on findings of a pilot study, which treated whiplash patients with similar method, and resulted in no improvement. Various treatment approaches were evaluated in relation to chronic or recurrent neck pain. Three RCTs studied the effectiveness of group exercise (Jordan et al. 1998, Vasseljen et al. 1995, Takala et al. 1994). Exercise regimes included resisted neck/ shoulder exercises and aerobic training. Jordan et al. (1998) and Vasseljen et al. (1995) both showed that group exercise reduced pain, thus with no significant advantage over individual physiotherapy. When compared to a control group (Takala et al. 1994), only slight, if any, short-term effect was shown. These three studies scored 6–7 on the PEDro scale, reflecting relatively high methodological quality. Proprioceptive exercise and its effect on chronic neck pain were challenged by Taimela et al. (2000) and Revel et al. (1994). Findings were partially consistent: Revel et al. (1994) reported significant beneficial effect of the proprioceptive exercise, demonstrated by both subjective and objective measures. Taimela et al. (2000) found significant differences in favour of the exercising group only in the subjective measures, but not in the objective ones. They scored higher than Revel et al. on the PEDro scale (7 compared with 5, respectively). Four RCTs (Bronfort et al. 2001, Wailing et al. 2000, Randlov et al. 1998 and Levoska and Keinanen-Kiukaanniemi 1993) have shown supportive findings for strengthening exercises in chronic neck disorders. All four studies included dynamic resisted exercises for the neck and shoulder region in their training protocols. Equipment used for that purpose # 2003 Elsevier Science Ltd. All rights reserved.
Exercise therapy for neck disorders 13 Table 3. Whiplash-associated disorders (WAD) Participants Rosenfeld et al. (2000) 97 Patients with acute whiplash associated disorder (WAD). 88 followed up after 6 months (29M, 59F) G1, n=21 G2, n=23 G3, n=22 G4, n =22
So¨derlund et al. (2000) 59 (35F, 24M) Symptomatic patients with acute whiplash injury. Mean age 34 years. RT, n=29 AT n=30
McKinney (1989) 170 (88M, 82F) Age: G1F28.778.9 G2F31.6711.3 G3F30.2711.3 Whiplash injury, Acute (o7 days).
Fitz-Ritson (1995) 30 patients: age 3777yr. 19M, 11F G1, n=15 G2, n=15 12 wk after a vehicle accident, with cervical pain/ stiffness.
Intervention
Outcome measures
Reported results
G1FActive treatment within 96 h: repeated active, small range rotational neck movements consistent with McKenzie’s principles. These movements were repeated 10 times in each direction every waking hour. G2FStandard treatment within 96 h: initial rest, recommended use of soft collar, gradual active movements 2–3 times daily a few weeks after injury. G3FActive treatment after 2 weeks. G4FStandard treatment after 2 weeks.
(1) Cervical ROM: Inclinometer was used to measure flexion– extension. A compass was used to measure rotation. (2) Pain was measured by VAS. Measures were registered initially and at 6 months.
Active treatment reduce pain more than standard treatment (Po0.01). Active management gained best results when administered early. Standard treatment had better effect on pain reduction when administered late.
G1F Regular treatment group (RT) was given an exercise programme including instructions for self-neck-care, fair distance walking, and three exercises to pain limit: cervical rotations; arms elevation; deep breaths with shoulder shrugging and relaxing. G2F Additional exercise treatment group (AT) was given the same programme, with an additional exercise, pressing the corners of an imaginative quadrangle against the floor, 3 reps, 3/ day.
(1) (2) (3) (4)
Pain disability index. Self-Efficacy Scale. Coping strategies questionnaire. Patients’ cervicothoracic posture was assessed by a manual goniometer. (5) Cervical rotation range of motion.
No significant interaction effects or group differences were shown (ANOVA analysis). All showed significant improvement in physical measures over time. No additional benefit was demonstrated in the AT group.
G1Frest of 10–14 days + analgesic (considered control). G2FPhysiotherapy: heat/cold, short wave, diathermy, hydrotherapy, traction and active and passive mobilization. G3FAdvice on self-mobilization: posture, home self-mobilization exercises, restricted use of collar to short periods. All patients were fitted with a soft collar and were given analgesic.
(1) Pain (VAS). (2) Recovery time. Monthly follow up, for 12 months.
Recovery was significantly better in patients given advice on early mobilization to do at home, than in other patients (w2=5.43, df=1, P=0.02). Early mobilization was found more effective in relieving neck pain in acute neck sprains, than physiotherapy or rest.
G1FChiropractic treatment + exercises including ROM exercises, stretching, isometric-toning, isokinetic-strengthening.* G2FChiropractic treatment + Phasic exercises for eye–neck–arm coordination. *G1 was considered by the author as a control group, based on a pilot study described. This study was defined an RCT.
Neck Pain Disability Index (adapted).
Significant improvement was reported in both groups, greater in G2 (G1 7.4%, P40.05, G2 48.3%, P40.001). No in-between group statistical analysis was presented, giving no base to any conclusion.
Key: F: Female, M: Male, Yr: Years, G1: Group one, G2: Group two, G3: Group three, VAS: Visual Analogue Scale, Min: Minute, Wk: Week.
varied: Wailing et al. (2000) used air machines, which resisted the concentric part of movement. Levoska and Keinanen-Kiukaanniemi (1993) preferred the higher technology omnikinetic machine, similar in concept to the MedX machine used by Bronfort et al. (2001). Randlov et al. (1998) favoured simple free weights to provide resistance. # 2003 Elsevier Science Ltd. All rights reserved.
Both Wailing et al. (2000) and Levoska and Keinanen-Kiukaanniemi (1993) showed strengthening exercise significantly effective compared to the control group, however, not more beneficial than endurance training, body awareness training (Wailing et al. 2000), and passive physiotherapy (Levoska and Keinanen-Kiukaanniemi 1993). In addition, Bronfort Manual Therapy (2003) 8(1), 10–20
14 Manual Therapy Table 4. Chronic/frequent neck disordersFgroup exercise Participants Jordan et al. (1998) 119 Subjects, 20–60 years of age. Chronic neck pain, non-radicular extremity pain.
Vasseljen et al. (1995) 24F office workers, neck and shoulder pain 4for 3 days continuously during last 2 wk. G1, n=12 G2, n=12 G3, n=9: additional group of patients with more severe symptoms.
