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

Manual Therapy (2003) 8(2), 63–65 r 2003 Published by Elsevier Science Ltd. 1356-689X/03/$ - see front matter doi:10.101...

Author: Editors: Ann Moore and Gwen Jull

153 downloads 578 Views 3MB Size Report

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

DOWNLOAD PDF

Manual Therapy (2003) 8(2), 63–65 r 2003 Published by Elsevier Science Ltd. 1356-689X/03/$ - see front matter doi:10.1016/S1356-689X(03)00005-5

Editorial

Bridging the gap across fields of practice signals are required to ensure stability. The more challenging tandem stance test implicates somatosensory and vestibular systems when vision is removed (Shumway-Cooke & Horak 1986; Woollacott 2000). Thus to prepare the musculoskeletal clinician, the knowledge, skills and interpretation of balance and mobility assessments need to be addressed in undergraduate programmes and applied in the ‘nonneurological’ context as well as to ageing clients and those with neurological dysfunction. In addition, post-graduate programmes in the musculoskeletal field need to reconsider these elements at a more advanced level to ensure optimal delivery of management programmes for WAD, and other non-neurological clients. In this regard, the treatment of postural instability following WAD and other musculoskeletal injuries needs to be addressed and consider the tasks that challenge the visual, somatosensory and vestibular systems. From a neurological perspective this would mean progressing from a stable surface and well-lit environment with eyes open to mastering balance on variable surfaces, with added weight shift and movement towards the limit of stability. Additional challenges can include working with the client in dim lighting and by removing visual cues (Horak et al. 1997; Shumway-Cooke et al. 1997). Consideration of these multiple aspects of postural control in the management of all nonneurological disorders should reduce the perceived tendency to relegate, to the ‘neurological box’, valuable knowledge and skills acquired during basic training as a physiotherapist. A second aspect that is being investigated by the research team is the relationship between dizziness, ocular control and postural stability in chronic WAD. Smooth pursuit difficulties and increased joint positioning error have been identified in chronic WAD, which together, may contribute to increased unsteadiness and visual disturbance and may be associated with complaints of dizziness (Heikkila & Astrom 1996; Tjell & Rosenhall 1998; Treleaven et al. 2002). The contributions of the visual, somatosensory and vestibular systems to ocular control are well known with the importance of the vestibular ocular reflex (VOR) to enable gaze stability during head movements established (Baloh 1998; Herdman, 2000). The vestibular contributions to gaze instability

Physiotherapists are working more collaboratively in the musculoskeletal and neurological fields with postural stability and motor control emerging as a common area of focus. This has led to a reduction in the polarized position of physiotherapists with any perceived gap gradually being bridged through identifying common ground and developing collaborative research opportunities which focus on improved outcomes for clients. One catalyst for this change in our institution has come through a productive collaboration between physiotherapists researching and working with chronic whiplash associated disorders (WAD) and those working with traumatic brain injuries (TBI). Many of the chronic WAD clients were presenting with unsteadiness and dizziness, making it timely to examine this problem from a broader perspective (Treleaven et al. 2002). As a physiotherapist working and researching with clients following TBI where unsteadiness and dizziness are also present, the opportunity to collaborate with colleagues ‘across fields of practice’ was most welcome and has led to ongoing and constructive outcomes. A study to examine standing balance control between WAD clients with complaints of dizziness and/or unsteadiness demonstrated increased instability in comfortable stance tasks on both a firm and a foam surface, particularly when vision was removed; and when the base of support was narrow, such as tandem stance. These findings support the recommendation that physiotherapists working with WAD clients should examine the postural mechanisms more thoroughly and use tasks that challenge balance in the initial and subsequent assessments (Treleavan et al. submitted). For this recommendation to be effectively addressed by physiotherapists in the musculoskeletal field, it is critical that knowledge of the visual, somato-sensory and vestibular contributions to balance (postural stability) are understood and that the practical skills of assessing balance by sequentially challenging these systems is clear. For example, bilateral stance on a firm surface with vision removed requires the somato-sensory and the vestibular systems to work together to ensure optimal balance; when a foam (soft) surface is introduced, the somatosensory system is less reliable and thus vestibular 63

64 Manual Therapy

and dizziness associated with head movement is frequently addressed by physiotherapists working with clients following primary vestibular pathology (Horak et al. 1992; Krebs et al. 1993; Shepherd & Telian 1995) and TBI (Shumway-Cooke 1992; Gizzi 1995; Fitzgerald 1996). These need to be considered also by physiotherapists working with WAD. The contribution of the cervical afferents to the cervical ocular reflex (COR) is currently being researched and the cervicogenic cause of dizziness following WAD is topical and receiving attention by researchers within and beyond our research group (Petersen et al. 1985; Tjell & Rosenhall 1998; Bracher et al. 2000; Wrisley et al. 2000; Treleaven et al. submitted). The challenge for the manual therapist working with cervical dysfunction and WAD in particular, is to attempt to differentiate between the multiple causes of ocular instability and dizziness and identify those that are amenable to physiotherapy intervention. Questions for consideration include: Has the acute trauma following WAD caused abnormal afferent input from the cervical mechanoreceptors and thus contributed to symptoms of dizziness, unsteadiness and visual disturbances? Could the trauma at the time of the WAD have caused damage to the vestibular receptor apparatus with hair cells being dislodged to form free floating particles in the semi-circular canals which cause intermittent dizziness associated with specific head movements i.e. according to the canal involved—benign paroxysmal positioning vertigo (BPPV)? Could the WAD be accompanied by a mild head injury and/or concussion which may complicate the WAD presentation? Have there been circumstances to involve the vertebral artery? It is critical that all physiotherapists know how to conduct a comprehensive assessment that may enable more effective differential diagnosis of the cervical, vestibular and central nervous system contributions to ocular instability, dizziness and balance. A combination of a careful history and well-directed clinical examination should ensure that the contribution of these systems to ocular stability, dizziness and postural control are considered. The findings need to be documented using outcome measures to monitor progress (Jacobsen & Newman 1990; Tesio et al. 1999; Whitney & Herdman 2000; Murray et al. 2001; Shumway-Cooke & Woollacott, 2001). Additional investigations can be offered by neurologists and neuro-otologists to assist with differential diagnosis and exclude other causes of ‘dizziness’ that may be outside our realm of practice. The dizziness caused by BPPV and other vestibular pathology, TBI and that of cervicogenic origin are all amenable to intervention by a physiotherapist. Specific protocols for BPPV are more established. The diagnosis of BPPV is confirmed by the Hall-Pike Dix Test and simple re-positioning manoeuvres (depending on the canal implicated) can be applied r 2003 Published by Elsevier Science Ltd.

to ‘move the particles’ toward the vestibule where reabsorption may occur (Lynn et al. 1995; Epley 1996; Wolfe et al. 1999; Blatts et al. 2000). A possible screening test for cervicogenic dizziness is being investigated with application of the smooth pursuit neck torsion test yielding promising results (Tjell & Rosenhall 1998). In this test, eye pursuit is examined and then the trunk is rotated up to 451 while the head is held stationary and maintained in this position before reintroducing eye movements. A change in the quality of smooth pursuit eye movements in the ‘torsioned’ position compared to the ‘neutral’ position suggests that cervicogenic dysfunction is contributing to the complaints of dizziness and unsteadiness (Tjell & Rosenhall 1998; In Press.). Once the cause(s) of dizziness are considered, a tailored series of exercises involving eye and head movements with and without vision could be introduced to address the dysfunctional systems (Shumway-Cooke 1992; Revel et al. 1994; Gizzi, 1995; Herdman, 1997, 2000). The prevalence of dizziness, unsteadiness and accompanying gaze instability following WAD requires that protocols be adopted to ensure that dizziness is addressed and that retraining ocular stability and balance is an integral part of WAD management. It has become clear from the association with the WAD research group that the neuro-motor control of movement is as relevant to the musculoskeletal field of practice as that required for the physiotherapist working in the neurological arena. Such mutual collaborations can only take a broader view for practice forward and help to minimize the potential fragmentation that may beset our profession as the number of physiotherapists who are specializing increase. While the physiotherapist does need to develop expertise in a specific field, it is critical to retain the broadest perspective for optimal client outcomes. It is in this climate of collaborative research and practice that the profession should effectively move forward. Nancy Low Choy Department of Physiotherapy, The University of Queensland, Australia E-mail address: [email protected]

References Baloh RW 1998 Dizziness, Hearing Loss and Tinnitus. FA Davis Company, Philadelphia Blatt PJ, Georgakakis GA, Herdman SJ, Clendaniel RA, Tusa RJ 2000 The effect of the canalith repositioning maneuver on resolving postural instability in patients with benign paroxysmal positional vertigo. American Journal of Otology 21: 356–363 Bracher E, Almeida C, Almedia R, Duprat A, Bracher C 2000 A combined approach for the treatment of cervical vertigo. Journal of Manipulative Physiological Therapy 23: 96–100 Manual Therapy (2003) 8(2), 63–65

Editorial 65

Epley JM 1996 Particle repositioning for BPPV. Otolaryngology Clinics of North America 29: 323–331 Fitzgerald D 1996 Head trauma: Hearing loss and dizziness. Journal Traumatic Injury, Infection and Critical Care 40: 488–497 Gizzi M 1995 The efficacy of vestibular rehabilitation for patients with head trauma. Journal of Head Trauma and Rehabilitation 10: 60–77 Heikkila H, Astrom P 1996 Cervicocephalic kinaesthetic sensibility in patients with whiplash injury. Scandinavian Journal of Rehabilitation 28: 133–138 Herdman S 1997 Advances in the treatment of vestibular disorders. Physical Therapy 77: 602–617 Herdman S 2000 Vestibular Rehabilitation. FA Davis Co., Phil, USA Horak FB, Henry SM, Shumway-Cook A 1997 Postural perturbations: new insights for treatment of balance disorders. Physical Therapy 77: 517–533 Horak FB, Jones-Rycewicz C, Black FO, Shumway-Cook A 1992 Effects of vestibular rehabilitation on dizziness and imbalance. Otolaryngology Head and Neck Surgery 106: 175–180. Jacobson GP, Newman CW 1990 The development of the dizziness handicap inventory. Archives of Otolarngology Head and Neck Surgery 116: 424–427 Krebs DE, Gill-Body KM, Riley PO, Parker SW 1993 Doubleblind, placebo-controlled trial of rehabilitation for bilateral vestibular hypofunction: preliminary report. Otolaryngology Head and Neck Surgery 109: 735–741. Lynn S, Pool A, Rose D, Brey R, Suman V 1995 Randomised trial of the canalith repositioning procedure. Otolarygnology Head and Neck Surgery 113: 712–720. Murray K, Carroll S, Hill K 2001 Relationship between change in balance and self reported handicap after vestibular rehabilitation therapy. Physiotherapy Research International 6: 251–163 Peterson B, Goldberg J, Bilotto G, Fuller J 1985 Cervicocollic reflex: Its dynamic properties and interaction with vestibular reflexes. Journal of Neurophysiology 54: 90–108 Revel, M, Andre-Deshays C, Minguet M 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: 895–899

Manual Therapy (2003) 8(2), 63–65

Shepard NT, Telian SA 1995 Programmatic vestibular rehabilitation. Otalaryngology Head and Neck Surgery 112: 173–182 Shumway-Cook A 1992 Rehabilitation of vestibular dysfunction in traumatic brain injury. Physical Medicine and Rehabilitation Clinics of North America 3: 355–368 Shumway-Cook A, Woollacott M 2001 Motor Control: Theory and Practical Applications. Williams and Wilkins, Baltimore Shumway-Cook A, Gruber W, Baldwin M, Liao S 1997 The effect of multi-dimensional exercises on balance, mobility and fall risk in community-dwelling older adults. Physical Therapy 77: 46–57 Shumway-Cook A, Horak FB 1986 Assessing the influence of sensory integration on balance. Physical Therapy 66: 1548–1550 Tesio L, Alpini D, Cesarani A, Perucca M 1999 Short form of the dizziness handicap inventory. American Journal of Physical Medicine and Rehabilitation 78: 233–241 Tjell C, Rosenhall U 1998 ‘Smooth pursuit neck torsion test: A specific test for cervical dizziness.’ American Journal of Otology 1: 76–81 Tjell C, Rosenhall U. ‘Smooth pursuit neck torsion test – a specific test for WAD.’ Journal of Whiplash and Related Disorders, In Press Treleaven J, Jull G, Murison R, Low Choy N, Brauer S. Standing balance in chronic whiplash, submitted for publication Treleaven J, Jull G, Sterling M 2002 ‘Dizziness and unsteadiness following whiplash injury — Characteristic features and relationship with cervical joint position error.’ Journal of Rehabilitation and Medicine 34: 1–8 Whitney SL, Herdman SJ 2000 Physical therapy assessment of vestibular hypofunction. In: Herdman S (ed.) Vestibular Rehabilitation. FA Davis Co; Philadelphia, pp 333–372 Wolf JS, Boyev KP, Manokey BJ, Mattox DE 1999 Success of the modified Epley maneouver in treating Benign Paroxysmal positional vertigo. Laryngoscope 109: 900–903 Woollacott MH 2000 Systems contributing to balance disorders in older adults. Journal of Gerontology Medical Science 55A (8): M424–M428 Wrisley D, Sparto D, Whitney S, Furman J 2000 Cervicogenic dizziness: A review of diagnosis and treatment. Journal of Orthopaedic and Sports Physical Therapy 30: 755–766

r 2003 Published by Elsevier Science Ltd.

Manual Therapy (2003) 8(2), 66–79 r 2003 Elsevier Science Ltd. All rights reserved. 1356-689X/03/$ - see front matter doi:10.1016/S1356-689X(02)00157-1

Masterclass

Lateral epicondylalgia: a musculoskeletal physiotherapy perspective B. Vicenzino Department of Physiotherapy, University of Queensland, Australia

SUMMARY. Tennis elbow or lateral epicondylalgia (LE) is a challenging musculoskeletal condition to treat. This is largely due to the lack of research-based evidence of the clinical efficacy of the myriad of treatment approaches espoused in the literature. In view of this, successful rehabilitation of LE is based on choosing treatments that address the physical impairments found during clinical examination. The primary physical impairment in LE is a deficit in grip strength predominately due to pain and its consequences on motor function. Hence the mainstay of successful management of this condition is therapeutic exercise, providing it is not pain provocative. Adjunctive procedures such as manipulative therapy and sports taping techniques have recently been shown to provide substantial initial pain relief. Early relief of pain in the rehabilitation program helps accelerate recovery and most importantly motivates the client to persist with the therapeutic exercise program. The manipulative therapy and taping treatments presented in this masterclass warrant consideration in the clinical best practice management of LE, and serve as a model for other similar musculoskeletal conditions. r 2003 Elsevier Science Ltd. All rights reserved.

Pain over the lateral humeral epicondyle which manifests during activities involving the hand in gripping or manipulating an object, such as that required when lifting a tea cup, shaking hands, dressing and desk or house work, will to most musculoskeletal health care practitioners signal the provisional diagnosis of ‘tennis elbow’ or more correctly lateral epicondylalgia (LE) (Vicenzino & Wright 1996). The cardinal physical signs of LE are pain to direct palpation over the lateral epicondyle and reproduction of pain and weakness during grip strength testing. Commonly, resisted contractions of the extensor muscles of the forearm, particularly the extensor carpi radialis brevis are also painful. No diagnostic imaging is usually required to confirm the diagnosis, although diagnostic imaging techniques, such as radiographs or CAT scans, can be used to exclude other conditions and injury of the underlying bone.

Epidemiological evidence indicates that LE is reasonably prevalent in the broad community (3% of general population (Allander 1974)) accounting for 5–7 in every 1000 general medical practitioner visits (Assendelft et al. 1996). Many sufferers of this condition who present to clinics for treatment do not play tennis, making the term ‘tennis elbow’ inappropriate for them. At risk populations, such as tennis players, fish processing workers, and those working in industries requiring repetitive manual tasks, express the condition in higher proportions, some found to be as high as 15% (Chiang et al. 1993; Ranney et al. 1995). Lateral epicondylalgia is an intriguing condition because while it presents with a reasonably uncomplicated clinical picture its underlying aetiology is not readily understood (Vicenzino & Wright 1996). It is also regarded as an overuse injury that is difficult to treat, prone to recurrent bouts and may last for 48 months (Murtagh 1988).

Received: 15 November 2002 Accepted: 30 November 2002

AETIOLOGY PERSPECTIVE

Bill Vicenzino PhD MSc BPhty Grad Dip Sports Phty, Senior Lecturer, Department of Physiotherapy, University of Queensland, St Lucia, Queensland 4072, Australia. Tel.: +61-7-3365-2781; fax: +61-7-3365-2775; E-mail: [email protected]

The aetiology of LE has not been fully elucidated but on current evidence it would appear that the condition in its chronic form is not one of acute

INTRODUCTION

66

Musculoskeletal physiotherapy perspective 67

inflammation. Studies conducted on biopsy material taken at the time of surgical treatment for LE have identified a lack of inflammatory markers (Ljung et al. 1999); instead, degenerative changes in connective tissue have been reported (Nirschl 1989; Regan et al. 1992; Verhaar et al. 1993). Degenerative changes have also been shown in other chronic tendinopathies (Nirschl 1989; Khan & Cook 2000; Khan et al. 2000). A recent microdyalysis study at the common extensor origin in four patients with chronic LE identified increased levels of glutamate, an excitatory amino acid, when compared to control asymptomatic subjects (Alfredson et al. 2000). This study also confirmed the lack of prostaglandin E2, a biochemical marker of inflammation at the study site. This suggests a disordered nociceptive system and concurs with findings from previous studies that used qualitative sensory testing to characterise LE pain. In brief, these qualitative sensory testing studies have indicated that the pain mechanism of LE may be one of secondary hyperalgesia (Wright et al. 1992, 1994; Smith & Wright 1993). The mechanism of secondary hyperalgesia represents disordered neural processing characterized by central sensitization (Sluka 1996; Sluka & Rees 1997). One of the characteristics of secondary hyperalgesia is that it is found in an area that is neurologically related to, but not at, the injured tissue site. Some evidence exists to support the involvement of the cervical spine (Gunn & Milbrandt 1976) and upper limb neural tissues (Yaxley & Jull 1993; Wright et al. 1994) as a source of chronic LE. Although clients with LE will classically report pain as the main feature of their condition they will invariably present with marked deficits in their muscle system. Weakness with grip dynamometer and isokinetic testing is a characteristic of LE (Stratford et al. 1993; Vicenzino et al. 1996, 1998; Pienimaki et al. 1997b). Recently the sensory-motor system changes that occur in this condition have been studied (Pienimaki et al. 1997a). Pienimaki et al. (1997a, b) evaluated sensory-motor function in 32 people with unilateral, chronic LE and showed that the affected arm had reduced performance on a number of tasks of reaction time, speed of movement and coordination. Interestingly, the unaffected side also displayed deficits compared to age and gender-matched controls, possibly implicating a central motor control problem. Abnormal muscle activation patterns of forearm extensor muscles and poor posture of the upper limb have been identified in LE sufferers (Kelley et al. 1994). Kelley et al. (1994) conducted a study of highspeed cinematography and electromyography of the forearm during the performance of a back hand tennis stroke in eight tennis players with LE and found that the extensors developed higher levels of Manual Therapy (2003) 8(2), 66–79

electrical activity at ball impact when compared to 14 asymptomatic subjects. Extensor carpi radialis brevis exhibited less activation in the early preparatory phase prior to ball impact in injured players, possibly representing impaired stability at the wrist. There was a ‘leading elbow’ posture during the back hand at ball impact in which the wrist was extended more in LE sufferers than the non-injured tennis players and the arm was further internally rotated (Kelley et al. 1994). In summary, the condition of LE is characterized by muscle and motor dysfunction as well as disordered pain system function. These changes should be evaluated in the physical examination and the findings form the basis of the physiotherapy management program.

EVIDENCE-BASED PRACTICE PERSPECTIVE The numerous treatments for LE described in the literature mirror the unknown elements of the condition’s aetiology and underscores the impression that it is a difficult condition to manage successfully. Labelle et al. attempted a meta-analysis of published research findings on the treatments for this condition and reported that it was not possible, mainly due to the poor methodological quality of the research (Labelle et al. 1992). Since Labelle’s paper, several Cochrane reviews have been published for some suggested treatments (e.g. acupuncture (Green et al. 2002a); orthotic therapy (Struijs et al. 2002); shock wave therapy (Buchbinder et al. 2002b); oral nonsteroidal anti-inflammatory medication (Green et al. 2002b); surgery (Buchbinder et al. 2002a) with little advancement in the conclusions of Labelle et al. (1992). Not surprising, there are no reviews of manipulative therapy as manipulative therapy is perceived to be joint therapy and LE is an apparent soft tissue disorder.

A MUSCULOSKELETAL PHYSIOTHERAPY PERSPECTIVE Pain relief and restoration of muscle condition are primary objectives of rehabilitation. Restoration of muscle condition is best effected through a progressive resistance exercise program of the upper limb muscles, concentrating on the extensors of the wrist and hand (Pienimaki et al. 1996, 1998). Pienimaki et al. (1996) studied the clinical efficacy of a progressive and slowly graduated program of strengthening and stretching exercises in 39 sufferers of chronic LE who had failed other forms of treatment. They found improvements in the exercise group to be significantly superior to a control group. r 2003 Elsevier Science Ltd. All rights reserved.