Takala et al. (1994) 44F, age 20–55yrs. Printing company. Frequent neck symptoms.
Intervention
Outcome measures
Reported results
G1FGroup exercise: bicycling 5 min, stretching 10 min, intensive training of neck muscles on isometric strength unit. 30% of maximal power, set=12 repetitions, 1 set for F, 3 sets for E, LF. Cool-down cycling 5 min. 1 h a session 2/wk for 6 wks. + home exercise programme. G2FIndividual physiotherapy: included a combination of passive (hot pack, US, traction, massage) and active elements = same home exercise given to G1. G3FChiropractic manipulation of cervical spine, traction, same home program. 45 min sessions 2/wk for 6 wks. All patients participated in a single ‘neck school’ session.
(1) Self-reporting disability scale (source reference given). (2) Doctor’s global assessment. (3) Patient perceived effect. (4) Self-reported pain (11-point scale). (5) Maximal isometric strength of flexor and extensor muscles. Follow-up at 4, 12 months.
Patients in all groups showed approximately 50% reduction in pain and disability. There was no significant difference between groups (P=0.44) at treatment conclusion.
G1FIndividual physiotherapy: 1 h treatment 10, included massage, strength and flexibility exercises, stretching, passive mobilization, ergonomic advice, home exercise. G2FGroup exercise: 30 min sessions, during working hours, 3/week, for 6 wk. Exercise regime adopted (Dyrssen et al. 1990) included resisted exercises for neck and shoulder. G3FIndividual physiotherapy: details were not provided.
(1) Trapezius muscle activity measured by surface EMG. (2) Pain (VAS). (3) Perceived general tension (VAS). (4) Trigger points, measured by an algometer for pressure pain sensitivity, and palpated. (5) Strength: for G3 only. Maximal shoulder elevation.
Perceived general tension and pain were significantly reduced in all groups (Po0.05), while muscle activity remained unchanged. Individual physiotherapy and group exercise at the workplace were approximately equally effective in alleviating pain and perceived general tension. The improvement was maintained better by G1 at 6 months follow-up than by G2.
Two groups were matched according to age, frequency of pain, work task. Cross-over design: treatment group and the control group were reversed in the second intervention. G1FGroup gymnastics during work hours, 45 min 1/wk, for 10 wk. Whole body training: aerobic dynamic exercise, stretching, relaxation. G2Fcontrol.
(1) Pain and disability (VAS). (2) Pressure pain threshold (PPT).
Only slight if any short-term effect of group gymnastics on neck pain, disability and PPT. The effect did not remain after cessation of the training.
Key: F: Female, M: Male, Yr: Years, G1: Group one, G2: Group two, G3: Group three, VAS: Visual Analogue Scale, Min: Minute, Wk: Week.
et al. (2001) could not demonstrate the superiority of the MedX program, and Randlov et al. (1998) showed no significant difference when altering training intensity. Sporadic trials studied additional aspects of exercise therapy in mechanical neck disorders. Hanten et al. (1997) studied patients with trigger points, and found one session of extension/retraction exercises to be of no benefit. Neck schools’ ineffectiveness was demonstrated in the work of Kamwendo and Linton (1991). Manual Therapy (2003) 8(1), 10–20
DISCUSSION Methodological quality The majority of trials were rated 7 or less on the PEDro scale, leading to two possible explanations. One explanation could be that the trials have presented limited quality. Another could be that the PEDro scale does not fully express the true methodological quality of physiotherapy trials. The ‘blind subjects’ and ‘Method# 2003 Elsevier Science Ltd. All rights reserved.
Exercise therapy for neck disorders 15 Table 5. Chronic/frequent neck disordersFproprioceptive exercises Participants Taimela et al. (2000) 76 Patients (22M, 54F) with nonspecific recurrent or chronic neck pain, longer than 3 months. G1, n=25 G2, n=25 G3, n=26 62 participated in 1-year follow-up.
Revel et al. (1994) 60 Subjects with chronic neck pain for more than 3 months. G1, n=30 G2, n=30
Intervention
Outcome measures
Reported results
G1FActive treatment included cervicothoracic stabilization, relaxation, eye fixation exercises, seated wobble board training to improve postural control and behavioral support to reduce anxiety. Two 45-min sessions per week, during 12 wk. G2FHome regimen included a neck lecture and two practical training sessions for home exercises. G3FControl group received one lecture regarding neck care and written information about home exercises.
(1) Subjective pain and disability: A questionnaire inquired about above and included a VAS. (2) Cervical ROM was assessed with a helmet equipped with a goniometer. (3) Pressure pain threshold in the upper trapezius and levator scapula muscles was assessed using a mechanical force gauge. All the above were measured at baseline, at 3 months, and at 12 months.
Subjective measurements differed significantly in favuor of the active group (Po0.01– 0.03) that emphasized exercises. No significant differences were shown in objective measurements of cervical function among the three groups.
G1Fproprioceptive rehabilitation: 15 individual exercise sessions 2/wk, for 8 wk. Exercise were mainly concerned with eye–neck coordination, detailed protocol presented in article. G2FControl: only symptomatic treatment (anti-inflammatory drugs, etc.).
(1) Pain (VAS). (2) Medication intake. (3) Measurements of cervicocephalic kinesthesia = head relocation ability. (4) Patient’s overall assessment of functional improvement. (5) Cervical ROM. Follow-up at 10 wk.
Difference between mean head relocation ability (HRA) before and after Rx was highly significant in G1 (P=0.0004), and none in G2. Neck pain decreased in both groups, but improvement in G1 was significantly greater. Small but significantly greater improvement in rotation ROM in G1 compared to G2.
Key: F: Female, M: Male, Yr: Years, G1: Group one, G2: Group two, G3: Group three, VAS: Visual Analogue Scale, Min: Minute, Wk: Week.
blind therapists’ criteria were never fulfilled. They seem to be irrelevant and unrealistic for physiotherapy trials, and therefore this strengthens the second theory. ‘Concealed allocation’ and ‘intention to treat’ were rarely fulfilled; however, the author believes these do demonstrate true quality faults. Methodological limitations of this systematic review included searching in English alone, lack of trials selection blinding and absence of metaanalyses.
persistent neck pain. Takala et al. (1994) could not demostrate evidence of benefit while Jordan et al. (1998) and Vesseljen et al. (1995) showed favourable results for exercising although not greater than that of individual physiotherapy. If one uses the weighing system alone, ignoring the negating evidence (Takala et al. 1994), it may seem that strong supportive evidence (2 RCTs) has been collected. Nevertheless, it is important to note that exercise protocols were not identical, e.g. frequency of sessions varied, which may limit comparability between trials.
Exercise therapy in whiplash associated disorders
Proprioceptive exercises for chronic neck pain
Strong evidence (level A) exists to support the effectiveness of early active mobilizing exercises in acute whiplash patients based on the findings of McKinney (1989), Rosenfeld et al. (2000), and So¨derlund et al. (2000). The effectiveness of phasic exercises in treatment of whiplash patients is questioned due to the low quality of the one RCT identified (Fitz-Ritson 1995) that studied the subject.
There is strong evidence (level A) to support the effectiveness of proprioceptive exercise in reducing subjective pain and disability. Conflicting evidence exists in regard to the effect of this intervention on objective neck function. Further research is needed of new and intriguing exercise method to reliably evaluate effectiveness.
Strengthening exercises for chronic neck pain Group exercise for chronic/frequent neck pain Takala et al. (1994), Vasseljen et al. (1995) and Jordan et al. (1998) provide inconsistent evidence regarding the use of group exercise when treating # 2003 Elsevier Science Ltd. All rights reserved.
Strong evidence (level A) supporting the use of strengthening exercises was identified, which consisted of dynamic resisted exercises for the neck and shoulder region. Although shown effective, these Manual Therapy (2003) 8(1), 10–20
16 Manual Therapy Table 6. Chronic/frequent neck disorders Participants Bronfort et al. (2001) 191 patients with chronic mechanical neck pain for 12 wk or more. Age: 20–65 years G1, n=63 G2, n=60 G3, n=64
Wailing et al. (2000) 103 Women with work-related neck–shoulder pain. Mean age 38.275.8. All had history of at least 1 year, decreased cervical ROM, and one or more trigger points tender in the Trapezius muscle.
Randlov et al. (1998) 77F: G1, n=36 G2, n=41 Chronic neck/shoulder (>6 months)
pain
Manual Therapy (2003) 8(1), 10–20
strengthening exercises Intervention
Outcome measures
Reported results
G1FSpinal manipulation with neck exercises: 20 sessions of 15-min manipulations by a chiropractor, followed by a 45 min exercise session including strengthening exercises for neck and upper body (push ups and dumbbell weights shoulder exercises), aerobic warm up and light stretching. G2FNeck exercise: Individual sessions supervised by a physiotherapist. Sessions included stretching, upper body, strengthening using MedX machine (resisted cervical extension and rotation), and 15– 20 min aerobic exercise. G3FSpinal Manipulation alone: 15 min chiropractic treatment as described in G1. This group also received 45 min sham micro-current therapy.
Subjective measures: (1) Neck painF11 box scale*. (2) Neck Disability Index (adapted). (3) Functional health statusmeasured by Short Form 36. (4) Global improvementF9 point ordinal scale*. (5) Satisfaction with careF7 point scale*. (6) Medication useF5 point scale*. *Reliability not reported. Objective measures (assessed by blinded examiners): (1) ROM for flexion, extension, rotation and side bending was measured with a CA6000 Spine Motion Analyzer. (2) Isometric muscle strength F measured using computerized dynamometer for cervical flexion, extension and rotation. (3) Muscle enduranceFstatic endurance was measured by elevating head just free of support with 60% MVC. Dynamic endurance was recorded as number of repartitions until failure.
There were no significant differences between groups in subjective measures. All groups presented substantial subjective improvement. Manipulation with exercise group showed greater gains in all objective measures than the manipulation group. Also gained more improvement in flexion endurance and flexion/rotation strength. Exercise group had better improvement in extension strength and flexion-extension ROM than manipulation group.
G1FStrength training: concentric resisted exercises including latissimus pulldown, triceps press, shoulder flexion and scapular retraction. 3 10 repetitions. G2FEndurance training: arm cycling 3 min + arm exercises using rubber expanders 3 min. G3FCo-ordination training: Body awareness training classes. G4FControl group: no exercise were performed. Control group studied and discussed stress management.
(1) PainFusing VAS for ‘pain in general’, ‘pain at worst’, ‘pain at present’. (2) Pressure pain threshold was evaluated using a pressure algometer, over 3 trigger points in the Trapezius muscle. (3) A five graded categorical scale evaluated satisfaction regarding effect of training.
The exercise groups decreased pain at present and at worst significantly compared to the control group (Po05). Pain thresholds were significantly reduced in the three trigger points in the exercisers compared to the controls (Po0.05). No significant differences were found in comparisons between exercise groups.
G1FIntensive training: bicycling and stretching 10 min, seven neck and shoulder exercises (different from the other group’s) 20 repetitions, five rounds, resistance increased. G2FLight training: Hot pack 14 min, bicycling and stretching 15 min, six neck and shoulder exercises, each 20 repetitions. Group sessions of 1.5 h 3/wk, for 3 months, total 36 sessions both groups.
(1) Pain (11-point scale). (2) Pain relieving medication intake. (3) Disability scale (demonstrated good reliability & validity). (4) Maximal voluntary isometric contraction of flexors and extensors of the cervical spine.
Both groups improved significantly with regards to objective measurements (Po0.05), but no significant difference between groups could be demonstrated.
# 2003 Elsevier Science Ltd. All rights reserved.
Exercise therapy for neck disorders 17 Levoska & Keinanen-Kiukaanniemi (1993) 47 Females who worked using personal computers. Neck & shoulder symptoms once a week or more. Muscle spasm and tenderness in neck & shoulder regions on palpation. G1, n=22 G2, n=20 G3, n=14
G1FPassive Physiotherapy: Surface heat, massage, stretching and physical exercising of neck & shoulder muscles. No home exercise. G2FActive physiotherapy: Stretching & dynamic muscle training of neck & shoulder regions. Resistance provided via an omnikinetic training machine, endurance was trained according to measurements before treatment. Daily home exercises programme. 60 min sessions 3/wk, total 15 sessions. G3FControl: no treatment group.