68 Manual Therapy

Most importantly the exercise program was not pain provocative. In order to treat pain and to facilitate pain free exercise a number of physical therapy modalities may be used. Interestingly, for a condition that is conceptualized as being predominantly a soft tissue injury, there are several manipulative therapy treatments that appear to provide useful short-term pain relief and restoration of function, allowing therapeutic exercise to progress optimally, or possibly at an accelerated rate. These treatment techniques include Mulligan’s Mobilization With Movement (MWM) (Mulligan 1999) and Elvey’s cervical lateral glide (Elvey 1986). Self-treatment with manual therapy and specific sports taping procedures are necessary in maintaining pain relief outside the clinical visits. In addition, there is a view that the chronicity and severity of the condition will be unduly protracted should some simple advice not be followed. This advice involves rest from activities that aggravate the pain in the initial stages of rehabilitation (including treatments used in rehabilitation). It is also important that clients avoid lifting objects with the hand facing the floor as this subjects the extensor muscles of the forearm to increased loads that frequently exacerbate pain.

Fig. 2—Forearm extensor muscle exercise using a free standing dumbbell and 6–10 s per repetition. Note that the forearm is fully stabilized by the bench and upper body in sound postural alignment.

Therapeutic exercise program The primary physical impairment in LE, which occurs in the muscle system, is best characterized as a deconditioning response of the forearm muscles to the pain. Hence, all cases of persistent tennis elbow will require a therapeutic exercise program for the forearm muscles (7 general forequarter muscles). As a bare minimum exercises for the muscles that are directly affected in LE should be performed. That is, exercises that involve pain free gripping tasks (Fig. 1) and the extensor muscles (Fig. 2). Ideally, other muscle groups of the forearm should also be exercised, as this will encourage a more functional activity pattern of all forearm muscles and provide the stimulus for coping with real world tasks. For example, exercises for flexion (Fig. 3), supination and pronation (Fig. 4) as well as radial and ulnar

Fig. 1—Pain-free gripping exercise with exercise putty. Exercise putty will allow practice of many different gripping actions. r 2003 Elsevier Science Ltd. All rights reserved.

Fig. 3—Dumbbell weight exercise for the forearm flexor muscle. Note that the forearm is fully stabilized by the bench and upper body in sound postural alignment. Duration per repetition should approximate 6–10 s.

Fig. 4—Exercises for the supinator and pronator muscles of the forearm performed here with an imbalanced adjustable dumbbell weight. At home the client may use a broom stick for a light weight or a hammer. The movement extends from end of range of supination to end range pronation with the client maintaining full active control of the weight. The arm is stabilized besides the trunk and the elbow bent to 901. Duration per repetition is 6–10 s. Progressions in load imposed on the muscles can be achieved by increasing the weight or by increasing the distance between weight and hand. Manual Therapy (2003) 8(2), 66–79


deviation (Fig. 5) should be incorporated in the therapeutic exercise program. Many forms of resistance and load may be used, such as, free weights (Figs. 2–5), rubber bands, manual resistance, isokinetic dynamometry or isometric contractions. The load mode is largely dictated by the circumstances and availability of equipment. If the client has been absent from the workforce, then before re-introduction into the workforce the client should have work-specific tasks and activities incorporated in the therapeutic exercise program. This may involve, grasping and placing of objects starting with light and easy to grasp objects and move in accordance with the overload principle to progressively heavier and harder to grasp objects. Any deficiency in other upper quadrant muscles should also be addressed, including correcting any poor postural alignment (Fig. 6) and movements of the upper limb. It is essential that all exercises that are performed for the upper limb must be done with

Fig. 5—Radial and ulnar deviation exercises, A and B, respectively, are performed with similar equipment shown in Fig. 4 and with similar guidelines.

Fig. 6—(A) poor and (B) corrected posture: A common upper body postural alignment shown here. Key points are: a kyphotic thoracic spine, lordotic cervical spine, poked chin, protracted scapulae, internally rotated arm and pronated forearm (A). Educating the client to recognize and correct the poor posture involves reversing the posture by starting at the pelvis and then working up to the neck. Once the spine and trunk are aligned more optimally then the upper limb position should be addressed (B). Manual Therapy (2003) 8(2), 66–79

sound alignment of the spine, trunk and proximal arm. Figures 7–11 show some of the base exercises that may be performed 2–3 times per week to address proximal limb weaknesses and deconditioning (three sets of 8–12 repetitions). The conditioning protocol that would be utilized is typically three sets of 8–12 repetitions (e.g. muscle

Fig. 7—Modified bench press with one arm using an exercise ball in this instance. Alternative benches to the ball are the floor, bed or an exercise table. Care should be taken to extend the arm upwards and slightly inwards so that the end point is vertically over the anterior shoulder.

Fig. 8—Bent over rowing with the elbow vertically aligned over the hand and weight. In this example an exercise ball is used to stabilize the trunk; a low sturdy table, bench or chair may be substituted. Note that the scapula undergoes a full range of motion with this exercise and the trunk and spine assume a near neutral alignment.

Fig. 9—Unilateral shoulder press with elevation being performed in the plane of the scapula. The start position is elbow flexed and arm by side and the end position is the elbow extended and the arm fully elevated such that the hand is vertically above the shoulder. r 2003 Elsevier Science Ltd. All rights reserved.

70 Manual Therapy

*

*

*

*

Fig. 10—Biceps exercise with the arm by the side and the movement going from elbow extension to full flexion and back to extension.

Accounting for the amount of incidental exercise that the muscles undergo at work, home and recreational activities to avoid aggravation of symptoms. Ensuring compliance by using positive strategies such as regular review and progression of exercises by the therapist. Allowing sufficient rest between sets (approximately 1–2 min) to ensure adequate time for recovery. The intensity of the exercises should not be such that delayed onset muscle soreness is a feature of the training response and therefore daily exercise sessions should be possible without exacerbation of the condition.

Manipulative therapy and sports tape In order to describe a systematic approach to the manual therapy management of LE it is helpful to categorize presenting clients into five types in which: Fig. 11—Triceps extensions performed with the trunk supported (exercise ball in this case) while the arm is maintained perpendicular to the floor and the elbow moves from flexion to extension and back.

strengthening regimen (McArdle et al. 1996)). In some cases of chronic LE the deconditioning of the muscle is so severe that one set per exercise session is all that is possible. If this is the case then at least two sessions per day should be encouraged. It is advisable that each repetition be performed slowly (e.g. 6–10 s duration). It appears that stretching the exercised muscles following exercise may offer advantages in the conditioning process and aid in the desensitization of the painful soft tissues even though stretches do not appear to have a role in the prevention of injury (Shrier 2000). Stretching exercises should be performed in a slow and sustained manner and should only engender a stretching sensation over the exercised muscles. A stretching session would typically involve 3–5 repetitions of 20–30 s holds for each muscle group. All exercises should be performed on both the affected and unaffected arms to encourage any cross midline adaptations in muscle and motor function and provide a practical means of timing the rest periods between sets if more than one set of exercise per session is performed. Factors governing the safe and optimum prescription of exercises are numerous and include: *

*

No exacerbation of symptoms (pain) during or after exercise. Maintaining correct form and posture throughout the exercise. Close monitoring by regular reviews with the therapist facilitates this.

r 2003 Elsevier Science Ltd. All rights reserved.

(a) Pain-free grip strength deficit is much larger than pain elicited on direct palpation of the lateral epicondyle (i.e. the pressure pain threshold). (b) Pressure pain threshold deficit is larger than the pain-free grip strength deficit. (c) There is a similar magnitude of deficit in painfree grip strength and pressure pain threshold. (d) Past not current history of cervical spine-related pain or dysfunction. (e) Night pain. In essence the criteria used in this classification process are pain-free grip strength, palpation pain or pressure pain threshold, and findings on physical examination of the cervical spine and neural tissues. Pressure pain threshold is a means by which to quantify the pain provoked on direct manual palpation of the lateral epicondyle. The amount of pressure required to elicit pain is the index used with this method and is usually measured with an algometer (for example see Vicenzino et al. (1996)). (a) Pain-free grip strength deficit predominates: A treatment approach that can be applied to the elbow and has been proving to be extremely beneficial in relieving pain and simultaneously restoring function is the Mulligan’s (1999) MWM. In brief, the MWM techniques can be described as the application of a manual force (‘Mobilization’) across a joint that is sustained during the performance of an impaired action (‘Movement’). The impaired action could be a movement but more commonly in LE is a muscle contraction. The manner in which the manual force is applied to the elbow is determined by a number of factors, the predominant one being the degree of pain relief and improvement in impairment that is achieved during the application of the treatment Manual Therapy (2003) 8(2), 66–79


technique. That is, the direction of the glide and the amount of force are determined on an iterative process in which feedback on the outcome either modifies the application or serves to validate its continued use. Most importantly the treatment technique is not deemed to be effective and should not be used unless there is a substantial improvement in pain and impairment, for example, greater than 50% improvement (Mulligan 1999). The technique of choice and the first one to be attempted in the physical treatment of a client with persistent LE is usually a sustained lateral glide across the elbow joint while the client performs a gripping action (Sustained Lateral Glide With PainFree Grip: SLGWPFG) (Figs. 12–14). See Table 1 for technical details of this technique. There is some evidence substantiating the claims that this treatment technique provides a substantial initial amelioration of pain and dysfunction (Vicenzino & Wright 1995;

Fig. 12—Sustained lateral glide with pain free grip strength (SLGWPFG): Client supine with upper limb fully supported on treatment bed. Upper limb position is arm internally rotated, forearm pronated and the hand gripping a dynamometer. Therapist’s right hand blocks the distal humerus from moving and the left hand effects a lateral glide at the elbow joint. The application point of force on the left hand is the palmar surface of the first metacarpal and proximal finger. See Table 1 for technical details. Note the grip dynamometer used to measure pain-free grip strength.

Table 1. Elbow sustained lateral glide with pain-free grip (SLGWPFG)* Indication Pain over lateral elbow on gripping that is worse than tenderness to direct palpation over the lateral epicondyle Positioning Client Upper limb Therapist Therapist hands

Supine with upper limb fully supported on treatment table Relaxed extension of the elbow with pronation of the forearm Adjacent to the affected elbow facing across the body of the client Stabilizing hand: heel and first web space placed on the lateral surface of the distal humerus Gliding hand: index finger and first metacarpal placed on the medial surface of the ulnar just distal to the joint line

Application guidelines * First ensure that the client has a reproducible aggravating action prior to applying glide (i.e. pain-free grip in this case) * A grip dynamometer is used to quantify the outcome measure, allowing for accurate assessment of treatment effects * Apply a laterally directed glide across the elbow joint * While sustaining the glide have the client repeat the isometric gripping action until the onset of pain and no more * Note the grip strength obtained before relaxing the grip and then release the glide * Repeat several times (6–10X) in a session, BUT ONLY IF there is a substantial relief of pain during the application of the technique and there is no latent pain immediately following the treatment technique Comment * Ensure that the stabilizing hand does not compress the lateral epicondyle in such a way to cause pressure pain that reproduces the client’s symptoms * Directing the glide in a purely lateral or slightly posterior of lateral (approx. 51) direction will be effective in most cases (Abbot et al. 2001). If pain relief is not achieved then inclining the glide anterior to lateral some 51 or slightly caudad should be trialed before discarding the technique. Attempt no more than four trials to elicit a positive response in any one treatment session, as failure to relieve pain over this number of trials will prove counter productive * Do not release the sustained lateral glide before grip has been relaxed * We have evaluated in a pilot study the amount of force that should be applied during this treatment technique and found it to be approximately two-thirds that of the therapist’s maximal force application across the joint (McLean et al. 2002) Variations * Alternate position as in Figure 13 can also be used * A treatment belt (Fig. 14) may be used to lessen the manual work load on the therapist but care should be taken not to be overly vigorous * Taping techniques (Fig. 15) that replicate the manual glide force are also beneficial in providing maintenance of pain relief outside of treatment in the clinic * Self-treatments in which the client performs the glide outside of treatment sessions (Fig. 16) are mandatory if gains made in treatment sessions are to be maintained and the condition ameliorated on a more longer term basis (Mulligan 1999) * Different elbow positions may be necessary in some clients * Substitute wrist and hand extension as the movement or other pain producing activity if they are more pain provocative than grip *See Figures 12–16. Manual Therapy (2003) 8(2), 66–79


72 Manual Therapy

Fig. 13—SLGWPFG performed in an alternative position to Fig. 12 in which the upper limb is not resting on the bed, now supported, instead, by the therapist. The therapist’s right hand is stabilizing the distal humerus while the left hand performs the lateral glide (Mulligan 1999). Note that the lateral side of the first metacarpal and proximal phalange are the point of force application. See Table 1 for technical details.

Fig. 15—Sports taping technique with the tape starting medially on the proximal forearm and tracking laterally across the joint line to anchor off on the distal humerus above the joint line, thus attempting to replicate the forces applied during the SLGWPFG. Non-elastic sports tape with adhesive backing is used (38 mm wide, BDF Australia).

Fig. 14—SLGWPFG as in Fig. 12 and Table 1 but with a treatment belt used to replicate the manual force (Mulligan 1999). Therapist’s right hand stabilizes distal humerus and the left hand maintains the forearm position. The therapist is in a walk stand position facing across the client and towards the client’s feet in a position such that the belt is over the right shoulder and the right shoulder is directly over the elbow. The treatment belt force is almost vertically up from the floor such that a small knee bend and extension by the therapist exerts the desired treatment force to the elbow.

Abbott 2001; Abbott et al. 2001). In a single case study we demonstrated the expected clinical pathway of a case successfully treated by this treatment technique (Vicenzino & Wright 1995). Clinically relevant was the finding that improvements in pain and function were highly correlated and that the pain improved earlier and at a faster rate than function. This supports the notion that the manual therapy treatment technique was useful in alleviating pain and rapidly restoring function. In the early stages of treatment, in which deficits in muscle strength and function still exist, it is important that self-treatment by the client is performed regularly. The client should develop a level of confidence to self-treat in the event of an exacerbation outside of scheduled visits to the clinic. Options available to extend the benefits of the MWM treatment technique beyond the treatment session, such as, the application of rigid sports adhesive tape (Fig. 15) and self applied manual therapy treatment (Fig. 16). Both these selftreatment techniques should be evaluated in the clinic to ensure effectiveness. If there is also reproduction of pain with movements of the elbow then the lateral glide of the elbow is performed while the offending movement is r 2003 Elsevier Science Ltd. All rights reserved.

Fig. 16—This photo shows the client performing a lateral glide of the elbow using the unaffected hand to apply the glide force to the proximal ulnar on the medial side and a belt to stabilize the distal humerus. Alternatively the client could prop the lateral arm up against a wall or door jam and hold it there by direct apposition to the trunk while performing the glide as shown here. Once the lateral glide is in place the client can perform a number of tasks, replicating the clinic MWM, e.g. gripping or flexion–extension. At no times should there be pain due to direct contact pressure from the belt or wall or door jam.

repeated (Sustained Lateral Glide with Movement: SLGWM) (Figs. 17 and 18, Table 2). In the event that the SLGWPFG or SLGWM are not effective then a sustained postero-anterior glide of the radio-humeral joint (Sustained P-A Glide with Pain-Free Grip: SPAWPFG) should be attempted. Figure 19 shows this technique and Table 3 describes the key technical aspects. Client self-treatment by way of self-manipulation (Fig. 20) and tape (Fig. 21) is applied with the same guiding principles described for the SLGWPFG. Manual Therapy (2003) 8(2), 66–79


High-velocity thrust of the elbow, particularly the radio-humeral joint, is not performed frequently but should be considered when there is marked

hypomobility on accessory glide testing of the radiohumeral joint and initial attempts with MWM treatment have proved less than optimal. The high-velocity

Fig. 17—This is an example of hand placement for the sustained lateral glide with movement (SLGWM) for elbow flexion. It is like that shown in Fig. 13 with the exception that for flexion the hands must be placed such that they do not prevent obtaining end of range flexion. To achieve this, the heel of the right hand blocks the distal humerus from moving laterally and the lateral side of the first metacarpal and phalange is used to apply the lateral glide while allowing full unimpeded flexion motion. The SLGWM for extension is exactly as shown in Fig. 13 but without a dynamometer in-situ. See Table 2 for further details. Note that once pain-free end of range is achieved, overpressure is added to optimize the effect.

Fig. 18—This shows use of the treatment belt to effect a SLGWM into flexion. Notice how the therapist’s right elbow, which blocks the distal humerus on the lateral side, propped up against the therapist abdomen and lies inside the treatment belt to allow unimpeded motion into flexion and out into extension. The difference between end range flexion and extension with this technique is in the therapist’s position. In flexion the therapist moves cephalad with the forearm and in terminal extension the therapist performs a small cephalad translation of the body as he/she pivots in a counter-clockwise direction on the right foot to accommodate the carrying angle of the elbow. See Table 2 for further details.

Table 2. Sustained lateral glide of the elbow with movements of the elbow (SLGWM)* Indication * Pain over the lateral elbow that is worse with movements of the elbow * After the SLGWPFG when there may be pain on first moving out of the extended position Positioning Client Upper limb Therapist Therapist hands for Flexion Therapist hands for Extension

Supine with upper body fully supported on treatment table Arm positioned by side with sufficient abduction to allow therapist access to medial side of the upper limb Facing across the body of the client’s head Stabilizing hand: heel on the lateral surface of the distal humerus Gliding hand: lateral border of second metacarpal placed on the medial surface of the ulnar just distal to the joint line Stabilizing hand: first web space and lateral border of second metacarpal placed over the lateral surface of the distal humerus Gliding hand: first web space placed on the medial surface of the ulnar just distal to the joint line

Application guidelines * Determine which motion (flexion, extension or both) are painful and or limited * Apply a laterally directed glide across the elbow joint in a non-painful part of the range (i.e. start in extension if flexion is the problem and vice versa) * While sustaining the glide have the client repeat the painful movement * Only release the sustained glide when the movement has returned to the start position * Repeat several times (6–10X) in a session Comment In addition to comments in Table 1. Therapist should foresee any restriction to flexion movement that may be due to the placement of digits over the anterior part of the joint and avoid this scenario Variations * A treatment belt (Fig. 18) may also be used with care being taken to place the stabilizing hand in such a way that does not interfere with elbow movement and the belt placement such as to be close to the joint line and orientated such that when end of range is reached the lateral glide through the belt is effective * Self-treatments as in Table 1 and Figure 16 with the exception that instead of gripping the client moves the elbow through ranges of flexion and extension * Taping techniques as seen in Figure 15 may also be of benefit * This technique can be used when pain on pain-free grip strength test occurs in a position other than extension but without movement (i.e. grip in the provocative position) *See Figures 17–18. Manual Therapy (2003) 8(2), 66–79


74 Manual Therapy

thrust manipulation seeks to gap the radio-humeral joint and restore joint play. See Table 4 and Fig. 22 for details. Once the manipulation has been applied and accessory movement of the radio-humeral joint restored, exercises are commenced and MWM once again attempted to reduce any remaining pain and dysfunction. (b) Pressure pain threshold deficit predominates: An interesting by-product of some of our laboratory studies (Vicenzino et al. 1998, 2001) is the finding that the SLGWPFG treatment technique of the elbow exerts a powerful effect on pain-free grip strength and substantially less of an effect on pressure pain threshold, whereas the Elvey (1986) lateral cervical glide technique (Table 5, Fig. 23) improves pressure pain threshold greater than it improves pain-free grip strength (2001). This has lead us to speculate that in the case in which there is comparatively and

substantially greater pain on direct pressure over the lateral epicondyle than there is deficit in pain-free grip strength, the cervical spine and relevant fore-

Fig. 19—A sustained posteroanterior glide of the radio-humeral joint with pair-free grip (SPAGWPFG) is performed here with full support of the trunk and upper limb. See Table 3 for further details.

Fig. 21—Sports tape (BDF, Australia) replicates the SPAGWPFG. Apply by laying tape on the posterior surface of the radial head and then apply traction to the tape in such a way as to replicate the SPAGWPG.

Fig. 20—Self-treatment with the SPAGWPFG.

Table 3. Radio-humeral joint sustained postero-anterior glide with pain-free grip (SPAWPFG)* Indication * Pain over lateral elbow on gripping that is relatively greater than tenderness to palpation over the lateral epicondyle * Poor response to SLGWPFG Positioning Client Upper limb Therapist Therapist hands

Supine with upper limb positioned by side The position may vary but is usually in the pain provocative position Adjacent to the affected elbow facing across the body of the client in line with the radio-humeral joint plane Stabilizing hand: the hand situated over the distal humerus holds the humerus down onto the treatment table and the thumb of this hand is placed over the radial head Movement hand: the thumb of the hand that is placed over the forearm is placed over the thumb of the stabilising hand while the rest of this hand rests on the forearm

Application guidelines * Determine the aggravating activity (gripping, wrist extension, etc.) * Apply a postero-anterior glide to the radio-humeral joint * While sustaining the glide have the client repeat the aggravating activity * Release the aggravating activity then release the glide * Repeat several times (6–10X) in a session Comment The contacting thumb pad should not produce pressure pain over the site of application Variations * Self-treatment should be as effective as that of the therapist’s (Fig. 20) * Taping that replicates the techniques (Fig. 21) is very useful *See Figures 19–21. r 2003 Elsevier Science Ltd. All rights reserved.