(1) Maximal isormetric neck muscle strengthFmeasured using a dynamometer for cervical E, LF, grip, elbow F & shoulder elevation. (2) Endurance forces of shoulder muscles. (3) Muscle tone in neck, shoulder and scapular areas, assessed by manual palpation. (4) Tender points in trapezius & levator scapulae ms. Assessed using a pressure threshold meter. (5) Neck and shoulder symptoms were assessed by a questionnaire standardized for this purpose.
Both active & passive physiotherapy relieved neck & shoulder symptoms effectively. Occurrence of those symptoms was significantly lower after active than after passive physiotherapy (Po0.05). Both interventions resulted in a decrease of muscle tone and of tender palpated points in neck region. Muscle tone decreased significantly only in G1. Maximal isometric & endurance forces were improved by active training. In conclusion, active physiotherapy was at least as effective as passive physiotherapy.
Key: F: Female, M: Male, Yr: Years, G1: Group one, G2: Group two, G3: Group three, VAS: Visual Analogue Scale, Min: Minute, Wk: Week.
Table 7. Others Participants Hanten et al. (1997) 60 Subjects (42F, 18M). Age: 2979.2 yr Subjects presented with one or more active or latent cervical and/ or scapular trigger points. Friedrich et al. (1996) 87 patients (33F, 54M). G1: n=47, age 49713.6 G2: n =40, age 47711.6. Neck or low-back pain for more than 6 wks.
Kamwendo & Linton (1991) 79 Females Age: 39.47 10.7 yr Disorder: Neck pain without radiation, or shoulder region. ‘During previous year’
Intervention
Outcome measures
Reported results
G1FOccipital release = manual traction for up to 15 min. G2FActive head retraction and retraction/ extension exercises. 10 repetitions 5 sets. G3FControlFNo treatment.
Pressure pain threshold was measured using a pressure algometer.
No significant difference was shown between the treatment groups and the control group (P40.05) after one session of treatment.
G1FSupervised group: individual instructions by a physiotherapist in 8 sessions+ daily home exercise 20 min G2FBrochure group: patients were given a brochure describing the exercises to carry out. Patients continued home exercising without guidance. Were told to exercise 20 min once daily. All patients received one of three different brochures.
(1) Pain (VAS) (2) Muscle force: The force of the deep cervical flexors, rhomboids, abdominal muscles, gluteus maximus & medius was assessed by a manual muscle testing (0–5 scale). (3) Muscle length: Muscles assessed: upper trapezius, pectorlais major, iliopasoas, quadratus lumbroum. 4level scale. (4) Performance of exercises (4-grade quality scale).
A significant difference between the groups was shown with in all outcome measures in favour of the supervised group. The quality of exercise performance was correlated both with muscle status (r= 0.47, Po0.01) and with pain relief (r=30, Po0.01).
(1) Traditional neck school: exercise, self-care, and relaxation. Exercise = active, stretching for neck and shoulder. ‘The importance of regularly performing exercise was stressed’. (2) Reinforced neck school: psychological counseling ergonomics, exercise, self- care, and relaxation. (3) Control = no treatment. 4 wk of treatment. Follow-up: 6 months.
(1) VAS for pain and for fatigue. (2) ROM. (3) Sick leave. (4) Ergonomic knowledge (13 question test). (5) Expectancy. (6) Workload rating. (7) Implemented change and acquired equipment. (8) Compliance. (9) Additional health care contacts.
No significant reduction in pain was reported by the authors (P40.05). No treatment effect was noted for either traditional neck school nor for traditional neck school.
Key: F: Female, M: Male, Yr: Years, G1: Group one, G2: Group two, G3: Group three, VAS: Visual Analogue Scale, Min: Minute, Wk: Week. # 2003 Elsevier Science Ltd. All rights reserved.
Manual Therapy (2003) 8(1), 10–20
18 Manual Therapy
exercises were not shown to be more beneficial than endurance training, body awareness and passive physiotherapy, i.e. manipulation alone. Other exercise programs, i.e. ‘neck schools’ and extension retraction exercises, were not shown effective in single trials.
CONCLUSION Findings revealed significant evidence to support the effectiveness of exercise in two main fields of mechanical neck disorders, whiplash-associated disorders and chronic neck pain. When evaluating different exercise methods for chronic or frequent neck pain, one may consider the use of proprioceptive or dynamic strengthening exercises, based on relatively strong evidence. Strong evidence exists to encourage clinicians to use early mobilizing exercises for acute whiplash-associated disorders. Evidence identified cannot support the use of group exercise, neck schools or single sessions of extension– retraction exercises. In relation to methodological quality, concealed allocation and analysis by ‘intention to treat’ should be addressed in future studies, as the reviewed papers rarely fulfilled this criteria. The results suggest that the subject- and therapistblinding criteria may be irrelevant for trials in the exercise-therapy field. A great need exists for well-designed randomized controlled trials to further enhance the conclusions regarding effectiveness of active exercises in mechanical neck disorders perhaps involving the study of exercise therapy in more specific disorders, such as discogenic disorders, myofascial pain, cervical facet joint disorders.
Acknowledgements The author would like to acknowledge the PEDro project for establishing a high standard collection of evidence, accessible and relevant to physiotherapists. The centre for Allied Health Research and especially Dr Karen Grimmer is acknowledged for conducting the evidence-based physiotherapy workshop, and coordinating the research project of the Master of Manipulative Physiotherapy program, University of South Australia. Thanks to Dr Ruth Dickstein (University of Haifa) and Mrs Karen Giddings (University of South Australia) for reviewing this text. Special thanks to my dearest husband, Lior Bahat, for his technical and spiritual support during the extended compilation of this paper.
References Bonfort G, Evans R, Nelson B, Aker PD, Goldshmith CH, Vernon H 2001 A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain. Spine 26(7): 788–797 Brison RJ, Hartling L, Pickett W 2000 A prospective study of acceleration–extension injuries following rear-end motor vehicle collisionsyWorld Congress on Whiplash-Associated Manual Therapy (2003) 8(1), 10–20
Disorders in Vancouver, British Colombia, Canada, February 1999. Journal of Musculoskeletal Pain 8(1/2): 7–113 Coˆte´ P, Cassidy JD, Carroll L 1998 The Saskatchewan Health and Back Pain Survey: The prevalence of neck pain and related disability in the Saskatchewan adults. Spine 23(15): 1689–1698 Dyrssen T, Paasikivi J, Svedenkrans M 1990 Beneficial exercise programme for office workers with shoulder and neck complaints. In: Berlinguet L, Berthelette D (eds) Work and Display Units 89. Elsevier Science, North Holland, Amsterdam, pp. 129–138 Fitz-Ritson D 1995 Phasic exercises for cervical rehabilitation after ‘whiplash’ trauma. Journal of Manipulative and Physiological Therapeutics 18(1): 21–24 Friedrich M, Cermak T, Maderbacher P 1996 The effect of brochure use versus therapist teaching on patients performing therapeutic exercise and on changes in impairment status. Physical Therapy 76(10): 1082–1088 Gross AR, Aker PD, Goldsmith CH, Peloso P 2001 Physical medicine modalities for mechanical neck disorders (Cochrane Review). In: The Cochrane Library, Issue 3. Update Software: Oxford Hanten WP, Barrett M, Gillespie-Plesko M, Jump KA, Olson SL 1997 Effects of active head retraction with retraction/extension and occipital release on the pressure pain threshold of cervical and scapular trigger points. Physiotherapy Theory and Practice 13(4): 285–291 Jordan A, Bendix T, Nielsen H, Hansen FR, Host D, Winkel A 1998 Intensive training, physiotherapy, or manipulation for patients with chronic neck pain. A prospective, single-blinded, randomized clinical trial. Spine 23(3): 311–317 Kamwendo K, Linton SJ 1991 A controlled study of the effect of neck school in medical secretaries. Scandinavian Journal of Rehabilitation Medicine 23: 143–152 Levoska S, Keinanen-Kiukaanniemi S 1993 Active or passive physiotherapy for occupational cervicobrachial disorders? A comparison of two treatment methods with a 1-year follow-up. Archives of Physical Medicine and Rehabilitation 74: 425–430 Linton SJ, Van Tudler MW 2001 Preventive interventions for back and neck pain problems: What is the evidence? Spine 26(7): 778–787 McKinney LA 1989 Early mobilisation and outcome in acute sprains of the neck. British Medical Journal 299: 1006–1008 Moher D, Cook DJ, Jadad AR, Tugwell P, Moher M, Jones A, Pham B, Klassen TP 1999 Assessing the quality of reports of randomised trials: Implications for the conduct of metaanalyses. Health Technology Assessment 3: 1–98 Moseley AM, Maher C, Herbert RD, Sherrington C 1999 Reliability of a scale for measuring the methodological quality of clinical trials. Proceedings of the VIIth Cochrane Colloquium, Rome, p 39 Moseley AM, Herbert RD, Sherrington C, Maher C 2002 Evidence for physiotherapy practice: A survey of the Physiotherapy Evidence Database (PEDro). Australian Journal of Physiotherapy 48(1): 43–49 Randlov A, Ostergaard M, Manniche C, Kryger P, Jordan A, Heegaard S, Holm B 1998 Intensive dynamic training for females with chronic neck/shoulder pain. A randomized controlled trial. Clinical Rehabilitation 12(3): 200–210 Revel M, Minguet M, Gregoy P, Vaillant J, Manuel JL 1994 Changes in cervicocephalic kinesthesia after a proprioceptive rehabilitation program in patients with neck pain: A randomized controlled study. Archives of Physical Medicine and Rehabilitation 75(8): 895–899 Rosenfeld ME, Gunnarsson R, Borenstein P, Cassidy JD 2000 Early intervention in whiplash-associated disorders: A comparison of two treatment protocols. Spine 25(14): 1782–1787 So¨derlund A, Olerud C, Lindberg P 2000 Acute whiplash associated disorders (WAD): The effect of early mobilisation and prognostic factors in long term symptomatology. Clinical Rehabilitation 14(5): 457–467 Spitzer WO, Leblanc FE, Dupuis M 1987 Scientific approach to the assessment and management of activity related spinal disorders. Spine 7(suppl): S1–S59 Taimela S, Takala E-P, Asklof T, Seppala K, Parviainen S 2000 Active treatment of chronic neck pain: A prospective randomized intervention. Spine 25(8): 1021–1027 # 2003 Elsevier Science Ltd. All rights reserved.
Exercise therapy for neck disorders 19 Takala EP, Viikari Juntura E, Tynkkynen EM 1994 Does group gymnastics at the workplace help in neck pain? A controlled study. Scandinavian Journal of Rehabilitation Medicine 26(1): 17–20 Vasseljen O Jr, Johansen BM, Westgaard RH 1995 The effect of pain reduction on perceived tension and EMG-recorded trapezius muscle activity in workers with shoulder and neck pain. Scandinavian Journal of Rehabilitation Medicine 27(4): 243–252 Verhagen AP, de Vet HC, de Bie RA, Kessels AG, Boers M, Bouter LM, Knipschild PG 1998 The Delphi list: A criteria list
for quality assessment of randomised clinical trials for conducting systematic reviews developed by Delphi consensus. Journal of Clinical Epidemiology 51: 1235–1241 Wailing K, Sundelin G, Ahlgren C, Jarvholm B 2000 Perceived pain before and after three exercise programsFa controlled clinical trial of women with work-related trapezius myalgia. Pain 85(1–2): 201–207
FURTHER READING Excluded references Reference
Reason for exclusion