Manual Therapy (2003) 8(2), 66–79

Musculoskeletal physiotherapy perspective 75 Table 4. High-velocity thrust to the radio-humeral joint* Indication * Pain over lateral elbow on gripping that is relatively greater than tenderness to palpation over the lateral epicondyle * Difficulty in achieving a consistent or substantial effect with SLGWPFG or SPAGWPFG and passive movement examination reveals hypomobility of this joint Positioning Client Upper limb Therapist Therapist hands

Supine and near the side of the treatment table Elbow joint is positioned just short of end of range of extension Standing in between the medial side of the upper limb and the trunk facing the client’s axilla Palpation hand: the index finger of this hand gently palpates the radio-humeral joint so as to sense tension and movement of the joint. The palm of this hand also applies a force that compresses the radius and ulna together Thrust hand: lateral border of the second metacarpal and index finger are placed over the medial ulna just distal to the joint line. Ensure that the wrist of this hand is in a functionally neutral position and not extended

Application guidelines * Apply compression across the superior radio-ulna joint so the forearm bones will now move as one * Apply longitudinal compression up the humerus so that the shoulder joint is stabilized * Check that the elbow is not fully extended * Apply a gapping movement of the RH joint by placing a valgus stress of the elbow such that tension develops in the RH joint * Perform a very small amplitude oscillatory mobilisation at this point of RHJ tension * Superimpose a high-velocity transverse thrust in a lateral direction by the thrust hand at the stage that optimal tension in the RH joint is achieved Comment * Setting up the technique is the most important part of the technique * Be sure not to thrust into extension, the thrust must be in a lateral direction * Do not proceed with the thrust if the gapping oscillations are painful or engender a reactive or guarding muscle response by the client *See Figure 22.

Fig. 22—High-velocity thrust technique for the radio-humeral joint. See Table 4 for detailed description.

quarter neural tissues should be thoroughly evaluated and any impairment in this region treated (Vicenzino et al. 2000). Treatment of the spine in sufferers of LE may also involve other spinal manipulative therapy treatments. A single case study of a 47-yr-old male with a 6month history of LE highlights the utility of treating the cervical and thoracic spines with high-velocity thrusts of the thoracic spine and cervicothoracic junction in addition to Elvey’s lateral cervical glide (Elvey, unpublished work). Apart from having a 60% deficit in pressure pain threshold over the elbow compared to 40% deficit in pain-free grip strength test, this client also had an increased thoracic spine kyphosis with compensatory poked chin and increased mid-cervical spine lordosis. Passive intervertebral motion testing revealed marked hypomobility Manual Therapy (2003) 8(2), 66–79

in the mid-thoracic spine and the cervico-thoracic junction as well as positive neural tissue provocation tests. Treatment involved exercises (described above) solely for 6 weeks after which spinal manipulative therapy was performed on five sessions over a 2.5 week period. Comparing the rate of change of data over time between spinal manual therapy and exercise showed that spinal manipulative therapy was responsible for improvements in pressure pain threshold whereas the exercise program had most impact on the pain-free grip strength test. The spinal posture exercises appeared to be easier to perform following spinal manipulation. There is also a MWM treatment technique that may also be beneficial in treating those who experience pain when elevating the arm, for example, swinging a tennis racket (Fig. 24), reaching for shelves and working over head (Table 6). The concept with this spinal manual therapy treatment technique is to effect a transverse glide on the spinous process in a direction contralateral to the affected arm. The sustained glide on the cervical spine should allow pain-free elevation of the affected arm and when repeated several times should result in improved pain-free elevation (Mulligan 1999). (c) Relatively similar deficits in pain-free grip strength and pressure pain threshold: In the case in which equal deficits are present an approach similar to that described above in (a) in which there is a predominant pain-free grip strength deficit would be the first option taken. Re-evaluation of the key r 2003 Elsevier Science Ltd. All rights reserved.

76 Manual Therapy Table 5. Lateral glide of the cervical spine (Elvey 1984)* Indication * Pain over lateral elbow that is markedly tender to palpation compared to deficit in grip strength * Past problems of the cervical spine * Physical examination reveal signs of intersegmental dysfunction in the lower cervical spine (mostly C5–C/T junction) and/or positive neural tissue provocation signs Positioning Client Cervical spine Upper limb

Therapist Therapist hands

Supine The motion segment that is most restricted is placed in a neutral flexion and extension position The upper limb position is determined by the degree of sensitivity elicited on neural tissue provocation testing. In cases of high sensitivity the upper limb is placed with the hand on the abdomen, scapula elevated, and the flexed elbow is raised off the table such that the shoulder is not extended In cases of low sensitivity the upper limb may be placed in the position of provocation. In no case should the distal end of the upper limb be rigidly fixed into a maximally stretch position during this technique Stands at the head of the bed Movement hand: cradles the head and neck above the motion segment to be treated. This is assisted by gently resting the head onto the therapist’s abdomen. The hand used to perform the movement is the opposite one to that of the affected arm The other hand: the other hand is placed on the scapula and acts to sense tension developing in the scapula elevators and to maintain shoulder position. Vigorous depression of the scapula should be avoided

Application guidelines * The movement is purely transverse and occurs to both sides of the neutral neck position in the frontal plane * The head and joints above the treated segment are not sideflexed towards the direction of the glide * In most cases of non-irratible tennis elbow in which there is no overt signs of irritable cervical joints or neural tissue (as opposed to a case of nerve root irritation) the oscillating frequency of the technique is reasonably high (approximately 1.3 Hz) (Vicenzino et al. 1999) Comment Reproduction of distal symptoms during treatment is a contra-indication *See Figure 23.

Fig. 23—The lateral glide of the cervical spine (Elvey 1986) performed through the therapist’s left hand in this photo. Note the therapist’s right hand DOES NOT force the scapula into depression, it merely monitors upper limb position and any changes in tension in the underlying muscles. See Table 5 for details.

physical examination findings will either confirm this approach or indicate the need to move to more of an approach in (b), pressure pain threshold deficit predominate. (d) Past history of neck and upper limb pain: This paper deals with pain over the lateral epicondyle with no overt signs of cervical radiculopathy or referred pain from the cervical spine. In the event where there is only pain over the lateral epicondyle with a past history of prior neck and upper limb pain (see (b) above) the cervical spine and forequarter neural r 2003 Elsevier Science Ltd. All rights reserved.

Fig. 24—A sustained transverse glide to the spinous process with Upper Limb Movement (STWULM) which in this case involves swinging a tennis racket. See Table 6 for details.

tissues should be evaluated. If impairments are elucidated on examination then they should be treated. (e) Night pain: If there is night pain present and it has not settled with the above described approaches Manual Therapy (2003) 8(2), 66–79

Musculoskeletal physiotherapy perspective 77 Table 6. Sustained contralateral transverse pressure of the cervical spine with upper limb movement (STWULM)* Indication * Usually performed as an alternative to the Elvey lateral glide of the cervical spine, so similar indications to that technique, especially if neural provocation tests are negative * Movements of the upper limb reproduce some of the elbow pain * Less than optimal response to techniques applied to the elbow Positioning Client Upper limb

Sitting with trunk support * If a movement exacerbates the elbow pain then it should be used * Otherwise use elevation of the arm in the scapula or sagittal planes Therapist Standing behind the client Therapist hands Stabilizing hand: the medial side of the thumb on the hand contralateral to the clients affected arm is placed over the side of the spinous process of the superior vertebra of the motion segment to be mobilized. This thumb contact will include some of the paraspinal tissue if the glide is to be effective and non-noxious. This thumb is purely a contact point through which to apply the force, not the applicator of the force Movement hand: the index finger supported by the middle finger of the other hand is placed over the lateral side of the thumb that was placed on to the spinous process Application guidelines * Determine the aggravating activity (e.g. shoulder elevation, horizontal flexion, etc.) * Apply a contralateral transverse glide to the spinous process by applying force to the contact point thumb with the reinforced index finger of the movement hand. (Figure 24) * While sustaining the glide have the client repeat the aggravating activity * Cease the aggravating activity before releasing the transverse glide of the spine * Repeat several times (6–10X) in a session, but only if pain and function improve Comment (see previous Tables also) * The contacting thumb pad should not produce pressure pain over the site of application * The therapist may need to apply the transverse glide to a number of spinous process before finding the most effective one (C5 usually tried first)

6

are

*See Figure 24.

Fig. 25—The McConnell (2000) Diamond box tape (A) and a view of one of the pieces of tape that make up the technique being applied (B). For each individual piece of applied tape, an example of which is demonstrated in B, the right thumb holds the tape firmly onto the skin while the left hand applies force along the length of the tape. The right index finger moves skin and soft tissues under where the tape is to be placed in towards the lateral epicondyle (i.e. perpendicular to the line of the tape). When all pieces of tape are in place a characteristic orange peel effect should be visible as seen here. See Table 7 for details.

then there are some further treatments that may be of use. It is important to note that this type of night pain is mechanical in nature. It is associated with a position or movement of the elbow that settles with some adjustment allowing the client to resume sleep as opposed to pain that consistently occurs in the early hours of the morning not associated with any positions or movements and is relentless in its persistence once it has appeared. If the taping procedures described above do not help, then a Manual Therapy (2003) 8(2), 66–79

diamond tape should be tested (Fig. 25A). This taping procedure is one of McConnell’s deloading procedures (McConnell 2000) in which the soft tissues are drawn in towards the area of pain at the lateral epicondyle in a manner described in Table 7 and shown in Fig. 25B. In an unpublished study of this taping technique in 14 sufferers of chronic LE we showed that it produced substantial improvements in pain-free grip strength and to a lesser extent pressure pain threshold. r 2003 Elsevier Science Ltd. All rights reserved.

78 Manual Therapy Table 7. Diamond tape of the elbow (McConnell 2000)* Indication * Lateral elbow pain which is present much of the time * Particularly useful for resting pain or pain at night Positioning Client Elbow

Therapist

Supine Small amount of flexion in most cases. The tape will reduce motion at end of range so if extension is especially a problem for the client then tape the elbow in more flexion and if the client has problems mostly at end of range of flexion apply the tape more in extension Stand by side of treatment table facing cephalad

Application guidelines * The centre of the diamond is located over the painful region * Start applying the tape distally anchoring it on or close to the midline of the forearm * Run the tape on a diagonal across the longitudinal axis of the forearm * Anchor the starting part of the tape to the client’s skin with your thumb * With the other hand apply a tensing force longitudinally along the direction of the tape * Before laying the tape down onto the skin make sure that the underlying skin is moved in towards the painful region. Do this by using the index finger of the hand that is anchoring the tape to the skin (Fig. 25B) * Tape will be orientated on the skin as shown in Fig. 25A Comment * There should be an orange peel effect present with puckering of the skin inside the diamond * Always lay the tape down in a cephalad direction along the long axis of the arm *See Figure 25.

Outcome measures Pain-free grip strength has been reported to be the most sensitive outcome measure of physical impairment in tracking change in LE (Stratford et al. 1993; Stratford & Levy 1994; Abbott et al. 2001) and should be at least one of the outcome measures used in clinical practice. In addition, MacDermid’s (2001) Patient-Rated Elbow Evaluation scale may also be used to track the responses to treatment. McDermid’s scale is primarily a client self-rated perception of pain and function scale that is a reliable and valid measure of disability (MacDermid 2001).

CONCLUSION Currently the recommended approach to clinical manual therapy management of LE is based on the findings from physical examination and matching the treatment approach to the deficits highlighted in the clinical examination. Essentially, therapeutic exercise forms the mainstay of the program. Manual therapy and sports tape are useful adjunctive therapies to achieve rapid pain relief that allow for effective and timely physical conditioning of the affected muscles.

References Abbott JH 2001 Mobilization with movement applied to the elbow affects shoulder range of movement in subjects with lateral epicondylalgia. Manual Therapy 6: 170–177 r 2003 Elsevier Science Ltd. All rights reserved.

Abbott JH, Patla CE, Jensen RH 2001 The initial effects of an elbow mobilization with movement technique on grip strength in subjects with lateral epicondylalgia. Manual Therapy 6: 163–169 Alfredson H, Ljung BO, Thorsen K, Lorentzon R 2000 In vivo investigation of ECRB tendons with microdialysis technique— no signs of inflammation but high amounts of glutamate in tennis elbow. Acta Orthopedica Scandinavica 71: 475–479 Allander E 1974 Prevalence, incidence and remission rates of some common rheumatic diseases or syndromes. Scandinavica Journal of Rheumatology 3: 145–153 Assendelft WJJ, Hay EM, Adshead R, Bouter LM 1996 Corticosteroid injections for lateral epicondylitis: a systematic overview. British Journal of General Practice 46: 209–216 Buchbinder R, Green S, Bell S, Barnsley L, Smidt N, Assendelft WJJ 2002a Surgery for lateral elbow pain (Cochrane Review). In: The Cochrane Library, Issue 4. Oxford: Updated Software Buchbinder R, Green S, White M, Barnsley L, Smidt N, Assendelft WJJ 2002b Shock wave therapy for lateral elbow pain (Cochrane Review). In: The Cochrane Library, Issue 4. Oxford: Updated Software Chiang HC, Ko YC, Chen SS, Yu HS, Wu TN, Chang PY 1993 Prevalence of shoulder and upper-limb disorders among workers in the fish-processing industry. Scandinavian Journal of Work Environment and Health 19: 126–131 Elvey R 1986 Treatment of arm pain associated with abnormal brachial plexus tension. Australian Journal of Physiotherapy 32: 225–230 Green S, Buchbinder R, Barnsley L, Hall S, White M, Smidt N, Assendelft WJJ 2002a Acupuncture for lateral elbow pain (Cochrane Review). In: The Cochrane Library, Issue 4. Oxford: Updated Software Green S, Buchbinder R, Barnsley L, Hall S, White M, Smidt N, Assendelft WJJ 2002b Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults. In: The Cochrane Library, Issue 4. Oxford: Updated Software Gunn C, Milbrandt W 1976 Tennis elbow and the cervical spine. Canadian Medical Association Journal 114: 803–809 Kelley JD, Lombardo SJ, Pink M, Perry J, Giangarra CE 1994 Electromyographic and cinematographic analysis of elbow function in tennis players with lateral epicondylitis. Amercian Journal of Sports Medicine 22: 359–363 Khan K, Cook J 2000 Overuse tendon injuries: where does the pain come from? In: Dilworth Cannon W, DeHaven K (eds) Sports Manual Therapy (2003) 8(2), 66–79


Medicine and Arthroscopy Review, Vol. 8. Lippincott Williams & Wilkins, Philadelphia, pp 17–31 Khan KM, Cook JL, Maffulli N, Kannus P 2000 Where is the pain coming from in tendinopathy? It may be biochemical, not only structural, in origin. British Journal of Sports Medicine 34: 81–83 Labelle H, Guibert R, Joncas J, Newman N, Fallaha M, Rivard C 1992 Lack of scientific evidence for the treatment of lateral epicondylitis of the elbow: an attempted meta-analysis. The Journal of Bone and Joint Surgery 74B: 646–651 Ljung BO, Forsgren S, Friden J 1999 Substance P and calcitonin gene-related peptide expression at the extensor carpi radialis brevis muscle origin: implications for the etiology of tennis elbow. Journal of Orthopaedic Research 17: 554–559 MacDermid J 2001 Outcome evaluation in patients with elbow pathology: issues in instrument development and evaluation. Journal of Hand Therapy 14: 105–114 McArdle W, Katch F, Katch V 1996 Exercise Physiology. Williams Wilkins, Baltimore McConnell J 2000 A novel approach to pain relief pre-therapeutic exercise. Journal of Science and Medicine in Sport 3: 325–334 McLean S, Naish R, Reed L, Urry S, Vicenzino B 2002 A pilot study of the manual force level required to produce manipulation induced hypoalgesia. Clinical Biomechanics 17: 304–308 Mulligan B 1999 Manual therapy—‘NAGS’, ‘SNAGS’, ‘MWMS’, etc. Plane View Services, Wellington Murtagh J 1988 Tennis elbow. Australian Family Physician 17: 90,91,94–95 Nirschl R 1989 Patterns of failed healing in tendon injury. In: Leadbetter W, Buckwalter J, Gordon S (eds) Sports-induced Inflammation. American Academy of Orthopaedic Surgeons, Illinois, pp 577–585 Pienimaki T, Karinen P, Kemila T, Koivukangas P, Vanharanta H 1998 Long-term follow-up of conservatively treated chronic tennis elbow patients. A prospective and retrospective analysis. Scandinavian Journal of Rehabilitation Medicine 30: 159–166 Pienimaki TT, Kauranen K, Vanharanta H 1997a Bilaterally decreased motor performance of arms in patients with chronic tennis elbow. Archives of Physical Medicine and Rehabilitation 78: 1092–1095 Pienimaki T, Siira P, Vanharanta H 1997b Muscle function of the hand, wrist and forearm in chronic lateral epicondylitis. European Journal of Physical Medicine and Rehabilitation 7: 171–178 Pienimaki T, Tarvainen T, Siira P, Vanharanta H 1996 Progressive strengthening and stretching exercises and ultrasound for chronic lateral epicondylitis. Physiotherapy 82: 522–530 Ranney D, Wells R, Moore A 1995 Upper limb musculoskeletal disorders in highly repetitive industries: precise anatomical physical findings, Department of Physiotherapy, ERGONOMICS University; Alberta, Edmonton, AB T6G 2GF, Canada, 38: 1408–1423 Regan W, Wold LE, Coonrad R, Morrey BF 1992 Microscopic histopathology of chronic refractory lateral epicondylitis. American Journal of Sports Medicine 20: 746–749 Shrier I 2000 Stretching before exercise: an evidence based approach. British Journal of Sports Medicine 34: 324–325

Manual Therapy (2003) 8(2), 66–79

Sluka KA 1996 Pain mechanisms involved in musculoskeletal disorders. Journal of Orthopaedic and Sports Physical Therapy 24: 240–254 Sluka KA, Rees H 1997 The neuronal response to pain. Physiotherapy Theory and Practice 13: 3–22 Smith J, Wright A 1993 The effect of selective blockade of myelinated afferent neurons on mechanical hyperalgesia in lateral epicondylalgia. The Pain Clinic 6: 9–16 Stratford P, Levy D 1994 Assessing valid change over time in patients with lateral epicondylitis at the elbow. Clinical Journal of Sport Medicine 4: 88–91 Stratford P, Levy D, Gowland C 1993 Evaluative properties of measures used to assess patients with lateral epicondylitis at the elbow. Physiotherapy Canada 45: 160–164 Struijs PAA, Smidt N, Arola H, Dijk VCN, Buchbinder R, Assendelft WJJ 2002 Orthotic devices for the treatment of tennis elbow (Cochrane Review). In: The Cochrane Library, Issue 4. Oxford: Updated Software Verhaar J, Walenkamp G, Kester A, Vanmameren H, Vanderlinden T 1993 Lateral extensor release for tennis elbow—a prospective long- term follow-up-study. Journal of Bone and Joint Surgery-American Volume 75A: 1034–1043 Vicenzino B, Buratowski S, Wright A 2000 A preliminary study of the initial hypoalgesic effect of a mobilisation with movement treatment for lateral epicondylalgia. In: Singer K (ed.) Proceedings of the 7th Scientific Conference of the IFOMT in conjunction with the MPAA. University of Western Australia, Perth, Australia, pp 460–464 Vicenzino B, Collins D, Benson H, Wright A 1998 An investigation of the interrelationship between manipulative therapy induced hypoalgesia and sympathoexcitation. Journal of Manipulative & Physiological Therapeutics 21: 448–453 Vicenzino B, Collins D, Wright A 1996 The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. Pain 68: 69–74 Vicenzino B, Neal R, Collins D, Wright A 1999 The displacement, velocity and frequency profile of the frontal plane motion produced by the cervical lateral glide treatment technique. Clinical Biomechanics 14: 515–521 Vicenzino B, Paungmali A, Buratowski S, Wright A 2001 Specific manipulative therapy treatment for chronic lateral epicondylalgia produces uniquely characteristic hypoalgesia. Manual Therapy 6: 205–212 Vicenzino B, Wright A 1995 Effects of a novel manipulative physiotherapy technique on tennis elbow: a single case study. Manual Therapy 1: 30–35 Vicenzino B, Wright A 1996 Lateral epicondylalgia I: a review of epidemiology, pathophysiology, aetiology and natural history. Physical Therapy Reviews 1: 23–34 Wright A, Thurnwald P, O’Callaghan J, Smith J, Vicenzino B 1994 Hyperalgesia in tennis elbow patients. Journal of Musculoskeletal Pain 2: 83–97 Wright A, Thurnwald P, Smith J 1992 An evaluation of mechanical and thermal hyperalgesia in patients with lateral epicondylalgia. The Pain Clinic 5: 221–227 Yaxley G, Jull G 1993 Adverse tension in the neural system. A preliminary study in patients with tennis elbow. Australian Journal of Physiotherapy 39: 15–22



Systematic review

A systematic review of physiotherapy for spondylolysis and spondylolisthesis Margaret L. McNeely, G. Torrance, D. J. Magee Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Canada

SUMMARY. The purpose of this systematic review was to assess the evidence concerning the effectiveness of physiotherapy intervention in the treatment of low back pain related to spondylolysis and spondylolisthesis. A literature search of published and unpublished articles resulted in the retrieval of 71 potential studies on the subject area. Fifty-two of the 71 articles were studies, and these studies were reviewed using preset relevance criteria. Given the inclusion and exclusion criteria chosen for this systematic review, there were very few acceptable studies and only two studies met the relevance criteria for the critical appraisal. Both studies provide evidence to suggest that specific exercise interventions, alone or in combination with other treatments, have a positive effect on low-back pain due to spondylolysis and spondylolisthesis; however, the type of exercise used was different in the two studies. In this review, very few prospective studies were found that examined the efficacy of physiotherapy on the topic area; therefore, few conclusions can be made, and further research is warranted. r 2003 Elsevier Science Ltd. All rights reserved.