Pollock ML, Graves JE, Bamman MM, Leggett SH, Carpenter DM, Carr C, Cirulli J, Matkozich J, Fulton M 1993 Frequency and volume of resistance training: effect on cervical extension strength. Archives of Physical Medicine and Rehabilitation 74: 1080–1086. Stump J, Rash G, Semon J, Christian W, Miller K 1993 A comparison of two modes of cervical exercise in adolescent male athletes. Journal of Manipulative and Physiological Therapeutics 16(3): 155–160. McCarthy PW, Olsen JP, Smeby IH 1997 Effects of contract-relax stretching procedures on active range of motion of the cervical spine in the transverse plane. Clinical Biomechanics 12(2): 136–138. Nelson BW, Carpenter DM, Dreisinger TE, Mitchell M, Kelly CE, Wegner JA 1999 Can spinal surgery be prevented by aggressive strengthening exercises? A prospective study of cervical and lumbar patients. Archives of Physical Medicine & Rehabilitation 80(1): 20–25. Koes BW, Bouter LM, van Mameren H, Esser AH, Verstegen GM, Hofhuizen DM, Houben JP, Knipschild PG 1993 A randomized clinical trial of manual therapy and Physiotherapy for persistent back and neck complaints: Subgroup analysis and relationship between outcome measures. Journal of Manipulative and Physiological Therapeutics 16(4): 211–219. Gam AN, Warming S, Hordum L, Jensen B, Hoydalsmo O, Allon I, Anderson B, Gotzsche NE, Petrsen M, Mathiesen B 1998 Treatment of myofacial trigger-points with ultrasound combined with massage and exercise, a randomised controlled trial. Pain 77: 17–19. Leggett SH, Graves JE, Pollock ML, Shank M, Carpenter DM, Holmes B, Fulton M 1991 Quantitative assessment and training of isometric cervical extension strength. The American Journal of Sports Medicine 18(6): 653–655. Axen K, Haas F, Schicchi J, Merrick J 1992 Progressive Resistance Neck Exercises Using a Compressible Ball Coupled with an Air Pressure Gauge. Journal of Orthopaedic and Sports Physical Therapy 16(6): 275–280. Pennie B, Agambar L 1990 Whiplash injuries. A trial of early management. Journal of Bone and Joint Surgery 72(2): 277–279. Highland TR, Dreisinger TE, Vie LL, Russel GS 1992 Changes in isometric strength and range of motion of the isolated cervical spine after eight weeks of clinical rehabilitation. Spine 17(6): 77–82. Yilnen J, Ruuska J (1994): Clinical use of neck isometric strength measurement in rehabilitation. Archives of Physical Medicine and Rehabilitation 75: 465–469. Berg HE, Berggren G, Tesch PA 1994 Dynamic neck strength training effect on pain and function. Archives of Physical Medicine and Rehabilitation 75(6): 661–665.
Population: volunteers with no neck disorder specified.
# 2003 Elsevier Science Ltd. All rights reserved.
Population: asymptomatic athletes, no prior injury or abnormality. Population: Asymptomatic volunteers.
Study design: prospective study. Not a comparative trial.
Intervention: exercise combined with other treatment modalities.
Intervention: exercise combined with other treatment modalities.
Population: healthy subjects, with no cervical problems.
Population: healthy subjects, with no cervical problems.
Intervention: exercise combined with other treatment modalities. Study design: non-comparative trial.
Study design: non-comparative trial. Study design: non-comparative trial.
Manual Therapy (2003) 8(1), 10–20
20 Manual Therapy Provinciali L, Baroni M, Illuminati L, Ceravolo MG 1996 Multimodal treatment to prevent the late whiplash syndrome. Scandinavian Journal of Rehabilitation Medicine 28: 105–111. Davidson D 1998 Effectiveness of cervical stabilisation training and correction of muscle imbalance, following reduction of Atlanto-Axial Rotary Subluxation: A single case study. Physiotherapy 54(3): 4–7. Beeton K, Jull G 1994 Effectiveness of manipulative physiotherapy in the management of cervicogenic headache: A single case study. Physiotherapy 80(7): 417–423. Jordan A, Ostergaard K 1995 Implementation of neck/shoulder rehabilitation in primary health care clinics. Journal of Manipulative and Physiological Therapeutics 19(1): 36–40. Helliwell PS, Abbott CA, Chamberlain MA 1996 A randomised trial of three different physiotherapy regimes in Ankylosing Spondylitis. Physiotherapy 82(2): 85–90. Olson VL 1997 Whiplash-associated chronic headache treated with home cervical traction. Physical Therapy 77: 417–424.
Manual Therapy (2003) 8(1), 10–20
Intervention: exercise combined with other treatment modalities. Study design: case study.
Study design: case study. Study design: review paper. Population = patients with Ankylosing Spondylitis. Intervention = home cervical traction. Although self-treatment, passive and not considered exercise.
# 2003 Elsevier Science Ltd. All rights reserved.
Manual Therapy (2003) 8(1), 21–28 1356-689X/03/$ - see front matter # 2003 Elsevier Science Ltd. All rights reserved. doi:10.1054/math.2002.0476
Original article
Neuromuscular control of walking with chronic low-back pain L. Vogt*, K. Pfeiferw, W. Banzer* *Department of Sports Medicine, Institute for Sport Sciences, Johann Wolfgang Goethe-University, Frankfurt/ Main, Germany, wOtto-von-Guericke University Magdeburg, Training and Health, Germany
SUMMARY. The reported association of low-back pain and musculoskeletal disorders contributed to the examination of the lumbar spine and hip extensor activation patterns in back pain sufferers during walking. Seventeen idiopathic low-back pain male subjects and 16 healthy volunteers participated in the study. Hip joint ROMs in the sagittal plane and neuromuscular activities of erector spinae [L3, T12], gluteus maximus and biceps femoris were recorded on one randomly selected body side in each group. Analysis using the Student’s t-test revealed significant differences for hip joint range of motion, stride time and significantly earlier onsets of the lumbar spine and hip extensors of the back pain sufferers compared with the healthy controls. It is assumed, that low-back disorders are related to changes of the lumbar spine and hip extensor recruitment pattern. r 2003 Elsevier Science Ltd. All rights reserved.