When doing a systematic literature review, large randomized controlled trials (RCTs) are sought, as they provide the strongest evidence (Stein & Cutler 1996; Magee 1998). Internal validity of the study, with an RCT, is enhanced as extraneous factors are controlled, and as randomization of subjects reduces selection bias (Portney & Watkins 2000, p 167). Valid and reliable measures, as well as valid, reliable, and sensitive measurements and instruments insure that data are accurate and meaningful (Warren 1994). In addition, having outcomes measured by independent (blinded) observers, or by the patients themselves, further enhance the validity of the study. To control for confounders and to assess the external validity of the study, inclusion and exclusion criteria should be clearly stated and details provided on the study population. Among these details, such things as agreement to participate, attrition and the reasons for subjects being lost to follow-up must be included. In treatment studies, pretreatment clinical signs and symptoms have to be documented, and treatment interventions explained in enough detail to allow for replication of the study (Magee 1998). The purpose of the present systematic review was to examine research studies assessing the efficacy of physiotherapy interventions in the treatment of low-back pain related to spondylolysis and spondylolisthesis.

INTRODUCTION A systematic review is an evaluation of existing literature using a research format. As such it constitutes research; it poses a question, identifies a population and draws a sample (Magee 1998). Published and unpublished studies are assembled using explicit searching methods, and a predetermined protocol of evaluation is used with inclusion and exclusion criteria (Jefferson & Deeks 1999, p 225). Research papers are read selectively and critically, measurements are analysed, and conclusions are drawn based on the scientific merit of the research findings. It is hoped that the findings of a systematic review will help guide practitioners in prescribing effective interventions for their patients (de Vet et al. 1997) and provide insight into future research directions. Received: 30 October 2001 Revised: 17 June 2002 Accepted: 2 July 2002 Margaret L. McNeely, MSc, PT, Graduate Student, Grace Torrance BSc PT, Graduate Student, Dr David J. Magee PhD, BPT, Professor, Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Canada Correspondence to: MM, Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, 250 Corbett Hall, Alberta, Canada T6G 2G4. Fax: +1 780 492 1626; E-mail: [email protected] 80

Spondylolysis and spondylolisthesis 81

THE PROBLEM Low-back pain has become a significant health problem and continues to be a major expense to the healthcare system (Linton et al. 1989; Cherkin et al. 1998). Segmental instability of the lumbar spine is a potential cause of low-back pain, and particularly, in children and adolescents, may be the result of spondylolysis and/or spondylolisthesis (Fritz et al. 1998). Spondylolysis is a defect or break in the narrow portion of the vertebral bone, lying between the superior and inferior articular facets of the vertebral arch (Johnson 1993), called the pars interarticularis. Spondylolisthesis, on the other hand, is the ‘slipping’, or forward displacement, of one vertebra over another (Magee 1997). Though the two conditions are distinct radiographically, spondylolysis in the lumbar spine is found in 50–81% of cases of spondylolisthesis (Szapalski et al. 1999), with spondylolytic spondylolisthesis the consequence of spondylolysis progressing to spondylolisthesis. Thus the two conditions are often reviewed and studied together (Lonstein 1999). Over the years there has been considerable interest in, and controversy over, both the aetiology and treatment of these conditions. This is because, to date, the correlation between radiographic evidence and clinical symptoms has been poor (Osterman et al. 1993). As well, many individuals with radiographic evidence of lumbar instability, spondylolysis and spondylolisthesis are asymptomatic (Magora 1976). Though the significance of lumbar instability in low-back pain remains unclear (Fritz et al. 1998), treatment, which may include surgery, is routinely prescribed (Spratt et al. 1993).

Incidence Spondylolysis occurs in approximately 6% of the population (Hensinger 1989). While defects in the pars interarticularis have not been found in newborns, the prevalence is approximately 5% by the age of 7 years (Hensinger 1989), and 6% by adulthood. These defects are twice as common in boys as in girls (Hensinger 1989). Interestingly, a high incidence of spondyloysis is found in certain subgroups of the population. A prevalence rate of 26% is found in the Inuit population (Lonstein 1999), for example, and a higher incidence is also found in those with a family history of spondylolysis (Johnson 1993). Of particular concern is that damage to the pars interarticularis is observed in 25–39% of sports-related low-back pain (Johnson 1993). This damage is especially common in young athletes in certain competitive sports, including power and weight lifting, skiing, racquet sports, football, gymnastics, diving, wresting and rowing (Johnson 1993). Manual Therapy (2003) 8(2), 80–91

The reported incidence of spondylolisthesis is estimated to be between 2% and 6% (Magora 1976; Osterman et al. 1993). An increased prevalence of spondylolisthesis is found between the ages of 10 and 15 years, and the forward displacement, or ‘slip’, is believed to occur during the adolescent growth spurt. Though spondylolisthesis is reported to rarely progress after skeletal maturity (Lonstein 1999), a recent study by Floman reported documented slip progression ranging from 9% to 30% in adults in the third decade of life (Floman 2000). The increased slip was associated with disc degeneration (spondylosis) and, as a result, previously asymptomatic lesions became symptomatic. Spondylolisthesis is normally divided into five categories: dysplastic or congenital, isthmic or spondylolytic, degenerative, traumatic and pathologic (Lonstein 1999). Aetiology Though the exact cause of spondylolysis is unknown, theories have evolved implicating both congenital and developmental causes (Hensinger 1989). The basis of the ‘congenital theory’ is that there is a genetically predisposed weakness in the pars interarticularis (Motley et al. 1998), and evidence for the theory is found in the increased incidence of both spondylolysis and spondylolisthesis in first-degree relatives of children with these conditions (Lonstein 1999). Genetic predisposition alone, however, is unlikely to be the sole cause, as lesions are not present in infants or pre-ambulatory children, and are also not found in those who have never walked (Newell 1995). The basis of the ‘developmental theory’ is that a fatigue fracture develops as a gradual response to mechanical usage (Newell 1995). It is believed that microtrauma or microstress causes this fracture of the pars interarticularis (Lonstein 1999) and though an episode of minor trauma often initiates symptoms, there is seldom a history of severe injury to the low back (Hensinger 1989). Supporting this hypothesis further, pars defects can be reproduced by fatigue loading in vitro (Newell 1995). However, these reproduced defects have been bilateral, and, thus, the presence of unilateral defects may suggest a congenital association (Newell 1995). Mechanically, the interarticular area, particularly that of the fifth lumbar vertebra, is in a position of special vulnerability, absorbing the force of weight due to the lumbo-sacral alignment and the normal lumbar lordosis of the spine (Newell 1995). The normal flexion contractures of the hip seen in childhood (Hensinger 1989) and/or poor posture result in an accentuated lumbar lordosis, and further increase the impact forces in this region. The pars r 2003 Elsevier Science Ltd. All rights reserved.

82 Manual Therapy

interarticularis is especially susceptible to damage in the growing child, due to incomplete ossification of the neural arches (Johnson 1993). In young athletes, it is believed that repetitive motions and/or overuse, on an already compromised region of the vertebra, cause fracture or elongation of the pars interarticularis (Johnson 1993). In summary, though genetic factors may predispose to spondylolysis, it is likely that mechanical forces related to normal weight bearing, posture, repetitive activities and mild trauma, especially on an immature spine, combine to produce the initial defect (Hensinger 1989; Lonstein 1999). Spondylolisthesis, as stated previously, usually results from spondylolysis. The normal resistance to forward displacement of the vertebra is provided by the posterior facets, ligaments and the intervertebral disc (Magee 1982). With fracture or elongation of the pars interarticularis, however, the posterior elements are compromised (Lonstein 1999) and the vertebral body is allowed to slip forward, resulting in instability (Magee 1982). Narrowing of the spinal canal will occur if posterior elements also slide forward (Magee 1982) and, as a result, symptoms may develop.

Treatment In the majority of symptomatic cases of spondylolysis and spondylolisthesis non-operative treatment is recommended. Physiotherapy is the most common method used to apply non-operative treatment and may include the use of modalities for pain relief, bracing, exercise, electrical stimulation and activity modification (Fellander-Tsai & Micheli 1998; Szapalski 1999). Physiotherapy treatment is recommended to reduce pain, to restore range of motion and function, and to strengthen and stabilize the spine (Fritz et al. 1998; Hall & Brody 1999). Though non-operative treatment is reported as being effective in relieving the symptoms of back pain due to spondylolysis and spondylolisthesis (Szapalski 1999), few studies have been done examining the efficacy of the various treatment interventions. Operative treatment is indicated to alleviate pain in patients not responding to conservative treatment, and to prevent progression of the slip in those with severe slip (>40%) of the vertebrae (Fritz et al. 1998; Szapalski 1999). As costs and complications due to surgery are high and long-term benefits uncertain (Fritz 1998), further study into the efficacy of nonoperative treatment is warranted.

Signs and symptoms The presenting signs and symptoms normally include pain, restricted range of motion, paraspinal muscle spasm, flattening of the sacrum and a peculiar gait (Magee 1982; Johnson 1993; Osterman et al. 1993. Pain is usually reported as mild to moderate, and is initially a dull ache that gradually increases in intensity (Motley 1998). Pain is commonly localized to the paraspinal region, gluteals (Hall & Brody 1999) and posterior aspect of the thighs (Barash et al. 1970). Initially pain may be associated with a very mobile spine, with symptoms appearing at extremes of lumbar range of motion only. In the adolescent athlete, extension- and rotation-type movements, specific to the individual’s sport, are reported to exacerbate symptoms (Johnson 1993). Progression results in hamstring tightness (Osterman et al. 1993), posterior tilting of the pelvis, and a flexed hip and knee posture (Barash et al. 1970). The individual may walk with a stiff legged, short-stride gait (Barash et al. 1970; Hensinger 1989) and a characteristic pelvic ‘waddle’ (pelvic rotation with stepping) may be observed (Hensinger 1989). On examination, pain is reproduced with the onelegged standing lumbar extension test, and with spondylolisthesis, a step deformity in the lumbar spine may be observed or palpated (Magee 1997). In moderate to severe cases, marked limitation of trunk flexion range of motion is often seen (Barash et al. 1970) and a limited straight leg raise found (Barash et al. 1970; Magee 1982). r 2003 Elsevier Science Ltd. All rights reserved.

METHODS AND MATERIALS The process of systematic reviewing involves thorough detective work aimed at identifying all studies on a specific topic. Studies are chosen based on preset criteria that may include, for example, study design, type of experimental intervention and specific outcome measures. For this review, the literature was searched for published studies and unpublished studies on physiotherapy interventions in treating spondylolysis and spondylolisthesis. Two independent investigators screened the titles of articles found on the databases, and if available, the abstract of the article as well. If either or both investigator felt that the article potentially met the inclusion criteria, or if there was inadequate information to make a decision, copies of the article were obtained. Search strategy A literature search was conducted to identify appropriate studies using numerous databases including MEDLINE and CINAHL (Table 1). Keywords and medical subject headings related to the condition and potential treatment were identified prior to initiating the search. If any of the searches resulted in less than 300 titles, then all articles found in the particular database were assessed for potential inclusion; otherwise, terms related to treatment such as ‘exercise(s)’, ‘physiotherapy’ and ‘rehabilitation’ were used to Manual Therapy (2003) 8(2), 80–91

Spondylolysis and spondylolisthesis 83 Table 1. Search strategy Search for published studies Keywords (medical subject headings are in italics): *

*

Terms related to the condition: Spondylolysis, Spondylolisthesis, Pars interarticularis, Lumbar instability, Low-back pain, Spinal vertebra (lumbar vertebra) Terms related to the intervention: Physical therapy (physiotherapy), Rehabilitation, Exercise(s) (Therapeutic exercise, Stabilization exercise(s), Pilates, McKenzie, Feldenkrais).

The Medical Librarian provided assistance on appropriate use of truncation, query and set operators (use of OR/AND) for combining terms. To allow for a broad search of the literature, limits for publication types were not used Databasen Medline: 1966–February 2001 CINAHL: 1982–February 2001 ERIC: 1986–2000 EMBASE (Excerpta Medica) (1982–March 2000) Sport Discus: 1975–l999 Best Evidence: 1991–1999 Dissertation Abstracts: 1999 Biological Abstracts: 1997–1999 Library of Congress Cochrane Collaboration: Database of RCT and systematic reviews Expanded search/search for unpublished studies 1. Hand-searching reference lists of all retrieved articles (including review articles) 2. Hand-search of the journal SPINE: 1994–2000 3. Citation searching: key authors—Rossi F, Davis IS, Farfan HF, Jackson DW, Magora A, Batts M, King AB, Verbostad A, Meyerding HW, Szapalski M, Gunzburg R, Pope M, Grieve GP 4. Local experts were contacted for additional information: * * *

ISSL (International Society for the Study of the Lumbar Spine) abstracts were provided Management of Low Back Pain: Beyond Rhetoric Toward Outcomes (September 1999): conference abstracts were provided Dr David Magee: permission to access personal orthopaedic research database

5. Research: Federal Research in Progress University of Iowa, USA Curtin University of Technology, Australia University of Alberta, Canada n

For some of the databases, slight modification in search strategy was required.

narrow the search. For the purposes of this review, the literature search was conducted from January 2000 to February 2001. The next phase of the search strategy involved searching for studies potentially overlooked or absent from the databases and for unpublished studies. This involved hand-searching the references of all retrieved articles for potential studies and handsearching the journal Spine. Citation indexing was used to track referencing of key authors in the field, conference abstracts were reviewed, and local experts were contacted for further information. Criteria development Criteria were developed at the beginning of the study to determine keywords to use in the search strategy, and to help determine whether the studies found were relevant to the topic area of this systematic review. The inclusion and exclusion criteria were deemed important for ensuring internal validity of the study. The base criterion required that the study include activities that could be classed as physiotherapy interventions within the scope of practice of physioManual Therapy (2003) 8(2), 80–91

therapists in Canada. This requirement meant that a researcher from any discipline could undertake the study, as long as one or more of the interventions was within the scope of practice of Canadian physiotherapists. Although randomized controlled studies were sought, because of the clinical nature of the topic and the paucity of research in the physiotherapy field in general, other research methods were considered eligible for the review. The investigators felt that other research methods might demonstrate differences and suggest important research hypotheses. However, to ensure that some degree of scientific rigour was maintained it was determined that only prospective studies would be included and that quantitative studies were required to have a control group (Lohr & Carey, 1999). Further inclusion criteria used to determine whether the study was relevant for this overview were: (a) male and female humans; (b) symptomatic low-back pain; (c) within the age of 10–60 years; (d) lumbar spine involvement and (e) radiographic evidence of spondylolysis or spondylolisthesis in the lumbar spine. The exclusion criteria were developed r 2003 Elsevier Science Ltd. All rights reserved.

84 Manual Therapy

to limit the influence that extraneous factors might have on the results of the treatment intervention (confounding variables), and in an attempt to limit the study to true symptomatic spondylolysis and spondylolisthesis. Exclusion criteria for this overview were: (a) no neurological or autonomic deficits; (b) no other fracture or bony abnormalities; (c) no rheumatic disease and (d) no other spinal problems. For outcome measurements, the study had to include one or more of the following: range of motion, pain, functional outcome measure or patient satisfaction. The information was developed into a relevance tool (Table 2) that was used by the investigators to independently evaluate the retrieved papers. Each criterion was graded on a yes/no basis—that is, the published study had to provide enough information to adequately meet the criterion. All criteria on the rating form had to be met for the study to be evaluated at the next level, the Critical Appraisal. Once the criteria were developed, a group of 10 studies were gathered. Interrater reliability of independent initial grading of these papers using the relevance tool was 100%. The next level of the systematic review, the Critical Appraisal, involved rating the accepted studies to

determine internal and external validity (Table 3). The two investigators independently reviewed the studies. Each study was analysed based on specific predetermined criteria. These criteria were then rated as pass (P), moderate (M) and fail (F). The rating system was based on a similar rating system developed by de Vet et al. (1997). The Critical Appraisal was then taken to the final stage for an overall assessment of the study (Table 4). At this point, the study was graded as weak, moderate or strong, depending on how well it met each of the critical appraisal criteria. All criteria were weighted equally.

Results A total of 71 articles were obtained through the literature search; 52 articles were studied and were reviewed using the relevance tool (Table 2). Out of the 52 studies reviewed, only two studies met all selection criteria (Spratt et al. 1993; O’Sullivan et al. 1997). Clarification was required by one author (Spratt et al. 1993) to verify that one specific criterion was met and this was done by e-mail communication. None of the other studies came close to meeting all

Table 2. Physiotherapy effectiveness project relevance tool—primary studies (Study: Physiotherapy intervention for low-back pain related to spondylolisthesis and spondylolysis) Instructions for completion 1. Circle Y or N for each relevance criterion 2. Record inclusion decision: article must satisfy all relevant criteria 3. Ensure that no exclusion criteria are included 4. Record if additional references are to be retrieved 5. Complete validity form for articles to be included Relevance criteria 1. Does this article evaluate a physiotherapy intervention or program? 2. Is the intervention within the scope of physiotherapy practice in Canada? 3. Are the subject inclusion criteria covered? a. male/female humans b. low back pain c. age 10–60 d. lumbar spine involvement e. radiographic evidence of spondylolisthesis and spondylolysis 4. Are patient exclusion criteria included? a. no neurological/autonomic deficits b. no other fracture/bony deformities c. no rheumatic disease d. no other spinal problems 5. Is one or more appropriate outcomes (ROM, Pain, outcome measure, patient satisfaction) measured? 6. Is the article a prospective study? (allocation, exposure to intervention occurs during research period and prior to measurement of outcome) 7. If a quantitative study, is there a control group?

Y Y

N N

Y Y Y Y Y

N N N N N

Y Y Y Y Y

N N N N N

Y Y

N N

Y

N

Y

N

If discreepancy inclusion decision Reason for discrepancy Oversight Differences in interpretation of criteria Differences in interpretation of study

Y Y Y

N N Y

Final decision: include in study

Y

N

Reviewer decision 1. Include in critical appraisal (Yes = Y to all relevance criteria) If yes, please complete validity form 2. Additional references If yes, mark items on reference list of article


Manual Therapy (2003) 8(2), 80–91

Spondylolysis and spondylolisthesis 85 Table 3. Critical appraisal—included studies (Study: Physical therapy intervention for low-back pain related to spondylolisthesis and spondylolysis (included studies)) 1. Type of study i. random/quasirandom ii. cohort/before-after iii. case control/cross-sectional iv. descriptive 2. Confounders controlled i. age ii. sex iii. classification iv. medication

3.

4.

5.

6.

(I) (II) (III) (IV)

(P) (M) (F) (F)

Y Y Y Y

N N N N

Differences between groups not statistically controlled P=all M=2–3 F=0–1 Agreement to participate i. >80% ii. 60–80% iii. o60% iv. cannot tell Intervention i. acupuncture ii. mobilization iii. manipulation iv. massage v. superficial heat vi. bracing vii. deep heat viii. ice ix. ultrasound x. traction xi. exercise xii. education xiii. TNS/IFC/HVG xiv. Other, pls. specify Physiotherapy treatment i. well described Y ii. specific to tested groups Y P=2 M=1 F=O (well described: dosage, time, placement) Sample size i. large >100 ii. medium 20–100 iii. small o20 o20

(P) (M) (F) (F)

Outcome: 6 or all=P, validity +(3–4)=M, validity + (0–2)=F N/A is not a fail for this category

N N

(P) (M) (F)

criteria. There was 100% agreement between reviewers about the rating of all papers. The two studies that were evaluated at the Critical Appraisal level were initially rated as ‘weak’. However, after e-mail communication with one of the authors, one study (O’Sullivan et al. 1997) was re-rated as strong. The results of the Critical Appraisal for each of the two studies are provided in Table 5.

DISCUSSION In this systematic review, few prospective studies were found that addressed the question of the efficacy of physiotherapy interventions in the treatment of low-back pain related to spondylolysis and spondylolisthesis. The strict criteria established for inclusion and exclusion criteria, as well as the requirement for a Manual Therapy (2003) 8(2), 80–91

7. Data collection methods i. self-reported (pain, functional outcome) inter-rater reliability Y N N/A intra-rater reliability Y N N/A reliable test inst. Y N validity test inst. Y N sensitivity Y N well described Y N ii. single blind assessor (pain, ROM, functional outcome) inter-rater reliability Y N N/A intra-rater reliability Y N reliable test inst. Y N validity test inst. Y N sensitivity Y N well described Y N iii. clinician performed (ROM, functional outcome) inter-rater reliability Y N N/A intra-rater reliability Y N reliable test inst. Y N validity test inst. Y N sensitivity Y N well described Y N

8. Subjects starting and finishing study i. immediate >80% (P) 60–80% (M) >60% (F) ii. post-treatment >80% (P) 60–80% (F) o60% (M) iii. follow-up >80% (P) 60–80% (M) >60% (F) 9. External validity Y N 10. Limitations i. Major ii. Minor 11. Was there statistical test(s) of the intervention effects? Y N

prospective study, eliminated many potential studies for review. The two studies that did meet our criteria were both randomized controlled trials and each study provided evidence of improvement in outcome measures from the physiotherapy intervention. A descriptive review of the two studies is provided in Table 6. O’Sullivan and colleagues provided evidence supporting the use of very specific exercise treatment regime for subjects with spondylolysis and spondylolisthesis. The treatment group (TG) demonstrated statistically significant decreases in pain (both in intensity and in description) and functional disability when compared to the control group (CG). The results were effective in the short term (3 months) as well as the long term (30 months). A statistically significant difference was found within the CG following the treatment period for pain descriptors r 2003 Elsevier Science Ltd. All rights reserved.

86 Manual Therapy Table 4. Critical appraisal—final decision (Study: Physiotherapy intervention for low back pain related to spondylolisthesis and spondylolysis (final decision)) Overall assessment of the study 1. Type of study 2. Confounders controlled 3. Agreement to participate 4. Intervention 5. Physiotherapy treatment 6. Sample size 7. Data collection methods i. Pain ii. ROM iii. Patient satisfaction/outcome 8. Subjects starting and finishing study i. Immediate ii. At end of treatment intervention iii. At follow-up (6 month) Review rating Weak (any F)

P P P P P P

M M M M M M

F F F F F F

P P P

M M M

F F F

P P

M M

F F

P

M

F

Moderate (No F; o4 P)

Strong (No F; 4+P)

If discrepancy in validity decision between reviewers Reason for discrepancy i. Oversight ii. Differences in interpretation of criteria iii. Differences in interpretation of study Final decision Weak

Moderate

Strong

only. No significant change was found in the CG for the follow-up period. Spratt et al. (1993) examined the efficacy of flexion and extension treatments, incorporating braces for low-back pain, in patients with retrodisplacement, spondylolisthesis and normal sagittal translation. The study used a mixed-model repeated measures design with the three classification categories, three treatment groups (flexion, extension and control) and pretest/post-test measures (3 3 2 design). The most important finding in this study was the reduction in pain in the extension treatment group. This finding occurred across all translation types and was significant. The primary concerns of the two studies identified by this review were as follows: (a) interventions/ control group activities were not well described; (b) the chosen outcome measure was not well described especially in terms of validity and reliability; (c) inadequate information was provided in regard to training of the individuals responsible for administering the outcome measures and (d) sample size The exercise description in the O’Sullivan study was well described and could be reproduced based on the published description; however, the control group activities were not clearly outlined or standardized. As the control group received many different, uncontrolled treatments, it is difficult to determine the actual effect of ‘conservative treatment’ on outcome. r 2003 Elsevier Science Ltd. All rights reserved.

The exact treatment provided to the groups in the Spratt study was also not explained in detail. For example, though the flexion group received a flexion brace, flexion exercises and education on avoiding lordotic postures, detail was not provided on the type, intensity, frequency and duration of the exercise programme, nor on instructions for expected brace wearing-time. The control group was provided with a ‘sham’ brace and subjects were assigned to a physiotherapist. It is not clear if the control group received alternate forms of physiotherapy or if monitoring of control group activities was done. The outcome measures utilized in the O’Sullivan study were: the McGill pain questionnaire, the Oswestry disability questionnaire, lumbar spine and hip sagittal range of motion (using a Cybex electronic digital inclinometer) and surface electromyography of abdominal muscle recruitment patterns. An independent assessor administered the outcome measures. The same assessor was used at the pre- and post-10-week treatment period and selfrated mail-out questionnaires were used during the follow-up period of the study. The chosen outcome measures were not well described in terms of reliability, and of concern was the validity of the Oswestry. However, in communication with the author, testing for reliability and validity of measures was done and intra-rater reliability of the independent assessor was reported as ‘good’ (O’Sullivan, personal communication, 2000). In the Spratt study, outcome measures included range of motion, trunk strength, compliance to treatment, patient perception of treatment effectiveness and pain assessment using a visual analogue scale. The primary outcome measure was pain. A visual analogue scale was used, which is a valid and sensitive measure, and was well described in this study. The subject’s assigned physiotherapist (who also provided the treatment) was responsible for measurement of range of motion and trunk strength. Information was not provided on the measurement methods or on the intra- and inter-rater reliability of the physiotherapists performing these measures. Independent assessors were not used but would have strengthened the study. As well, inadequate information was provided with respect to the questionnaire used to evaluate subject perception of treatment effect. The review findings also suggest that in future more attention should be given to the size of the study populations. In the two studies reviewed, information was not provided on how the sample size was predetermined. Specifically in the Spratt study, the final sample size of 56 subjects was inadequate for the study design. As well, there were only 19 subjects in total with spondylolisthesis and this classification included both degenerative and Manual Therapy (2003) 8(2), 80–91

Spondylolysis and spondylolisthesis 87 Table 5. Results of critical appraisal O’Sullivan et al.

Rating: O’Sullivan

Spratt et al.

Rating: Spratt

Type of study Confounders controlled age, sex, classification, medicine

Randomized controlled trial Age: 16–49, sex: males >females Classification: limited to isthmic spondylolysis and spondylolisthesis (degree of slip: 0–2) Medication: monitored n No significant differences between groups

P P

P F

Agreement to participare Physiotherapy Intervention Intervention described in enough detail to allow for replication

100%

P

Randomized controlled trial Age 18–60 years: age and gender not equal across groups Classification: both spondylolytic (isthmic) and degenerative spondylolisthesis included n Stringent inclusion criteria to control for age-related conditions Medication: no information provided 100%

Stabilization exercises

Yes

Yes

Treatment group: well described and could be reproduced based on description Control group: not clearly outlined or standardized 44 subjects McGill Pain Questionnaire: selfreported, valid measure, reliable, sensitive

M

Bracing Exercise Insufficient details on intervention to allow for replication

Sample size Primary outcome measure

M P

Additional outcome measure

Oswestry Disability Questionnaire: self-reported, concurrent validity: unclear, reliable, sensitive

P

Additional outcome measure

Range of motion: single independent assessor (blinded), valid measure, reliable, sensitive, intra-rater reliability reported as ‘good’ 44 subjects randomized: immediate 42 subjects completed the treatment period (21 SEG and 21 CG)=95% 41 subjects completed 3-months follow-up (21 SEG and 20 CG)=93% 40 subjects completed 6-month followup (21 SEG and 19 CG)=90% 34 subjects completed full protocol (30 months) (19 SEG and 15 CG)=77% * Generalizability of results to those with isthmic spondylolysis and spondylolisthesis from 0 to 2nd degree ‘slip’ * Reasons provided for loss to follow-up * Control group treatments not standardized TG showed a significant improvement at 30 months when compared to the CG

M

Subjects starting and finishing

External validity/ limitations

Statistical tests Overall rating: Weak (any F) Moderate (No F; o4 P) Strong (No F; 4+P)

P P

65 subjects VAS: Self-reported Valid measure: yes, reliable: yes, sensitive: yes ROM: * Independent (blinded) assessors not used ROM: validity, reliability, sensitivity: unclear, not described * No information on inter-rater and intra-rater reliability testing Patient perception of treatment effect: Self-administered: yes Validity, reliability, sensitivity of measure: unclear 65 subjects randomized: immediate 56 finished treatment=86%

M P

F

F

P P

P (M) Yes

Reason not provided for loss for loss to follow-up Authors acknowledge limitations: small sample size

No

Significant improvement in pain in the extension treatment group (all translation categories)

Yes

*

Yes Minor Yes Strong

Weak F=3 M=3

P=8

P=4

Manual Therapy (2003) 8(2), 80–91

M

P

F=0 M=3

spondylolytic types. As there is limited knowledge of the aetiology of low-back pain related to spondylolysis and spondylolisthesis, a potential difficulty would be to obtain a homogeneous study population

P

(Koes 1992). A larger sample size would provide more confidence that randomization of subjects had adequately controlled for known and unknown confounding factors (Koes 1992). r 2003 Elsevier Science Ltd. All rights reserved.


RCT 65 subjects Subacute and chronic low-back pain: 4 weeks to under 5 years 3 3 2 design * 3 instability categories * 3 treatments * pre-post-test measures Three categories of instability 1. Retrodisplacement 2. Spondylolisthesis 3. Normal translation

Spratt et al. (1993) Location: United States

All groups received education on low-back care.

RCT 44 subjects >3 months history of low-back pain 10-week intervention pre-post-test design with follow-up at 3, 6, 30 months Single independent assessor (blinded)

O’Sullivan et al. (1997) Location: Australia

n

Key features

Reference TG showed a significant improvement at 30 months when compared to the CG Pain intensity: F=14.4, Po0.0006 Pain descriptors: F=6.1, P=0.0187 Oswestry disability: F=4.2, Po0.0481

Pain: extension group showed improvement over time: F=11.61, Po0.03 Patient perception: flexion group reported low benefit from treatment, whereas extension group reported large benefit from brace and education components: F=3.65, Po0.04

Pain: modified VAS ROM: Strength: Compliance monitored Patient perception of treatment effect

Randomized to one of: 1. Flexion exercises and flexion bracen 2. Extension excercises and extension bracen 3. Control (sham treatment group)n

Statistics

Pain: VAS Function: Oswestry ROM: cybex digital inclinometer Abdominal muscle recruitment: surface electromyography

Outcome measures

Randomized to one of: 1. Treatment group: Strengtheing of deep abdominal muscles with coactivation of lumbar multifidus 2. Control group: Treatment as recommended by medical practitioner

Intervention

Table 6. Comparative summary of studies meeting relevance criteria

Significant improvement in pain in the extension treatment group (all translation categories) Authors suggest that improvement found with extension treatment may indicate advanced disease of the disc as underlying pathology

Specific exercise to train trunk stabilizer musculature is effective to decrease pain, functional disability, reduce use of pain medication Exercise effective in long term: to 30 months

Authors conclusions

Both spondylolytic and degenerative spondylolisthesis studied (one classification) Poor compliance with the flexion treatment especially in those with spondylolisthesis Inadequate sample for study design: low power

Study rated as weak initially until further information obtained from the author Exercise program lends itself to reproducibility within clinic setting Control group activities not standarized

Comments

88 Manual Therapy

Manual Therapy (2003) 8(2), 80–91


Limitations The findings of this review are specific to low-back pain due to spondylolysis and spondylolisthesis and to the field of physiotherapy. As time and resources were limited, the focus of the search was on studies written in the English language. Attempts were made to identify unpublished studies; however, no such studies were found. Therefore, the studies identified in this review may not represent all existing research in the area but a representative sample. As it was anticipated that very few acceptable studies would be found, this systematic review was open to the inclusion of any prospective study. As a result, the Critical Appraisal focused more on the methodological criteria related to clinical significance (subjects, description of treatments, and the validity and reliability of the chosen outcome measures). Therefore, an additional limitation of this review is that it did not consider criteria that have been shown to discriminate between biased and unbiased randomized controlled trials such as the random allocation procedure and method of concealment of allocation.

blading. As the current sporting trend is likely to result in an increased number of individuals presenting with spondylolysis and spondylolisthesis, further study is needed specifically within the young athletic population. It is also apparent from this review that authors of clinical trials need to publish study methods and results in enough detail to allow for analysis of scientific rigour. In conclusion, as the results of this systematic review are very limited, the field is wide open for further research in this area.

Acknowledgements The authors would like to acknowledge the assistance of librarian Sandra Shores, BA, MLS, Reference Librarian, John W. Scott Health Sciences Library at the University of Alberta. Her assistance in the search component of this systematic review was invaluable. The authors would also like to thank Trevor McNeely, MA, English Professor, Brandon University for his review of the manuscript.

References CONCLUSION Systematic reviews in physiotherapy are used to assess the literature to determine the efficacy of treatment. In this review, very few prospective studies were found that examined the efficacy of physiotherapy on the topic area. The two studies undergoing critical appraisal were both initially rated as weak. Despite this, there is evidence suggesting that special trunk stabilizing exercises have a positive effect on low-back pain related to spondylolysis and spondylolisthesis. There was also evidence indicating that combined extension exercise, extension bracing and education are beneficial, though it is not possible to separate the individual effects of this combined programme. Future research is needed in examining the aetiology of the two conditions and the relationship between instability and presenting symptoms. This will hopefully allow for prevention, early detection and appropriate treatment. Specifically, in physiotherapy, randomized controlled trials are needed and should extend to examining the efficacy of treatment modalities. As well, to effectively study these conditions, treatment response should be evaluated with subjects of different ages and in different stages of ‘slip’ and therefore may necessitate multicentre trials. Increased exposure time and sports participation, among children and adolescents, have been correlated with an increase in reported low-back pain (Motley 1998). In present-day society, rising numbers are participating in the new acrobatic variations of snowboarding, cycling, skate boarding and roller Manual Therapy (2003) 8(2), 80–91

Barash HL, Galante JO, Lambert CN, Ray RD 1970 Spondylolisthesis and tight hamstrings. Journal of Bone and Joint Surgery 52-A(7): 1319–1328 Cherkin DC, Deyo RA, Battie M, Street J, Barlow W 1998 A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. New England Journal of Medicine 339(15): 1021–1029 de Vet HCW, de Bie RA, van der Heijden GJMG, Verhagen AP, Sijpkes P, Knipschild PG. 1997 Systematic reviews on the basis of methodological criteria. Physiotherapy 83(6): 284–289 Fellander-Tsai L, Micheli LJ 1998 Treatment of spondylolysis with external electrical stimulation and bracing in adolescent athletes: A report of two cases. Clinical Journal of Sport Medicine 8(3): 232–234 Floman Y 2000 Progression of lumbosacral isthmic spondylolisthesis in adults. Spine 25(3): 342–347 Fritz JM, Erhard RE, Hagen BF 1998 Segmental instability of the lumbar spine. Physical Therapy 78(8): 889–896 Hall CM, Brody LT 1999 Therapeutic Exercise: Moving toward Function. Lippincott Williams and Wilkins, Philadelphia, Ch 18, pp 344–345 Hensinger RN 1989 Spondylolysis and spondylolisthesis in children and adolescents. Journal of Bone and Joint Surgery 71(7): 1098–1107 Jefferson T, Deeks J 1999 The use of systematic reviews for editorial peer reviewing: A population approach. In: Godlee F, Jefferson T (eds) Peer Review in Health Sciences. BMJ Books, London, p 225 Johnson RJ 1993 Low-back pain in sports: Managing spondylolysis in young patients. The Physician and Sports Medicine 21(4): 53–59 Koes BW, Bouter LM, Beckerman H, van der Heijden GJMG, Knipschild PG 1992 Physiotherapy exercises and back pain: A blinded review. British Medical Journal 302: 1572–l576 Linton SJ, Bradley LA, Jensen I, Spangfort E, Sundell L 1989 The secondary prevention of low back pain: A controlled study with follow-up. Pain 36: 197–207 Lohr KN, Carey TS 1999 Assessing ‘best evidence’: Issues in grading the quality of studies for systematic review. Journal of Quality Improvement 25(9): 470–479 Lonstein JE 1999 Spondylolisthesis in children. Spine 24(24): 2640–2648 r 2003 Elsevier Science Ltd. All rights reserved.

90 Manual Therapy

Magee DJ 1982 Orthopaedics: Conditions, Assessment and Treatment, 4th edn, Volume I manual, Course Manual. University of Alberta Magee DJ 1997 Orthopedic Physical Assessment, 3rd edn. W.B. Saunders Company, Philadelphia Magee DJ 1998 Systematic Reviews (Meta-analysis) and Functional Outcome Measures, Course Manual. University of Alberta Magora A 1976 Conservative treatment in spondylolisthesis. Clinical Orthopaedics 117: 74–79 Motley G, Nyland J, Jacobs J, Caborn DNM 1998 The pars interarticularis stress reaction, spondylolysis and spondylolisthesis progression. Journal of Athletic Training 33(4): 351–358 Newell RLM 1995 Historical perspective: Spondylolysis. Spine 20(17): 1950–1956 Osterman K, Schlenzka D, Poussa M, Seitsalo S, Virta L 1993 Isthmic spondylolisthesis in symptomatic and asymptomatic subjects, epidemiology, and natural history with special reference to disk abnormality and mode of treatment. Clinical Orthopaedics 297: 65–70 O’Sullivan PB, Twomey LT, Allison GT 1997 Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine 22(24): 2959–2967 Portney LG, Watkins MP 2000 Foundations of Clinical Research Applications to Clinical Practice. Appleton and Lange, East Norwalk, CT, p 167 Spratt KF, Weinstein JN, Lehmann TR, Woody J, Sayre H 1993 Efficacy of flexion and extension treatments incorporating braces for low-back pain patients with retrodisplacement, spondylolisthesis, or normal sagittal translation. Spine 18(13): 1839–1849 Stein F, Cutler SK 1996 Clinical Research in Allied Health and Special Education, 3rd edn. Singular Publishing Group, San Diego Szapalski M, Gunzberg R, Pope M 1999 Lumbar Segmental Instability. Lippincott, Williams and Wilkins, Philadelphia Warren S 1994 Research Theory in Rehabilitation. Rehabilitation Research Centre, Faculty of Rehabilitation Medicine, University of Alberta

Further Reading Arnold P, Winter M, Scheller G 1996 Clinical and radiological results of osteosynthesis of the vertebral lamina for lumbar spondylolysis and minor form of spondylolisthesis in childhood and adolescents. Zeitschrift fur Orthopadie und Ihre Grenzgebiete 134(3): 226–232 Bell DF, Ehrhich MG, Zaleske DJ 1988 Brace treatment for symptomatic spondylolisthesis Clinical Orthopaedics and Related Research 236: 192–198 Blanda J, Bethem D, Moats W, Lew M 1993 Defects of pars interarticularis in athletes: A protocol for nonoperative treatment. Journal of Spinal Disorders 6(50): 406–411 Buswell J 1982 Low back pain: A comparison of two treatment programmes. New Zealand Journal of Physiotherapy August: 13–17 Cherkin DC, Deyo RA, Battie M, Street J, Barlow W 1998 A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. New England Journal of Medicine 339(15): 1021–1029 Crawford JP, Noble WJ, Vernon H 1988 Chiropractic management of spondylolisthesis with spondylosis of the pars interarticularis: An example of the singlecase study experimental design. Journal of Manipulative and Physiological Therapeutics 11(2): 89–93 Delitto A, Cibulka MT, Erhard RE, Bowling RW, Tenhula JA 1993 Evidence for use of an extension–mobilization category in acute low back syndrome: A prescriptive validation pilot study. Physical Therapy 73: 216–228 Deyo RA, Walsh NE, Martin DC, Schoenfeld LS, Ramamurthy S 1990 A controlled trial of transcutaneous electrical nerve r 2003 Elsevier Science Ltd. All rights reserved.

stimulation (TENS) and exercise for chronic low back pain. New England Journal of Medicine 322(23): 1627–1634 Dixon M, Fricker P 1993 Injuries to elite gymnasts over 10 yrs. Medicine Science Sports Exercise 25(12): 1322–1329 Elnaggar IM, Nordin M, Sheikhzadel A, Parnianpour M, Kahanovitz N 1991 Effects of spinal flexion and extension exercises on low-back pain and spinal mobility in chronic mechanical low-back pain patients. Spine 16: 967–972 Evans C, Gilbert JR, Taylor W, Hildebrand A 1987 A randomized controlled trial of flexion exercises, education, and bed rest for patients with acute low back pain. Physiotherapy Canada 39: 96–101 Faas A, Chavannes AW, van Eijk JThM, Gubbels JW 1995 A randomized, placebo-controlled trial of exercise therapy in patients with acute low back pain. Spine 18: 1388–1395 Farrell JP, Twomey LT 1982 Acute low back pain: Comparison of two conservative treatment approaches. Medical Journal of Australia 1(4): 160– 164 Fellander-Tsai L, Micheli LJ 1998 Treatment of spondylolysis with external electrical stimulation and bracing in adolescent athletes: A report of two cases. Clinical Journal of Sport Medicine 8(3): 232–234 Frennered A, Danielson B, Nachemson AL 1991 Natural history of symptomatic isthmic low-grade spondylolisthesis in children and adolescents: A seven-year follow-up study. Journal of Pediatric Orthopaedics 11(2): 209–213 Gramse RR, Sinaki M, Ilstrup DM 1980 Lumbar spondylolisthesis: A rational approach to conservative treatment. Mayo Clinical Proceedings 55: 68l–686 Halpern BC, Smith AD 1991 Catching the cause of low-back pain. The Physician and Sports Medicine 19(6): 7l–79 Handa N, Yamamoto H, Tanis O, Kawakami E, Takemasa Y 2000 The effect of trunk muscle exercises in patients over 40 years of age with chronic low back pain. Journal of Orthopaedic Science 5: 210–216 Hansen FR, Bendix T, Skov P, Jensen CV, Kristensen Jh, Krohn L, Schioeler H, 1993 Intensive, dynamic back-muscle exercises, conventional physiotherapy, or placebo-control treatment of low-back pain. Spine 18: 98–107 Herkowitz HN 1995 Degenerative lumbar spondylolisthesis. Spine 20(9): 1084–1090 Johanssen F, Remvig L, Kryger P, Beck P, Warming S, Lybeck K, Dreyer V, Larsen LH 1995 Exercises for chronic low back pain: A clinical trial. Journal of Orthopaedic Sports Physical Therapy 22: 52–59 Lindgren KA, Sihnoven T, Ieino E, Pitkanen M, Manninen H 1993 Exercise therapy effects on functional radiographic findings and segmental electromyographic activity in lumbar spine instability. Archives of Physical Medicine 74(9): 933–939 Linton SJ, Bradley LA, Jensen I, Spangfort E, Sundell L 1989 The secondary prevention of low back pain: A controlled study with follow-up. Pain 36: 197–207 Lusins J, Elting JJ, Cicoria AD, Goldsmith SJ 1994 SPECT evaluation of lumbar spondylolysis and spondylolisthesis. Spine 19(S): 608–612 Malmivaara A, Hakkinen U, Aro T, Heinrichs ML, Koskenniemi L, Kuosma E, Lappi S, Paloheimo R, Servo C, Vaaranen V, Hernberg S 1995 The treatment of acute low back pain—bed rest, exercises, or ordinary activity? New England Journal of Medicine (6): 351–355 Manniche C, Hesselsoe G, Bentzen L, Christensen I, Lundberg E 1988 Clinical trial of intensive muscle training for chronic low back pain. Lancet: 2(8626–8627): 1473–1476 Mardjetko SM, Connolly PJ, Shott S 1994 Degenerative lumbar spondylolisthesis: A meta-analysis of literature 1970–l993. Spine 19(205): 22 565–22 655 Martin PR, Rose M, Nichols PJR, Russell PL, Hughes IG 1980 Physiotherapy exercises for low back pain: Process and clinical outcome. International Rehabilitation Medicine 8: 34–38 Matsunaga S, Ijiri K, Hayashi K 2000 Nonsurgically managed patients with degenerative spondylolisthesis: A 10- to 18-year follow-up study. Journal of Neurosurgery: Spine 93(2 suppl): 194–198 McCarroll JR, Miller JM, Ritter MA 1986 Lumbar spondylolysis and spondylolisthesis in college football players: A prospective study. The American Journal of Sports Medicine 14(5): 404–406 Manual Therapy (2003) 8(2), 80–91