suggested that deficiencies in movement patterns and motor regulation play a major role in the development of musculoskeletal dysfunction (Singer 1986; Jull & Janda 1987, Janda 1992; Bittmann & Badtke 1994). Neural dysregulation due to musculoskeletal pain syndromes might contribute to alterations in the recruitment pattern of various synergistic muscles. Alterations in motor control may cause muscles to be activated in an inappropriate manner (i.e. timing, rate of force development), interfering with a subject’s ability to automatically perform adequate movement patterns. Janda postulated in 1978 that at least some cases of low-back pain may occur due to deficiencies in the central nervous control of locomotion. It is assumed that especially disturbances of the activation pattern of the hip extensor and pelvic stabilization muscles are a factor in the genesis of low-back disorders. Even impairments in the peripheral parts of the body seem to be complemented by changes in the central nervous system regulation of the muscles in the lumbo-pelvic region (Bullock-Saxton et al. 1994, Bullock-Saxton 1994; Beckmann & Buchanan 1995). Prone hip extension is an assessment procedure which has been used by various authors (Pierce & Lee 1990; Liefring et al. 1991; Janda 1992; Lewit 1992; Badtke et al. 1994; Bullock-Saxton et al. 1994; Vogt & Banzer 1997) to evaluate the neuromuscular
INTRODUCTION Low-back pain is one of the most common musculoskeletal problems in modern society. Demonstrated by the high direct and indirect costs, it also causes major economic problems in industrialized nations (Berger-Schmitt et al. 1996; Maniadakis & Gray 2000). Thus, chronic low-back pain problems have been the reason for many clinical investigations. Although there is disagreement in the literature with regard to the etiology (White & Gordon 1982; Bernard & Kirkaldy-Willis 1987; Nachemson 1992), it seems evident that idiopathic low-back pain is often associated with musculoskeletal disorders and imbalances in lumbar spine and pelvic stabilization muscles (Schneider 1981; Janda 1984; Liebenson 1990; Bourdillon et al. 1994; Norris 1995). It is Received: 30 January 2002 Revised: 20 June 2002 Accepted: 18 July 2002 Lutz Vogt PhD, Winfried Banzer MD, PhD, Department of Sports Medicine, Institute for Sport Sciences, Johann Wolfgang GoetheUniversity, Frankfurt/Main, Klaus Pfeifer PhD, Otto-vonGuericke University, Magdeburg, Training and Health, Germany. Correspondence to: LV, Department of Sports Medicine, Institute for Sport Sciences, Johann Wolfgang Goethe-University, Ginnheimer Landstrasse 39, 60487 Frankfurt/Main, Germany. Tel.: +49-69-798-24586; Fax: +49-69-798-24592; E-mail:
[email protected] 21
22 Manual Therapy
activation pattern (order of muscle contraction) of surrounding hip muscles. Isolated extension of the hip from the neutral position is normally selected because of its functional importance in stance and locomotion. However, prone hip extension is a open kinetic chain non-weight-bearing position performed by concentric muscle contraction, so joint afferent activity and muscle recruitment strategies will be considerably different from those in gait. Thus, it seems questionable if isolated laboratory test conditions will be able to monitor the authentic muscle recruitment pattern around the trunk and pelvis and identify functional adaptations to back pain. Although a few back pain studies have already analysed muscle activity during gait (Ahern et al. 1986, Arendt-Nielsen et al. 1995, Arendt-Nielsen 1996) no study has clearly described the muscle firing order of the lumbar and hip muscles in walking. Therefore, it still remains unclear how human musculoskeletal pain modulates motor performance in every day tasks. The aim of the current study was to examine changes in the lumbar spine and hip extensor activation patterns in chronic low-back pain patients in a more functional and complex test situation like walking.
METHODS Seventeen male subjects (Age: 36.372.1 year, Height: 174.777.3 cm, Weight: 78.8714.6 kg) with chronic idiopathic low-back pain (CLBP) diagnosed by a physician (Table 1) and 16 age matched healthy males (Age: 33.773.1 year, Height: 178.875.2 cm, Weight: 77.276.4 kg) (Table 2) participated in the study. Due to the small sample size, and to control for confounding variables, such as gender differences, the study concentrated on one gender only. Individuals were recruited from co-operating rehabilitation clinics and university staff. In both groups, measurements were carried out unilaterally on one randomly selected side of the body. The visual analogue scale (VAS; 0=no pain and 10=most severe pain) (Triano et al. 1993) and Oswestry Disability Questionnaire (Fairbanks et al. 1980) were used for actual pain intensity and disability ratings. Both of these instruments have
previously been tested for reliability and validity (Deyo et al. 1986, Graver et al. 1998). To ensure that the back pain sufferers experienced at least moderate pain intensities at the time of testing, patients with self-reported pain ratings below 3 (VAS) were not included in the study (Arendt-Nielsen et al. 1996). Hip joint range of motion in the sagittal plane and neuromuscular activities of lumbar and thoracolumbar erector spinae [L3, T12], gluteus maximus and biceps femoris were recorded unilaterally during treadmill walking (HP-Cosmoss-Quasarmed, Germany) at 1.25 m/s. Relative hip flexion and extension was recorded by an electronic goniometer (Biovisions, Germany) with the axis of rotation aligned to the greater trochanter. The goniometer was calibrated in neutral upright standing. Pregelled (Ag/ AgCl) surface electrodes (BlueSensors) with an interelectrode distance of 20 mm were applied longitudinally over the selected muscles referring to international recommendations (Hermens & Freriks 1997). The reference electrode was attached to the subjects’ posterior superior iliac spine. The skin of the recording site was prepared according to the International Society of Electrophysiology and Kinesiology (ISEK) standards (Winter et al. 1980) by shaving as required, sanding, and rubbing with gauze, saturated with alcohol. All electrode cables were lightly secured with tape to reduce any possibility of artefacts produced by cable movement. In order to relate the EMG activity to the instant of heel-strike, pressure-sensitive footswitches were secured at both heels. The subjects had time to practice treadmill walking until they reported that they had become accustomed to the walking conditions. After a rest period of at least 15 min the subjects started to walk again until they reported to feel comfortable. Then data over a minimum of 20 strides were collected for each subject using a multi-channel EMG datalogger system (Biovisions, Germany; input impedance: 10 GO, CMRR: 130 db, RTI noise 8 nV/Hz, gain: 2500, filter: 10 Hz low cut-off, 700 Hz high cut-off, amplifier close to the detection site) operating at 1000 Hz per channel. Muscle on/offset was considered to have occurred when 25 consecutive data points of a sliding window exceeded the current mean baseline by three-standard deviations. The threestandard deviation threshold was selected referring to
Table 1. Inclusion and exclusion criteria for 17 male subjects of CLBP group Inclusion criteria
Exclusion criteria
Age between 25 and 55, full-time employment LBP limited to the lumbar area and buttocks (between T12 and gluteal folds) Low-back pain on at least half the days in a single or in multiple episodes within the past 12 months
LBP lower than buttocks Bowel or urinary tract problems Neurological deficit or nerve root tension signs Leg length discrepancy 41 cm Vascular insufficiency Any major surgery of the spine or lower limbs Systemic problems (cancer, cardiovascular, endocrine, etc.)