Micheli LJ, Hall JE, Miller ME 1980 Use of modified Boston brace for back injuries in athletes. The American Journal of Sports Medicine 8(5): 351–356 Mierau D, Cassidy DC, McGregor M, Kirkaldy-Willis WHA 1987 Comparison of the effectiveness of spinal manipulative therapy for low back pain patients with and without spondylolisthesis. Journal of Manipulative and Physiological Therapeutics l0(2): 49–55 Moller H, Hedlund R 2000 Surgery versus conservative management in adult isthmic spondylolisthesis. Spine 25(13): 1711–l715 Morita T, Ikata T, Katoh S, Miyake R 1995 Lumbar spondylolysis in children and adolescents. The Journal of Bone and Joint Surgery 77B(4): 620–625 Nelson BW, Carpenter DM, Dreisinger T, 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 and Rehabilitation 80: 20–25 Nwaga G, Nwaga V, 1985 Relative therapeutic efficacy of the Williams and Mckenzie protocols in back pain management. Physiotherapy Practice 1: 99–105 Nwaga VCB, 1982 Relative therapeutic efficacy of vertebral manipulation and conventional treatment in back pain management. American Journal of Physical Medicine and Rehabilitation 61: 273–287 O’Sullivan PB, Twomey LT, Allison GT 1997 Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine 22(24): 2959–2967 Peretto L, Gambaretti R, Berlusconi M, Silvestrini E 1992 Spondylolysis-lysthesis: An approach toward sports activity. Medicina Della Sport 45(4): 523–539 Perugia L, Rossi F 1998 Spondylolysis and spondylolisthesis in sport: review of a case series. Journal of Sports Traumatology Related Research 20(4): 209–212 Pettine K, Salib R, Walker S 1993 External electrical stimulation and bracing for treatment of spondylolysis: A case report. Spine 18(4): 436–439 Pizzutillo PD, Hummer CD 1989 Nonoperative treatment for painful adolescent spondylolysis or spondylolisthesis. Journal of Pediatric Orthopaedics 9(5): 538–540

Manual Therapy (2003) 8(2), 80–91

Poussa M, Tallroth K 1993 Disc herniation in lumbar spondylolisthesis: Report of 3 symptomatic cases. Acta Orthopaedic Scandinavia 64(1): 13–16 Rupert RL, Wagnon R, Thompson P, Ezzeldin MT 1985 Chiropractic adjustments: Results of a controlled clinical trial in Egypt. International Review of Chiropractic Winter: 58–60 Sachs BL, Ahmad SS, Lacroix M, Olimpio D, Heath R, David J, Scala AD 1994 Objective assessment for exercise treatment on the B-200 isostation as part of work tolerance rehabilitation. Spine 19: 49–52 Seitsalo S, Schlenzka D, Poussa M, Osterman K 1997 Disc degeneration in young patients with isthmic spondylolisthesis treated operatively or conservatively: A long-term follow-up. European Spine Journal 6(6): 393–397 Sinaki M, Lutness MP, Ilstrup DM, Chu CP, Gramse RR 1989 Lumbar spondylolisthesis: Retrospective comparison and threeyear follow-up of two conservative treatment programs. Archives of Physical Medicine and Rehabilitation 70: 594–598 Soren A, Waugh TR 1985 Spondylolisthesis and related disorders: A correlative study of 105 patients. Clinical Orthopaedics and Related Research 193: 171–l77 Spratt KF, Weinstein JN, Lehmann TR, Woody J, Sayre H 1993 Efficacy of flexion and extension treatments incorporating braces for low-back pain patients with retrodisplacement, spondylolisthesis, or normal sagittal translation. Spine 18(13): 1839–1849 Stankovic R, Johnell O 1995 Conservative treatment of acute low back pain: A 5-year follow-up study of two methods of treatment. Spine 20: 469–472 Stankovic R, Johnell O 1990 Conservative treatment of acute low back pain: A prospective randomized trial: McKenzie method of treatment versus patient education in ‘Mini back school’. Spine 15(2): 120–123 Steiner ME, Micheli LJ 1985 Treatment of symptomatic spondylolysis and spondylolisthesis with the modified boston brace. Spine 10(10): 937–943 Tokuhashi Y, Matsuzaki H, Sano S 1993 Evaluation of clinical lumbar instability using the treadmill. Spine 18(15): 2321–2324 Waterworth FR, Hunter IA 1985 An open study of diflunisal, conservative and manipulative therapy in the management of acute mechanical low back pain. New Zealand Medical Journal 95: 372–375



Technical and measurement note

Relationship between cranio-cervical flexion range of motion and pressure change during the cranio-cervical flexion test Deborah L. Falla, Carolyn D. Campbell, Amy E. Fagan, David C. Thompson, Gwendolen A. Jull Department of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia

SUMMARY. The purpose of this study was to quantify the sagittal angular displacement of the head (craniocervical flexion) for the five incremental stages of the cranio-cervical flexion test (CCFT). Range of cranio-cervical flexion during the CCFT was measured using a digital imaging method in 20 healthy volunteer subjects. The intraand inter-rater reliability of the digital imaging technique for the assessment of this movement were also examined. The results of this study demonstrated a linear relationship between the incremental pressure targets of the CCFT and the percentages of full range cranio-cervical flexion range of motion (ROM) measured in the supine lying position of the test using a digital imaging technique. A mean of 22.9% full range cranio-cervical flexion was used to reach the first pressure target of the CCFT followed by linear increments up to 76.6% for the last stage of the test. An increasing amount of cranio-cervical flexion ROM was used to achieve the five successive stages of the CCFT reflecting an increasing contractile demand on the deep cervical flexor muscles. Excellent inter-rater (ICC=0.994) and intra-rater reliability (ICC=0.988–0.998) were demonstrated for the angular measurements using this digital imaging technique. r 2003 Elsevier Science Ltd. All rights reserved.

and the scalenes) and on the hypothesis of an altered neuro-motor strategy in the neck flexor synergy with neck pain (Jull et al. 1999). The CCFT requires the patient to perform the head nodding action of cranio-cervical flexion in five progressive stages from a neutral starting position in the supine crook lying position. In the absence of a direct method to measure deep neck flexor muscle activity, this test utilizes an air-filled pressure sensor placed behind the subject’s neck to monitor the slight flattening of the cervical lordosis, which occurs with the contraction of longus colli (Vitti et al. 1973; Mayoux-Benhamou et al. 1994). The patient is instructed to perform a gentle head nodding action of cranio-cervical flexion, and with the aid of a visual feedback device, to reach five incremental pressure targets. In an ideal performance, an increasing amount of cranio-cervical flexion could be expected during the five successive stages of the CCFT (Jull et al., 1999), representing increasing contractile demand on the deep neck flexor muscles. However, this pattern has not been confirmed.

INTRODUCTION The cranio-cervical flexion test (CCFT) (Jull et al. 1999, Jull 2000) is a low-load test to target the deep cervical muscles, longus capitus and longus colli. The clinical test has been designed to assess the tonic holding abilities of the deep neck flexors. It has been based on anatomical grounds (that is, cranio-cervical flexion or a head nodding movement is the action of longus capitus and colli and not the action of other superficial neck flexors such as sternocleidomastoid Received: 23 November 2001 Revised: 28 August 2002 Accepted: 15 January 2003 Deborah L. Falla, BPht (Hons), PhD Candidate, Carolyn D. Campbell, BSc (P.T.), MPhty (Manipulative Physiotherapy), Amy E. Fagan, P.T., MPhty (Manipulative Physiotherapy), David C. Thompson, BPhty, MPhty (Manipulative Physiotherapy), Gwendolen A. Jull, MPhty, PhD, Department of Physiotherapy, The University of Queensland, Brisbane, QLD 4072, Australia Correspondence to: DLF. Tel.: +61 7 33654529; Fax: +61 7 3365 2775; E-mail: [email protected] 92

Cranio-cervical flexion range of motion and pressure change 93

The aim of this investigation was to quantify the angle of head nod (cranio-cervical flexion) for the five incremental stages of the CCFT and to establish whether a relationship exists between cranio-cervical flexion range of motion (ROM) and pressure changes during the CCFT. It was anticipated that the results of this research would further our understanding and enhance the practical applications of the CCFT.

METHODS Subjects Twenty healthy volunteer subjects (12 male, 8 female) aged between 18 and 44 years (mean 29.8, SD 8.2) participated in this study. Subjects were not considered for the study if they had a past or present history of cervical or upper thoracic pain, were perceived to have limited range or tightness in the upper cervical extensor muscles assessed with the clinical muscle test (Evjenth & Hamberg 1984), or were unable to successfully perform the five stages of the CCFT. Ethical approval for the study was granted by the School of Health and Rehabilitation Sciences Ethics Committee at The University of Queensland, Australia. Instrumentation and measurements The Pressure Biofeedback Unit (PBU) (Chattanooga Group Inc., Hixson, TN) is an inflatable air-filled pressure sensor, which is placed behind the patient’s neck during the CCFT. The PBU is inflated to a baseline pressure of 20 mmHg which is sufficient to fill the space between the back of the neck and the testing surface. During the CCFT, subjects are required to perform a gentle head nodding action of cranio-cervical flexion and increase the pressure by increments of 2 mmHg with a final pressure target of 30 mmHg. The linear relationship between pressure output and load on the pressure sensor has been demonstrated in previous work (Jull et al. 1993). Recording of pressure measures was achieved by connecting the PBU to a pressure transducer (RS Components) via flexible plastic tubing. Electrical signals from the pressure transducer were amplified and relayed to a visual feedback device and to an integrated amplifier, analogue to digital converter and data storage system (Amlab II). The visual feedback device consisted of an electronic voltmeter, marked in 2 mmHg increments from 20 to 30 mmHg, and was calibrated to display the pressure in the PBU, based on the pressure transducer output. Sampling frequency for pressure measures was 1000 Hz. A digital camera (Canon Digital IXUS, Japan) and custom designed analytical software (LabVIEW 6i, Manual Therapy (2003) 8(2), 92–96

National Instruments) was utilized to measure the sagittal angular displacement of the head (to one decimal place) achieved during the cranio-cervical flexion action. This methodology does not provide definitive angles of cranio-cervical flexion as would be demonstrated with radiographic measures; however, it is capable of providing an estimation of the percentages of full range of cranio-cervical flexion that are achieved for the five stages of the CCFT. Yang et al. (2001) utilized this digital imaging technique to record a number of pre-determined angles set on a standard universal goniometer. Mean absolute errors ranging from 1.601 to 1.811 were demonstrated indicating that this digital imaging technique produces highly accurate representations of goniometric angles. As suggested by Yang et al. (2001) a constant distance and camera zoom should be included in the standardization process in order to obtain accurate measures using a digital imaging method. The digital camera was positioned on a tripod horizontally parallel to the subject’s head/neck region at a distance of 80 cm and the wide-angle zoom was selected for all photos. Anatomical markers were positioned on the tragus of the ear, the mental protuberance of the mandible and the lateral aspect of the neck–7 cm inferior to the mastoid process (Fig. 1). A distance of 7 cm (approximately at the level of the forth or fifth cervical transverse process) was selected to provide a standardized stationary reference point. Markers were fixed with double-sided medical tape. Clinically it has been observed that neck retraction is a common substitution strategy employed by patients who have difficulty achieving the stages of the CCFT (Jull 2002). To monitor and prevent neck retraction, subjects were positioned comfortably in supine crook lying with their head resting on the padded head support of a force measuring apparatus. The aluminium frame housed two load cells (CCT Transducers, Torino, Italy) with a full scale of 25 kg each. The offset of the transducers was adjusted to accommodate the weight of the subject’s head. Electrical signals from the load cells were amplified (MISO1, LISiN Centro di Bioingegneria, Politecnico di Torino, Italy) and displayed in real time. During the screening process for inclusion into the study it was noted that a change of 0.75 kg or greater correlated with visual observation of neck retraction. Any increase in force greater than 0.75 kg recorded by the loads cells during any stage of the CCFT necessitated repetition of that portion of the test. Experimental procedure Subjects were comfortably positioned in supine crook lying. The starting position was standardized by placing the cranio-cervical and cervical spine in a mid-position such that the subject’s forehead and chin r 2003 Elsevier Science Ltd. All rights reserved.

94 Manual Therapy

Fig. 1—Custom designed software program (LabVIEW 6i, National Instruments) designed to calculate range of motion. The investigator highlights the centre of three anatomical markers and an angle is generated.

were basically in the horizontal plane and an imaginary line, which extended from the tragus of the ear to bisect the neck longitudinally, was parallel to the plinth (Jull 2000; Falla et al. 2002). The vertical height of the force measuring apparatus was adjusted as required to achieve this position. Anatomical markers were placed on the subjects’ face and neck (Fig. 1). To ensure accurate performance during the CCFT, subjects initially practiced the test and any neck retraction was identified and discouraged. The PBU was placed behind the subject’s neck, abutting against the occiput and set to a baseline pressure of 20 mmHg. Implementation of the test followed previously published guidelines (Jull 2000). An initial photograph was taken of the subject in the starting position, followed by a photograph at the full range of active cranio-cervical flexion available in the supine lying position. The subjects were then instructed to perform the five incremental stages (22–30 mmHg) of the CCFT, maintaining the pressure steady on each target for a duration of 10 s. A photograph was taken as each pressure target was achieved. An interval of 15 s was given between each contraction during which time the investigator checked the subject’s head and neck position to r 2003 Elsevier Science Ltd. All rights reserved.

ensure the subject returned to their starting position. Each subject attended one testing session and repeated the test procedure three times with an interval of 5 min between trials. The anatomical markers were not removed between trials. The intra and inter-tester repeatability of the digital imaging method for the assessment of the absolute angles of sagittal head displacement were measured at each stage of the CCFT. Four testers processed the photos of each subject’s first trial. Each tester repeated this process a total of three times in a randomized order to allow the intra-tester reliability to be examined. Data management The intraclass correlation coefficient (ICC) (Shrout & Fleiss, 1979) was used to determine the inter-tester (3,4) and intra-tester (1, 1) reliability of the digital imagining technique. The tester with the highest intra-tester repeatability processed the photos for the further two trials for each subject. Full craniocervical flexion ROM was calculated by subtracting the mean angle measured at full active cranio-cervical flexion from the mean angle of the starting position. Manual Therapy (2003) 8(2), 92–96

The relative range of movement obtained at each stage of the CCFT was obtained by expressing each angle as a percentage of full range of cranio-cervical flexion measured with the digital imaging technique and was averaged across the three trials. For each subject the pressure traces were plotted and reviewed to ensure that each pressure target was reached and maintained for the 10-s duration. Complete data from three subjects did not conform to this criterion and were discarded. Descriptive statistics were used to present the relative amount of cranio-cervical flexion ROM for each of the five incremental stages of the CCFT. A Pearson’s correlation was carried out to calculate the relationship between the pressure targets and craniocervical flexion ROM. A repeated measures analysis of variance (ANOVA) was performed to determine whether the amount of cranio-cervical flexion ROM was significantly different between the successive stages of the CCFT. A value of Po0.05 was considered statistically significant. All statistical analyses were performed with SPSS statistical software.

RESULTS A very high inter-rater (ICC=0.994) and intra-rater reliability (ICC=0.988–0.998) were demonstrated for the digital imaging method for the assessment of absolute cranio-cervical flexion ROM angles. The 95% confidence intervals for these estimates were 70.005. The standard error of measurement for the absolute cranio-cervical flexion ROM values used in the ICC calculations ranged from 0.458 to 0.651. Absolute values of full range cranio-cervical flexion achieved in the supine lying test position (N=20) ranged between 4.91 and 16.51. Table 1 presents the mean and standard deviation of the absolute values of full range cranio-cervical flexion range of motion (N=20) and the relative amounts of cranio-cervical flexion ROM obtained for each stage of the CCFT (N=17). Table 1. Mean, standard deviation (SD) and 95% confidence intervals (CI) of full range of cranio-cervical flexion achieved in the supine position (in degrees) (N=20) and relative amounts of cranio-cervical flexion range of motion (ROM) (%) for the five stages of the cranio-cervical flexion test (CCFT) (N=17) Stage of the CCFT (mmHg)

Mean (%)

SD (%)

95% CI (%)

22 24 26 28 30

24.9 41.9 55.8 66.5 76.6

10.8 11.8 12.5 11.5 11.1

19.2–30.4 35.8–48.0 49.3–62.2 60.5–72.4 70.8–82.2

Full ROM

8.51

Manual Therapy (2003) 8(2), 92–96

2.71

7.2–9.71

RELATIVE CRANIO-CERVICAL FLEXION ROM (%)

Cranio-cervical flexion range of motion and pressure change 95

90 80 70 60 50 40 30 20 10 22

24

26

28

30

STAGE OF THE CCFT IN mmHg

Fig. 2—Mean and 95% confidence intervals of cranio-cervical flexion range of motion (ROM) (expressed as a percentage relative to full range of motion) obtained for each stage of the craniocervical flexion test (CCFT) (N=17).

Results of the ANOVA demonstrated a significantly greater amount of cranio-cervical flexion ROM was used to target each successive stage of the CCFT (all Po0.001). As can be observed in Figure 2, the relationship between cranio-cervical flexion ROM and the successive pressure targets is predominately linear.

DISCUSSION Clinical description of the CCFT suggests that in a correct performance, an increasing amount of craniocervical flexion would be evident for the five incremental stages of the test reflecting increasing contractile demand on the deep neck flexor muscles. The results of this study demonstrated that a linear relationship does exist between the amount of craniocervical flexion and the successive pressure targets in asymptomatic subjects. A mean of 24.9% of the full available range craniocervical flexion was used to reach the first pressure target of the CCFT followed by linear increments up to a total of 76.6% for the last stage of the test (Fig. 2). This study highlights that in the clinical application of the test, the practitioner should expect to see progressively increasing ranges of craniocervical flexion with each of the five progressive stages of the test. If this relationship is not observed, and the excursion of cranio-cervical flexion remains static or decreases with the test, it indicates that the patient has substituted a change in the pattern of movement to achieve the test pressure targets. Clinical experience suggests that this substitution r 2003 Elsevier Science Ltd. All rights reserved.

96 Manual Therapy

for cranio-cervical flexion is often inappropriate neck retraction movement. Excellent levels of intra-tester and inter-tester reliability were evident for the angular head displacement measures assessed with the digital imaging technique. This indicates that it is possible to obtain consistent measures of head angle despite the small angles recorded.

CONCLUSION This study revealed that a significantly increasing amount of cranio-cervical flexion is required to achieve the five incremental stages of the CCFT. Furthermore, excellent levels of reliability were obtained for the angular measures using the digital imaging software employed in this study that indicate the suitability of this technique for the assessment of range of motion in future research.

Acknowledgements This study was supported by the UQ Small Grant Scheme.