Manual Therapy (2003) 8(1), 21–28
# 2003 Elsevier Science Ltd. All rights reserved.
Neuromuscular control of walking with chronic low-back pain 23 Table 2. Inclusion and exclusion criteria for male control (normal) group (n=16) Inclusion criteria
Exclusion criteria
Full-time employment Age between 25 and 55 Normal spinal curvature and range of motion (total flexion o871, total extension o181, lateral flexion o241, Waddell 1998) No thoracic or lumbar pathology, including history
Previous surgery of the spine or lower extremities Any low-back pain in the previous 12 months Any loss of time from work for low-back pain Leg length discrepancy 41 cm Any history of arthritis in the lower extremities joints
DiFabio (1987). To account for different cycle durations between subjects selected EMG onset and cessation times were normalized in time for each muscle group and each stride per subject. This was achieved by computing on/offset times relative to the cycle duration of the recording site (heel contact to heel contact corresponding to 0–100%) (Fig. 1). The heel-strike, determined by the footswitch signal ipsilateral to the recording site, was used to define the start/stop of each cycle and to calculate cycle durations. Herewith, the analysis focused on the temporal characteristics (onset and cessation times) of the raw EMG signals during the gait cycle. To gain additional information from the ‘phasic’ EMG activity and to concentrate on the shape of the EMG profiles, linear envelopes (full-wave-rectifier followed by a second-order low-pass filter with cutoff at 8 Hz) were calculated (Winter 1984). This reliable method (Kadaba et al. 1989; Kleissen et al. 1997), applied in most gait laboratories (Harris & Wertsch 1994; Whittle 1996), is thought to mathematically model the muscle tension by the use of a single pass second-order low-pass system (Winter
1984, 1990). Due to the time delays introduced by the applied digital filter and the thereby affected occurrence of peaks the current analysis focused on the pattern of the averaged EMG profiles instead of peak characteristics. The signals were normalized with regard to the stride time (one cycle corresponds to 100%) to maintain timing relative to the walking cycle for the comparison of different subjects. In this way, more than 20 time-normalized EMG profiles formed the data base for the within-subject ensemble average. EMG amplitudes were normalized to the average EMG activity per gait cycle (Yang & Winter 1984). The second averaging procedure resulted in a profile for each group (grand average; CLBP, Controls). Kinematic signals were filtered using a low-pass, zero-lag, critical damped, fourth-order filter (8 Hz cut-off) (Wells & Winter 1980) to allow smoothing without introducing any time delay and time normalized to the ipsilateral heel strike. Student’s independent samples t-tests were selected to determine significant differences in muscle on/offset, hip movement, and cycle durations between groups.
Heel strike
Heel strike
Heel strike
Offset %
Onset %
100% gait cycle
1200
Offset %
100% gait cycle
Onset %
Foot switch signals
800
EMG offset
EMG onset
EMG offset
EMG onset
400
µV 0
0
500
1000
1500
2000
2500
Real time
-400
-800
-1200
Fig. 1FNormalized EMG on/offset time detection. # 2003 Elsevier Science Ltd. All rights reserved.
Manual Therapy (2003) 8(1), 21–28
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Cross-correlation values were computed for pairwise comparisons of the time history of the interindividual EMG profiles between groups. Po0.05 was regarded as significant.
in EMG profiles between groups (Fig. 3). Phase shifts identified by the cross-correlation calculations confirmed the pre-matured EMG activity of the biceps femoris and gluteus maximus in CLBP patients (Fig. 3).
RESULTS DISCUSSION In chronic low-back pain subjects the self-reported back pain intensity (VAS) ranged from 3 to 5.3 (mean: 3.9) indicating intermediate pain intensities during testing. The subjective disability index (Oswestry-Questionnaire) demonstrated moderate limitations in every day life activities (mean: 26.3%; range: 24–48) within the patient sample. The history of low-back pain ranged from 24 months to 4 years. Student’s t-tests demonstrated significant differences (Po0.01) for hip joint range of motion (38.379.11 vs 25.277.91) and stride time (1.0670.05s vs 1.0370.09 s) between healthy controls and back pain patients. Significant EMG onset differences (Po0.01) were found in comparing hip extensors (biceps femoris muscle, gluteus maximus muscle) of the pathological group and the healthy controls. Significant group differences (Po0.01) were also calculated for the onset of both EMG bursts of the bi-phasic activation pattern of the lumbar erector spinae [L3] muscles. Additionally, the analysis revealed a significantly prolonged electrical activity of the gluteus maximus and lumbar erector spinae muscles in the back pain group (Po0.01). No significant group differences in EMG peak characteristics were detected for the thoracolumbar erector spinae [T12]. EMG onset and cessation times of all selected muscles for the independent groups are given in Fig. 2. Cross-correlation values demonstrated almost identical patterns of falling and rising trends
The neuromuscular activation of the muscles in the pelvic region plays a primary role for the physiologic coordination and interaction of pelvis, spine and lower limb movements in human gait. Referring to the stabilization concept postulated by Panjabi (1992a,b; Norris 1995), disturbances of the musculoskeletal and fascial system can be prerequisites for or also consequences of pathological syndromes of the spine. Thus, in pain syndromes of the lumbar/ sacral/hip region the gluteal and hamstring muscles may play a role which is often overlooked. The recent study, therefore, intends to provide a more detailed look on low-back pain subjects’ muscle contractile patterns of lumbar spine and hip extensors in cyclic movements like walking. Concentrating on patients with a history of back pain, the recent investigation demonstrated reductions in hip flexion/extension movements as well as reduced gait cycle durations. The kinematic changes seen in the current investigation are consistent with those of other authors (Keefe & Hill 1985; Khodadadeh et al. 1988), who also found that back pain patients walked more slowly and took shorter strides. Therefore, the results provide support for the short strided gait and the observations of a more cautious walking pattern in chronic low-back patients (Zebouni et al. 1992; Dananberg 1998). The detection procedure of relative EMG on/offset times used in the present study tried to account for
38.6
M.erector spinae [T12]
M.gluteus maximus
M.biceps femoris
60.3
38.9
CLBP
M.erector spinae [L3]
58.1
Controls
8.7
Controls
44.4
60.4
92.9
p