References Jull GA 2000 Deep cervical flexor muscle dysfunction in whiplash. Journal of Musculoskeletal Pain 8: 143–154 Jull GA 2002 Cervicogenic headache. In Grant R (ed.) Physical Therapy of the Cervical and Thoracic Spines, 3rd edn, Churchill Livingstone, New York Jull GA, Barrett C, Magee R, Ho P 1999 Further clinical clarification of the muscle dysfunction in cervical headache. Cephalalgia 19: 179–185 Jull GA, Richardson CA, Toppenberg R, Comerford M, Bui B 1993 Towards a measurement of active muscle control for lumbar stabilisation. Australian Journal of Physiotherapy 39: 187–193 Evjenth O, Hamberg J 1984 Muscle Stretching in Manual Therapy, Vols. I and II. Alfta Rehab Forlag, Alfta Falla D, Dall’Alba P, Rainoldi A, Merletti R, Jull G 2002 Identification of innervation zones of sternocleidomastoid and scalene muscles: A basis for clinical and research electromyography applications. Clinical Neurophysiology 113: 57–63 Mayoux-Benhamou MA, Revel M, Vallee C, Roudier R, Barbet JP, Bargy F 1994 Longus colli has a postural function on cervical curvature. Surgical and Radiologic Anatomy 16: 367–371 Shrout PE, Fleiss JL 1979 Intraclass correlations: Uses in assessing rater reliability. Psychological Bulletin 86: 420–428 Vitti M, Fujiwara M, Basmajian JV, Iida M. 1973 The integrated roles of longus colli and sternocleidomastoid muscles: An electromyographic study. Anatomical Record 177: 471–484 Yang C-H, Falla D, Vicenzino B 2001 Validity of angle measurement using digital camera. 12th Manipulative Physiotherapists Association of Australia (MPAA) Biennial Conference – More Than Skin Deep, South Australia, Australia

Manual Therapy (2003) 8(2), 92–96


Original article

Quantitative analysis of traction in the glenohumeral joint. In vivo radiographic measurements Alli Gokeler*, G. H. van Paridon-Edauwn, S. DeClercqw, O. Matthijsn, P. U. Dijkstraz International Academy of Orthopaedic Medicine, Deutschland, Germany, w BVBA Medische Beeldvorming, Schoten, Belgium, z Department of Oral and Maxillo Facial Surgery, Pain Centre, University Hospital Groningen, The Netherlands

n

SUMMARY. Purpose: To analyse change in distance between the humeral head and the glenoid fossa during traction in the maximally loose-packed position (MLPP) and the maximally closed-packed position (MCPP) under standardized conditions. Subjects: Six healthy subjects (three male and three female) with a mean age of 40.5 years, volunteered to participate in this study. Materials and methods: Subjects were placed with the right shoulder in a modified shoulder brace (Otto Bock Armabduktions-Orthese in Modular Bauweises) in 451 abduction in the plane of the scapula with neutral rotation (MLPP). A standard anterior–posterior radiograph of the glenohumeral joint was made. A 14 kg traction force was applied for 40 s, and a second radiograph was made. The same procedure was repeated with the shoulder placed in the MCPP, which was 901 abduction and 901 external rotation. A radiologist, blinded for the variable traction or no traction, performed all radiographic measurements. Measurements were made on the same radiographs on two separate occasions (O1 and O2) with a 2-month interval. Results: No significant differences were found in mean distance between the humeral head and the glenoid fossa during traction in the MLPP compared to traction in the MCPP (O1: P=1.00) and (O2: P=0.63). Conclusions: Application of a 14 kg force does not result in a significant increase of distance between the humeral head and the glenoid fossa. No significant difference was found between the change in distance of the humeral head and the glenoid fossa after traction in the MLPP compared to traction in the MCPP. r 2003 Elsevier Science Ltd. All rights reserved.

techniques including traction, glide mobilizations and manipulations to improve the ROM of the glenohumeral joint. According to manual therapy textbooks, traction can be used as a diagnostic tool to assess joint play, or as treatment to relieve pain or to improve joint mobility (Kaltenborn 1985; Mink et al. 1990; Frisch 1996). Different grades of traction have been defined, ranging from Grade 1 to 3 (Kaltenborn 1985). In Grade 1, there is no appreciable joint separation. Grade 1 represents the force necessary to abolish the compressive forces acting on the joint. In Grade 2, the slack is taken up from the tissue surrounding the joint, which are then tightened. Finally in Grade 3, additional force is applied and the soft tissues surrounding the joint are stretched and separation of the joint surfaces is achieved. Joint play is defined as an accessory motion, not under voluntary control, produced with a short, linear,

INTRODUCTION Restricted shoulder range of motion (ROM) is a common condition encountered in daily orthopaedic physical therapy practice and remains challenging to treat. Clinicians frequently apply manual therapy Received: 21 February 2002 Revised: 4 September 2002 Accepted: 25 September 2002 A. Gokeler, PT, MT, G.H. van Paridon-Edauw, PT, MT, O. Matthijs, PT, MT, International Academy of Orthopaedic Medicine, Deutschland, Germany, S. DeClercq MD, BVBA Medische Beeldvorming, Schoten, Belgium, P.U. Dijkstra PT, MT, PhD, Clinical Epidemiologist, Department of Rehabilitation, Department of Oral and Maxillo Facial Surgery, Pain Centre, University Hospital Groningen, The Netherlands Correspondence to: AG, Medisch Centrum Zuid, Van KetwichVerschuurlaan 287, 9721 SM Groningen, The Netherlands. Tel.: + 31 50 527 1613; E-mail: [email protected] 97

98 Manual Therapy

passive bone movement. Joint play motions used in Manual Therapy are traction, compression and gliding. These motions are used mainly to assess how much ‘play’ or motion there is between two articular surfaces of a joint, and determine hypomobility or hypermobility of a joint system (Kaltenborn 1985). Traction, when used for joint play testing, is preferably performed in the maximal loose-packed position (MLPP) of the joint (for the shoulder: 551 abduction, 301 horizontal adduction and the forearm in the transverse plane). It is generally assumed that in the MLPP the joint play can be appreciated best because the joint capsule is most relaxed (Kaltenborn 1985). Dvorak and co-workers (Dvorak et al. 1997) stated that up to 5 mm of separation of the joint surfaces is physiological during joint play testing. In the maximal closed-packed position (MCPP) (for the shoulder: 901 abduction and 901 external rotation), the joint capsule and ligaments are maximally taut and there is maximal contact between the joint surfaces. In the MCPP the articular surfaces cannot be separated by traction forces according to Kaltenborn (1985). Thus, a greater amount of separation between the joint surfaces might be expected when applying traction in MLPP compared to traction in the MCPP. However, these claims about joint separation have never been substantiated by means of research. In a pilot study by Gielen et al. (unpublished data) traction was applied to the glenohumeral joint in approximately 451 abduction in four subjects. Radiographs were taken during traction and no separation of the humerus from the glenoid fossa could be demonstrated. The aim of this study was to analyse separation of the humeral head and the glenoid fossa during traction in the MLPP and the MCPP under standardized conditions.

We followed the principles outlined in the Declaration of Helsinki. The nature, purposes and risks of the research were explained to the volunteers by the researchers and informed consent was obtained. All volunteers were instructors in manual therapy who wanted to know whether traction did indeed separate the joint surfaces or not. They were aware that participating in the study meant repeated exposure to radiation. The subjects were free to withdraw from the study at any time.

MATERIAL AND METHODS

Test procedure

Subjects

Before traction was applied each subject performed 20 repetitions of active arm elevation of the right shoulder as a warm-up. The right shoulder of the subjects was placed in a modified shoulder brace (Otto Bock Armabduktions-Orthese in Modular . Bauweises, Gottingen, Germany). This brace held the shoulder in a position of 451 abduction in the plane of the scapula and in neutral rotation (MLPP). The abduction position was verified using a goniometer (Fred Sammons, Inc. Brookfield, IL). The arm was secured with Velcros straps to prevent any other movement except traction. The subjects were then placed at a distance of 1.15 m to the radiographic beam. A radiograph was taken without applying a traction force for reference values. The spring gauge was then attached with a metal hook to the arm cuff and an assistant applied a 14 kg traction force in a

Six healthy volunteers, three men and three women, with a mean age of 40.6 years (range: 33–51) participated in this study. Five subjects were righthanded and one was ambidextrous. Three were involved in recreational sports (two in running and one in tennis). None of the subjects had a history of previous shoulder injury, surgery or had experienced any shoulder symptoms 6 months prior to and at the time of the study. All subjects had normal pain-free ROM being equal to the non-tested side. Prior to the study a standard radiograph was taken of the right shoulder and no abnormalities or degenerative changes were observed on radiographic films, thus all shoulders were classified as normal by the radiologist involved in the study. r 2003 Elsevier Science Ltd. All rights reserved.

Preliminary study In a preliminary study, the maximal traction force that would normally be applied to the glenohumeral joint was determined. Twelve experienced manual therapists were instructed to apply a maximal amount of traction to the glenohumeral joint of a volunteer as they would do during glenohumeral mobilization. As a prerequisite, the traction had to be tolerated well by the volunteer. A spring gauge with a scale in kilograms (Federwage, Regensburg, Germany) was used to record the amount of force applied. The spring gauge was calibrated before and after each test. The spring gauge was attached to a cuff wrapped around the upper arm of the subject, as close to the glenohumeral joint as possible. The subject was seated on a stool with the glenohumeral joint shoulder in 451 abduction. A lateral, slightly anterior and superior directed pull was applied, as described in the textbooks (Mink et al. 1990; Frisch 1996). The subject had no difficulty relaxing during these test trials. The mean value of the traction applied by the 12 therapists was 12 kg (range: 5–14 kg). Therefore, 14 kg was used in the remaining part of the current research because it was believed that this force would be sufficient to produce increase in distance between the humeral head and the glenoid fossa.

Manual Therapy (2003) 8(2), 97–102

Quantitative analysis of traction 99

lateral, slightly anterior and superior direction. The scapula was stabilized by a second assistant by pulling on a belt (Soft Belts, OPTP, Minneapolis, MN) that was wrapped diagonally over the shoulder covering the acromion and the lateral margin of the scapula (Fig. 1). Traction was sustained for 40 s before the second radiograph was taken. During the test procedure volunteers and assistants were protected by means of standard safety measures (lead gloves and lead apron). The radiation dose per radiograph was o0.01 mSv and was within the recommended safety limit standards set by the European Community (European Commission 2000). The same assistants performed scapular fixation and application of the traction during the test procedure for all subjects. The shoulder brace was then adjusted to a position with the glenohumeral joint in 901 abduction in the scapular plane and 901 external rotation representing the MCPP. The radiographic beam was slightly adjusted as the scapula had moved to a more lateral position in the MCPP. Similar to the previous position (MLPP) one assistant stabilized the scapula and the other applied the traction. Again two radiographs were made, one as a reference without traction and one after 40 s of traction. Thus, in total, four radiographs were taken from each subject, two from the MLPP and two from the MCPP. During the test procedure, the subjects were asked whether they experienced any discomfort and whether they were able to relax. Quantitative analysis consisted of comparative measurements of each position. The geometric centre of the humeral head and the glenoid fossa were determined, similar to the technique used by Petersson and Redlund-Johnell (1983) and were taken as reference points for measurements. The displacement of the humeral head with the application of traction was determined from these radiographs to the nearest millimetre with a standard ruler, as used in radiology. A radiologist, blinded for the dependant variable

traction or no traction, performed all radiographic measurements. To determine the intra-tester reliability of the radiologist, the measurements were made on the same radiographs on two separate occasions with a 2-month interval. The results from the previous measurements were withheld from the radiologist. Statistical analysis Data analysis was performed using SPSS for Windows version 10. Paired t-tests were used to analyse intra-observer reliability and to analyse the differences in the distance between humeral head and glenoid fossa before and after traction in the MLLP and the MCCP. Because of the small sample size, the results of the t-tests were verified using non-parametric tests (Wilcoxon signed rank sum test).

RESULTS During the test procedure none of the subjects experienced discomfort and all were able to relax adequately. Intra-tester reliability The mean distance between the humeral head and the glenoid fossa assessed on occasion 1 (O1) differed significantly from that on occasion 2 (O2) (mean difference 0.4 mm) (Table 1). Of the 24 paired observations, 22 exhibited a difference between the first and the second observation of 1 mm or less. Because of this significant difference between O1 and O2, the results of both are given in the Tables 2 and 3. No significant change in distance between the humeral head and the glenoid fossa occurred with traction either in the MLPP or in the MCPP (Figs 2 and 3, Table 2). No significant difference was found between the change in distance of the humeral head and the glenoid fossa after traction in the MLPP compared to traction in the MCPP (Table 3). The results of the t-tests in Tables 2 and 3 were verified

Table 1. Intra-tester reliability of the radiologist. Mean and standard deviation of the distance between humerus and glenoid fossa (in mm) assessed on O1 and O2. Additionally, the mean difference between O1 and O2 and the 95% confidence interval of the difference is presented

Fig. 1—Set up brace for experiment in MLPP. Manual Therapy (2003) 8(2), 97–102

O1 mean (SD)

O2 mean (SD)

Difference between 95% CI O1 and O2 mean (SD)

4.54 (0.86)

4.17 (0.55)

0.38 (0.58)

0.13 to 0.62

95% CI: 95% confidence interval; The difference between O1 and O2 is significant (P=0.004) (Results of t-test for dependent observations). It can be debated whether the mean difference (0.4 mm) is clinically relevant. r 2003 Elsevier Science Ltd. All rights reserved.

100 Manual Therapy Table 2. Comparison of the distance between humeral head and the glenoid fossa (in mm) assessed before and during traction in the MLPP and MCPP on O1 and O2 Before traction Mean (SD) MLPP (O1) MLPP (O2) MCPP (O1) MCPP (O2)

4.3 4.0 4.5 4.3

Traction Mean (SD)

(1.0) (0.5) (0.5) (0.6)

4.6 4.2 4.8 4.3

(1.1) (0.5) (0.9) (0.6)

Difference Mean (SD) 0.3 (0.5) 0.2 (0.3) 0.3 (0.6) 0.0 (0.3)

95% CI 0.8 0.4 0.9 0.3

to to to to

0.3 0.1 0.4 0.3

MLPP: maximally loose-packed position, MCPP: maximally close-packed position, O1: occasion 1, O2: occasion 2, 95% CI: 95% confidence interval (results of t-test for dependent observations).

Table 3. Comparison of the change in distance between humeral head and glenoid fossa (in mm) with and without traction assessed in the MLPP and MCPP on O1 and O2 Assessment

MLPP (n=6) Mean change (SD)

MCPP (n=6) Mean change (SD)

Mean difference in change (SD)

Occasion 1 Occasion 2

0.3 (0.5) 0.2 (0.3)

0.3 (0.6) 0.0 (0.3)

0.0 (0.8) 0.2 (0.4)

95% CI of the difference 0.9 to 0.9 0.3 to 0.6

MLPP: maximally loose-packed position, MCPP: maximally close-packed position. The difference in change between MLPP and MCPP is non-significant (t1: P=1.00) and (t2: P=0.63) (results of t-test for dependent observations).

Fig. 2—Radiograph in MLPP before traction.

Fig. 3—Radiograph in MLPP with traction.

using non-parametric tests because of the small sample size (Wilcoxon signed rank sum test). These non-parametric tests yielded non-significant results.

the humeral head and the glenoid fossa in the MLPP, or in the MCPP. The current paper is the first study to our knowledge that examined traction of the glenohumeral joint quantitatively under standardized conditions using radiographs to assess the distance between the humeral head and glenoid fossa. To ensure that all measurements were obtained under similar standardized conditions, the same test sequence was followed

DISCUSSION Based on the results of this study, a traction force of 14 kg does not induce an increase in distance between r 2003 Elsevier Science Ltd. All rights reserved.

Manual Therapy (2003) 8(2), 97–102

Quantitative analysis of traction 101

for all subjects. Additionally, prior to the measurements all subjects performed 20 cycles of active arm elevation to precondition the soft tissue and reduce variations caused by the viscoelastic properties of the shoulder joint (Bigliani et al. 1992; Panjabi et al. 1994). The traction force was applied for 40 s before taking the radiograph. It was decided to use 40 s because when stretching muscle–tendon units for 30 s under laboratory conditions an increase in length occurs (Taylor et al. 1990). The traction force used was 14 kg because it was assumed that this force would be sufficient to produce a Grade 3 traction and an increase in distance between the humeral head and the glenod fossa should occur. Additionally, 14 kg was the highest force used by manual therapists clinically, as measured in the preliminary study. Finally, 14 kg of traction was thought to be well within the zone of safety, Reeves (1968) demonstrated that forces of 26.8–61.7 kg are necessary to rupture the glenohumeral capsule or the glenoid labrum. Abduction of 451 in the plane of the scapula was operationalized as the MLPP since it has been demonstrated that the capsulo-ligamenteous structures are the loosest in this position (Warner et al. 1992). This position seems to be similar to the MLPP described by Kaltenborn (1985) and has the advantage that it can be reproduced more easily under research conditions. Clinically, after a standard examination of the glenohumeral joint, manual therapists perform additional tests such as a joint distraction test. The magnitude and the end-feel of traction aids in the diagnostic process and in decision making about therapeutic interventions. In spite of the use of traction in daily practice, validity and reliability tests have not been carried out to the best of our knowledge. Our results indicate that it is unlikely that joint distraction occurs in a clinical situation in healthy glenohumeral joints. It has been stated that in the MLPP the greatest amount of joint separation is possible, relative to the MCPP, but the amount of separation has not been quantified (Kaltenborn 1985; Mink et al. 1990; Frisch 1996). Dvorak and coworkers (Dvorak et al. 1997) stated that up to 5 mm of separation is normal in the MLPP during joint play testing without providing evidence for the statement. The results of the current study do not support these statements because no increase in distance between the humeral head and the glenoid fossa occurred, in the MLPP or in the MCPP (Tables 2 and 3) when 14 kg of traction was applied. Joint play testing is performed with one hand of the therapist grasping the upper arm applying the traction while the other hand ‘fixates’ the scapula by holding the acromion and coracoid process (Kaltenborn 1985; Mink et al. 1990; Frisch 1996; Dvorak et al. 1997). The traction forces applied during joint play testing are probably less than the Manual Therapy (2003) 8(2), 97–102

14 kg applied in the current study. This may indicate that in a clinical setting the increase in distance between the humeral head and the glenoid fossa during traction are even less than that found in the current study. It is our impression that it is mainly soft tissues that are moved during traction and that in spite of the therapist’s feeling of a ‘joint separation’, no such separation occurs. Although this study was performed under standardized conditions it must be recognized that it was not possible to fixate the scapula entirely during testing, especially with the shoulder in 901 abduction, despite the maximal manual force applied by the assistant. However, the results of this study are probably not influenced by this inability to fixate the scapula because the distance between humeral head and glenoid fossa were measured on each separate radiograph. Further, the inability to fixate the scapula adequately during the experiment is probably similar to therapeutic conditions because the therapist fixates the scapula with a belt as well as performing the traction. No significant differences were found in the mean distance between the humeral head and the glenoid fossa during traction in the MLPP compared to traction in the MCPP (O1: P=1.00) and (O2: P=0.63). This questions the use of the MLPP for joint play testing using traction based on the fact that a mean increase of 0.3 mm (O1) during traction was found. We are confident that such subtle motions cannot be detected manually through the soft tissues surrounding the glenohumeral joint. This paper cannot answer the question whether hypomobility or hypermobility can be assessed with traction as only healthy shoulders were included in this study. Although it was not the aim of this study to describe the stabilizing factors acting on the shoulder joint, it appears that these stabilizing factors are sufficient to prevent separation with manual traction. Of particular interest may be the stabilizing effect of negative intra-articular pressure (NIP). Measurements of the NIP in 15 cadaver shoulders revealed that NIP changes depending on the position of the glenohumeral joint. Mean values ranged from 82.9 mmHg at 201 abduction to approximately 10 mmHg at 801 abduction (Inokuchi et al. 1997). Warner and co-workers demonstrated that NIP is not important for inferior stability at 451 abduction (Warner et al. 1992). It is uncertain at this time what the effect of NIP is on resistance against traction. It may be possible that NIP is able to resist larger than the traction forces used in this study, thereby preventing an increase in distance between the humeral head and glenoid fossa. However, the studies mentioned have analysed the effect of NIP on translations (Warner et al. 1992; Inokuchi et al. r 2003 Elsevier Science Ltd. All rights reserved.

102 Manual Therapy

1997). Therefore, the effects of NIP on traction are unknown. Several limitations of the current study should be taken into consideration. The study sample was only six subjects and as a result the chance of a type 2 error is considerable. However, looking at the results in Tables 2 and 3, the mean differences are very small and these differences might become statistically significant in a larger study. The clinical relevance of these small differences remains questionable. Secondly, muscle guarding may have been a source of error in this study but none of the volunteers mentioned that the traction was uncomfortable or that they could not relax. Thirdly, the intra-tester reliability of the radiologist was analysed using the ttest for paired observations. The difference between O1 and O2 was significant (Table 1). However, the mean difference between the values on the first occasion and the second occasion was only 0.4 mm. The clinical relevance of this difference is doubtful. Further, of the 24 paired observations, 22 demonstrated a difference between the first and the second observation of only 1 mm or less.

CONCLUSION Application of a 14 kg traction force to the humerus does not result in a significant increase in the distance between the humeral head and the glenoid fossa in a healthy shoulder joint.

Acknowledgements Technical support from Otto Bock Company, Duderstadt, Germany and the assistance of Bert Corbiere and the members of the IAOM is gratefully acknowledged. We thank Dr. Michael


Lehmann and Elmar Knopf for reviewing the manuscript. No financial support was received for this study.

References Bigliani LU, Pollock RG, Soslowsky LJ 1992 Tensile properties of the inferior glenohumeral ligament. Journal of Orthopedic Research 10: 197–197 Dvorak J, Dvorak V, Schneider W, Spring H, Tritschler T 1997 Manuelle Medizin. Diagnostik, 5th edn. Georg Thieme Verlag, Stuttgart, New York, 240pp European Commission. Guidelines for refererral for diagnostic radiology. Europese Commissie Richtsnoeren voor verwijzing naar beeldvormend Onderzoek Bureau voor offici.ele publicaties der Europese Gemeenschappen, Stralingsbescherming 118 Luxemburg, 2000 Frisch H 1996 Programmierte Therapie am Bewegungsapparat. Chirotherapie, 2nd edn, Springer Verlag, Berlin Gielen J, Matthijs O, van Paridon-Edauw GH, Phelps V, Winkel D 1993. Unpublished data Inokuchi W, Sanderhoff B, Sojberg JO, Sneppen O 1997 The relation between the position of the GHJ and the intra-articular pressure: an experimental study. Journal of Shoulder and Elbow Surgery 6: 144–149 Kaltenborn FM 1985 Mobilization of the Extremity Joints, 3rd Edn. Olaf Norlis Bokhandel, Oslo, Norway Mink AJF, Veer ter HJ, Vorselaars JAC 1990 Extremiteiten. Functie-onderzoek en manuele therapie, 6th edn. Bohn, Scholtema en Holkema, Utrecht/Antwerpen Panjabi MM, Oxland TR, Yamamoto I, Crisco JJ 1994 Mechanical behavior of the human lumbar and lumbosacral spine as shown by three-dimensional load–displacement curves. Journal of Bone and Joint Surgery 76-A: 413–424 Petersson CJ, Redlund-Johnell I 1983 Joint space in normal gleno-humeral radiographs. Acta Orthopaedica Scandinavica 54: 274–276 Reeves BJ 1968 Experiments on the tensile strength of the anterior capsular structures of the shoulder in man. Journal of Bone and Joint Surgery 50-B: 858–865 Taylor DC, Dalton JD, Seaber AV, Garrett WE 1990 Visco elastic properties of muscle-tendon units. The biomechanical effects of stretching. American Journal of Sports Medicine 18: 300–309 Warner JJP, Deng X-H, Warren RF, Torzilli PA 1992 Static capsuloligamenteous restraints to superior–inferior translation of the glenohumeral joint. American Journal of Sports Medicine 20: 675–685

Manual Therapy (2003) 8(2), 97–102


Orginal article

The effect of cervical rotation on blood flow in the contralateral vertebral artery C. Zaina*, R. Grantw, C. Johnsonn, B. Dansiez, J. Taylory, P. Spyropolousy Private Practitioner, South Australia, w Division of Health Sciences, University of South Australia, z School of Mathematics, University of South Australia, y Department of Radiology, Royal Adelaide Hospital, South Australia

n

SUMMARY. Twenty asymptomatic volunteers (mean age 33 years, range 26 – 54 years) underwent investigation using duplex Doppler ultrasound with real-time imaging and colour flow enhancement. With the subjects seated, peak velocity at C1-2 and volume flow rate at C5-6 were measured in the artery contralateral to the direction of rotation, in the four positions of neutral, 451 and end range rotation, plus a subsequent neutral position. No change in peak velocity at C1-2 between the initial neutral measurement and the measurements at 451 and end range rotation was found (P>0.05). Peak velocity was less in both vertebral arteries on return to the neutral position as compared with end range rotation, however the difference was significant for the left vertebral artery only (P=0.005). This lends support for the rest period, which is taken between cervical movement tests when conducting pre-manipulative testing, to allow for any latent effect on blood flow of the tests themselves. There was no change in volume flow rate between any of the test positions (P=0.349). There was no indication of a cumulative effect of the test procedure (P>0.05). r 2003 Elsevier Science Ltd. All rights reserved.

indication to a manipulative thrust technique but also to end range passive rotation techniques in treatment. In 1988 following work by Grant (1987, 1988), the Australian Physiotherapy Association formalized a Protocol for Pre-manipulative testing of the cervical spine. Recently, following a survey of manipulative physiotherapists, extensive consultation and consideration of VA blood flow studies, a somewhat modified and expanded set of Clinical Guidelines for Pre-manipulative Procedures of the Cervical Spine (2000) have been developed and accepted by the APA/MPA and represent an evolution of the APA Protocol for Pre-manipulative Testing of the Cervical Spine (1988, Grant 1988). The minimum mandatory movement test under these clinical guidelines is sustained cervical rotation to each side. The effects of sustained rotation on vertebral artery blood flow remain somewhat conflicting (Refshauge 1994, Thiel et al. 1994, Cote et al. 1996, Licht et al. 1998a, b, Rivett et al. 1998, Licht et al. 1999a, b, Licht et al. 2000, Rivett et al. 2000). To an important extent this is dependent upon a number of methodological factors—including whether the method used had established reliability, which blood flow parameter(s) were used, at what level the VA blood flow was measured, which movements and/or combi-

INTRODUCTION Vertebral artery testing has been a part of screening undertaken by physiotherapists for over 30 years. Maitland in 1968 was the first physiotherapist to describe such testing which at that time consisted of sustained cervical rotation to both sides. The onset of dizziness in particular, but any of the symptoms suggestive of VBI, was considered not only a contra-

Received: 9 April 2002 Revised: 14 October 2002 Accepted: 11 December 2002 Cassandra Zaina, B App Sc (Physio), M App Sc (Manip Ther), Clinical Lecturer (part-time), School of Physiotherapy, University of South Australia and Private Practitioner, Adelaide, South Australia, Ruth Grant, Dip Physio BPT, M App Sc, Grad Dip Adv Manip Ther, Pro-Vice Chancellor, Division of Health Sciences, University of South Australia, Catherine Johnson, B App Sc (Physio), M App Sc (Manip Ther), Private Practitioner, Malvern, South Australia, Brenton Dansie, BSc (Hons), PhD, Head, School of Mathematics, University of South Australia, James Taylor, MBBS, FRACR, Department of Radiology, Royal Adelaide Hospital, South Australia, Peter Spyropolous, Assoc Dip Rad Tech, DMU, Department of Radiology, Royal Adelaide Hospital, South Australia. Correspondence to: CZ, 53 Ormond Grove, Toorak Gardens Adelaide, SA 5065, Australia. E-mail: [email protected] 103

104 Manual Therapy

Critical level

Volume flow rate

Velocity

Increasing stenosis

Fig. 1—The relationship between vessel narrowing, blood velocity and volume flow rate. Modified from Spencer and Reid (1979, p. 329) Reproduced with kind permission of the publishers of Stroke: A Journal of Cerebral Circulation (American Heart Association).

nation of movements were studied, whether one or both vertebral arteries were measured, whether subjects were tested in sitting or supine, whether subjects were symptomatic or asymptomatic, the type of ultrasound equipment used and the level of expertise of the ultrasonographer employed. In 2000, our research group reported the development of a reliable and comprehensive method of measurement of vertebral artery blood flow which incorporated the measurement of peak velocity of blood flow at C1-2, the level of maximum rotation and potential maximum stress on the contralateral vertebral artery, and the measurement of volume flow rate at C5-6 (Johnson et al. 2000). Both measurements should be undertaken to allow a full understanding of the impact of cervical movement on VA blood flow. That is to identify whether a change in peak velocity in the narrowed portion of the VA is sufficient to maintain volume flow rate, or whether the artery is narrowed past the critical level after which changes in blood velocity are unable to maintain a constant volume flow rate and hence blood flow through the vessel is compromized (Spencer & Reid 1979; Zierler 1990; Arbeille et al. 1995). The relationship between these measurements is represented graphically in Fig. 1 (Modified from Spencer & Reid 1979). The current study had the following aims: 1. To investigate the effect of cervical rotation on the peak velocity of blood flow in the contralateral vertebral artery at the level of C1-2. 2. To investigate the effect of cervical rotation on the volume flow rate in the contralateral vertebral artery at the level of C5-6. 3. To investigate whether there was a cumulative effect of the test procedures on these blood flow parameters. r 2003 Elsevier Science Ltd. All rights reserved.

METHOD Ethical approval for this study was granted by the Human Research Ethics Committee of the University of South Australia. Twenty subjects (with a mean age of 32.7 years, SD 8.82 years) were drawn from individuals who volunteered for the study, and who met the essential criteria. Subjects were excluded if they described symptoms of possible VBI origin, cervical pain or stiffness in the preceding 3 months, cardiac problems, pregnancy, known hypotension or hypertension, or were taking medication that may affect blood pressure or haemodynamics of VA flow. Prior to testing, all subjects rested for 15 min to promote haemodynamic stabilization (Brown et al. 1993; Zananiri et al. 1993). Subjects were tested in the sitting position, a position frequently employed clinically for pre-manipulative testing of the cervical spine. Ultrasound evaluation was undertaken using methods previously established to be reliable in our laboratory (Johnson et al. 2000) and using the same ultrasonographer and protocol as in Johnson’s study. This comprised a series of three measurements of peak velocity at C1-2 and a single measurement of volume flow rate at C5-6. (Reliability of these parameters had been previously established—see Johnson et al. 2000; C1-2, ICC of 0.73 deemed ‘fair’ reliability and C5-6, ICC of 0.81 deemed ‘good’ reliability, Blesh 1974). Data were collected for these blood flow parameters in the neutral head position, in 451 rotation and in full range rotation, and on return to neutral head position. These parameters were taken for blood flow in the artery contralateral to the direction of rotation. Both cervical rotations were measured, with the first direction randomly allocated. An ATL colour duplex Doppler HDI 3000 machine with a 7 MHz linear array transducer was used to collect the data.

RESULTS No potential VBI or other symptoms were reported by any subject throughout the procedure. No significant differences were found in the mean diameters of the VAs when comparing left to right, as measured at the level of C5-6 (mean diameter of VA: left= 0.34470.043 cm, right=0.31070.06 cm; P=0.095). The effect of cervical rotation on peak velocity of blood flow in the contralateral VA at C1-2 A repeated measures ANOVA with one within subject factor of repetition was performed for the data sets of the first period (viz. measurements taken in the first direction of rotation), to identify any Manual Therapy (2003) 8(2), 103–109

repetition effect that may have occurred from the three measurements. This was not significant in any position (P>0.05) and hence calculation was continued using the mean of three measurements for peak velocity at C1-2 in each position. Analysis was then undertaken to ascertain whether there was an order effect with respect to rotation. A repeated measures ANOVA with an ‘order’ factor (left rotation followed by right rotation or vice versa) and a ‘period’ factor (first measurement period with first direction of rotation, second measurement period with second direction of rotation) was undertaken along with the main factors of interest, namely the ‘left/right’ rotation factor and a ‘position’ factor (neutral, 451, end of range and neutral). No statistically significant main effects due to order (P=0.19), period (P=0.52) or between order and position (P=0.23) or between period and position (P=0.52) were found. Order and period factors were consequently removed from the analysis and the main factors of interest, namely the direction of cervical rotation and the position of the head, were analysed using a two-factor repeated measures ANOVA. Further analysis revealed that the usual assumptions for applying the ANOVA procedure were more reasonable for the logarithmic data than they were for the raw data, since the distribution against the fitted values was more uniform. Consequently, the remaining analysis was based on ANOVA for the logarithms of peak velocity at C1-2, as the variance is more consistent and independent of velocity for logarithms of peak velocity at C1-2 when compared with the original method, viz. a repeated measures ANOVA using the raw data. Since ‘repetition’ of peak velocity at C1-2 had been shown to have no significant effect, nor had ‘period’ and ‘order’, data were then combined across period and order, and a one-way repeated measures ANOVA with two within subject factors (‘position’ and ‘left/right’) was performed. Head ‘position’ had a significant interaction effect (P=0.027) whilst the interaction between the ‘left/ right’ rotation factor and the ‘position’ factor was close to significance (P=0.056). The means and standard deviations of the logarithms of peak velocity at C1-2 for the left and right VAs in each of the four positions is presented in Fig. 2. This highlights the difference between the left and right VAs in the behaviour of peak velocity at C1-2 in each position. Figure 2 reveals that there was no pattern for peak velocity at C1-2 to increase at 451 of contralateral rotation and decrease at end range contralateral rotation in the left or the right VA. Peak velocity of blood flow was found to be less in both VAs on return to the neutral position as compared with end range rotation, however the difference was significant for the left VA only (P=0.005). This is well illustrated in Fig. 2. Manual Therapy (2003) 8(2), 103–109

Mean logarithms of peak velocity at C1-2 (cm/s)

Effect of cervical rotation 105

Left VA

4.4

Right VA

4.3 4.2 4.1 4 3.9 3.8 3.7 N

45

ER

N

Test Seq uence Fig. 2—The effect of the test sequence on the peak velocity blood flow at C1-2. Means of the logarithms of peak velocity and the standard deviations (Tukey least significant difference) are given for both VAs in N (neutral), 45 (451 contralateral rotation) and ER (end of range contralateral rotation) positions.

The effect of cervical rotation on volume flow rate in the contralateral VA at C5-6 A two-way repeated measures ANOVA was conducted with two between subject factors, namely ‘order’ of rotation and ‘period’ (first rotation compared with the second), and ‘left/right’ (direction of rotation). No significant changes in volume flow rate were demonstrated when considering all interaction factors. Figure 3 illustrates the behaviour of volume flow rate at C5-6 in the VAs with the test sequence. There was no significant change in volume flow rate at C5-6 (P=0.349). It is noted that for the left VA, there is a trend for volume flow rate to decrease at end range however this was not significant. Cumulative effect of the test sequence on peak velocity of blood flow at C1-2 and volume flow rate at C5-6 in the contralateral VAs Cumulative effect was determined by the analysis of the values of these parameters in the three neutral head positions (pre,-mid-and end-test sequence). Two-way repeated measures ANOVAs with one between subject factor of ‘order’ (of rotation) and one within subject factor of ‘neutral 3’ (pre,-mid-and end-test measurements in neutral) of peak velocity at C1-2, and volume flow rate at C5-6 were conducted to determine the presence, if any, of a cumulative effect of repeated rotational positioning on these blood flow parameters. No significant effect of repeated rotation positioning on VA blood flow parameters of peak velocity at C1-2 and volume flow rate at C5-6 was found. r 2003 Elsevier Science Ltd. All rights reserved.

Mean volume flow rate at C5-6 (ml/min)

106 Manual Therapy

Left VA

120 110 100 90 80 70 60 50 40 30 N

45

Right VA

ER

N

Test sequence Fig. 3—The effect of the test sequence on the volume flow rate in the VAs at C5-6 (ml/min). Means for volume flow rate at N (neutral), 45 (451 contralateral rotation) and ER (end of range contralateral rotation) positions are given.

DISCUSSION The relatively recent development of colour Duplex Doppler ultrasound provides the most informative method of sampling blood flow in the vertebral arteries. The relevant current literature is now discussed and results compared with the findings of this study. The effect of cervical rotation on peak velocity of vertebral artery blood flow at C1-2 No significant change in peak velocity in the contralateral artery at C1-2 either at 451 or at end range rotation from the initial pre-test measurement in neutral, was found. The subject sample comprised young asymptomatic volunteers (mean age 32.7 years, SD 8.8 years) and perhaps it is not unexpected to observe a non-significant change in vessel haemodynamics. Comparison with Refshauge’s work (Refshauge 1994) is appropriate, however there are fundamental differences between the studies, so comparisons are made with caution. The differences include the following points. Refshauge sampled peak frequency (a function of peak velocity) at the C2-3 level. This parameter was found to be unreliable and technically difficult to obtain in a study by Johnson et al. (2000)(ICC=0.37). Furthermore, since the measurements were sampled at C2-3, i.e. upstream from the narrowed segment of the VA (viz. C1-2), changes in blood velocity may not be detected. That said, Refshauge’s study was similar to the current study as the subject sample was asymptomatic, and the effect of cervical rotation was assessed using a function of peak velocity of VA flow. Peak velocity at C1-2 for the right VA behaved in a similar fashion to that shown by Refshauge (1994). That is, there was a decrease at 451 and a further decrease at end range rotation. Peak velocity in the r 2003 Elsevier Science Ltd. All rights reserved.

left VA increased at 451 in both studies. At end of range however, the current study showed a further increase in peak velocity, which was not significant, whilst Refshauge (1994) found a significant decrease in velocity. It may be hypothesized that since the supine position was used by Refshauge (1994) as compared to the current study, this may well have provided greater relaxation and permitted a larger range of passive cervical rotation, in turn narrowing the VA sufficiently past the critical level to result in a decrease in blood velocity at end range rotation. Rivett et al. (1999) used the same measurement parameters as Refshauge (1994) and also sampled flow rate parameters at C2-3. These authors investigated the effect of contralateral rotation and combined contralateral rotation/extension on two groups of subjects in supine, one group exhibiting VBI symptoms upon testing, and the other being asymptomatic. Like Refshauge, they found that peak velocity of VA blood flow decreased with contralateral rotation, further decreasing at end range. There was no significant difference between the symptomatic and asymptomatic groups. The 2000 study by Rivett et al. used the same parameters, but this time they sampled at the level of C1-2, in 100 subjects comprising two groups—asymptomatic and symptomatic. Rivett et al. (2000) identified that while the positions of end range contralateral rotation and combined contralateral rotation/extension can occlude the VA, this was not consistently associated with VBI symptoms (only two of 20 patients where partial or complete occlusion of the VA was demonstrated experienced VBI symptoms). Hence these test movements may not predict possible damage to the VAs due to stretching/narrowing with cervical movements. Licht et al. (1998a, b, 1999a, 2000) sampled the VA blood flow in the first part of the VA, specifically between its origin at the subclavian artery and its point of entry into the C6 transverse foramen. This is a suitable site to sample volume flow rate, as there should be minimal morphological alteration to the vessel at this point and consequent turbulence of blood flow which would maximize the reliability of measurement. However, the sampling site is too far upstream to detect changes in velocity of blood flow occurring with narrowing of the VA at C1-2 with cervical rotation. During pre-manipulative testing patients are returned to the neutral cervical position and maintained there for 10 s following each end range test position, to allow for any latent onset of symptoms. Latent symptoms may be a result of altered haemodynamics following the application of the test movements. Partial support was found for this clinical approach in that there was a pattern of reduced peak velocity at C1-2 on return to the neutral position compared with the end range rotation Manual Therapy (2003) 8(2), 103–109


position for both VAs, however it was significant only for the left VA. A review of the literature has failed to indicate why this decrease in peak velocity may have occurred between end range rotation and the subsequent neutral position in young asymptomatic subjects. The angiographic study of Faris et al. (1963) showed that in some asymptomatic individuals, when a vessel was occluded on contralateral rotation, the vessel failed to fill with blood immediately once returned to the neutral position. However, there was no elaboration as to why this might be so. It could be hypothesized that longitudinal stress applied to the VA at C1-2, such as occurs with end range cervical rotation, results in strain of the elastic fibres within the arterial wall. This may create a creep effect as for other elastic tissue (McGill 1997), hence requiring a period of time to normalize once the stress is released. This would suggest that following rotation, once the neutral position is regained, the lengthened elastic tissue would allow the vessel to expand crosssectionally, until the original elastic fibre length is restored. This would effectively increase the diameter of the VA, with a concomitant reduction in peak velocity. Once the elastic fibres have returned to their original length, the peak velocity would be restored to its original resting value. Further research could elucidate the average time required for peak velocity of VA blood flow to return to pretest levels following sustained contralateral end range rotation. Such research may indicate the optimal rest period required between test positions to ensure that peak velocity of VA blood flow has ‘settled’ prior to undertaking tests in the subsequent positions, or indeed moving on to cervical manipulation or other treatment. The effect of cervical rotation on volume flow rate of vertebral artery blood flow at C5-6 No significant change in volume flow rate at C5-6 was found as a result of cervical rotation. As there was no significant change in peak velocity at C1-2 at full rotation compared with the initial neutral measurement, this is not surprising. These results may indicate that in the healthy, asymptomatic individual, there is minimal change to VA volume flow rate with cervical rotation. It may be the case that greater amounts of rotation are required, such as may occur if the subject is tested in supine rather than sitting, where greater relaxation of the subject may promote increased range of cervical rotation and hence place more stress on the contralateral VA. Alternatively, a combination of cervical movements may be required to further stress the VA, for example, combined rotation/extension. Volume flow rate measurements undertaken by Licht et al. (1999a) in the first part of the VA were Manual Therapy (2003) 8(2), 103–109

conducted with the subject’s head in neutral, in 451 rotation and end-range rotation to either side. These authors found no significant difference in volume flow rate between any cervical positions and this lends support to the findings of the current study. Cumulative effect of the test procedure on vertebral artery blood flow Several authors have raised the possibility of a cumulative effect on blood flow parameters in the VAs with pre-manipulative protocol testing procedures (Terrett 1983; Grieve 1994, Meadows & Magee 1994; Grant 1996). In our laboratory, Schmidt et al. (unpublished) investigated this possibility by sampling peak velocity at C1-2 and volume flow rate at C5-6 before and after the application of the APA Protocol for Pre-manipulative Testing of the Cervical Spine (minus the simulated manipulation position). They found no significant changes in volume flow rate or peak velocity following the application of the pre-manipulative protocol in young asymptomatic volunteers. The current study included this analysis to contribute to the body of knowledge regarding the possibility of a cumulative effect. It must be acknowledged that the test sequence undertaken comprised only a portion of the APA Protocol for Premanipulative Testing of the Cervical Spine (1988) and as such was hypothesized to provide less stress on the VAs and hence a reduced cumulative effect if such existed. However, there were more repetitions of rotational positioning in our test procedures compared with the Protocol (four repetitions, vs one in each direction) and positions were also sustained for a greater period of time due to the requirements of data collection (approximately 90 vs. 10 s hold in the clinical setting). Despite the potential additional stresses on the VAs deriving from the methodology of this current study, no significant difference in peak velocity at C12 or volume flow rate at C5-6 between any of the three neutral measurements was found. This finding identified that the movements of the test sequence provided minimal risk of a cumulative effect upon VA blood flow in this sample of asymptomatic volunteers. Consideration of different patterns of blood flow in the left and right vertebral arteries on rotation The results of this study suggest that with contralateral rotation, the response of peak velocity in the left and right VA may behave differently. Other published research has provided some support for a different pattern of behaviour for blood flow parameters in the left and right VAs but no consistent r 2003 Elsevier Science Ltd. All rights reserved.

108 Manual Therapy

pattern emerges (Refshauge 1994, Stevens 1984; Rivett et al. 1998, 1999). It may be that the size of the VA is a contributing factor, since it is widely documented that the left VA is in general, larger than its counterpart (Scialfa et al. 1975; Cameron & Browning 1982; Thiel et al. 1994; Hedera 1995; Weintraub & Khoury 1995). It is not clear as to why this asymmetry exists, and theories of embryological formation and vascular requirements of the brain have been put forward without evidence. However in the studies where lumen diameter has been reported (Refshauge 1994; Rivett et al. 1998) there was no significant difference between the left and right VAs, yet there was a difference in pattern of blood flow response. In the current study too, although there was a tendency for lumen diameter, peak velocity at C1-2 and volume flow rate at C5-6 to be greater in the left VA compared with its counterpart, there was no significant difference (P=0.095, 0.062 and 0.117 respectively). This suggests that there may be reasons other than vessel size for the different patterns of blood flow within the left and right vessels, and as such could provide a basis for further research.

CONCLUSION In this study of the effects of cervical rotation on blood flow in the contralateral vertebral artery, no significant differences overall were found in the blood flow parameters of peak velocity at C1-2 and volume flow rate at C5-6 at 451 rotation or end range rotation. However, a significant reduction in peak flow velocity at C1-2 in the left VA occurred between end range rotation to the right and return to the neutral position. Although not significant, a similar pattern was evident in the right VA, on return to neutral from left rotation. Whilst this finding needs demonstrating in a sample which includes both symptomatic and asymptomatic subjects it does begin to provide support for the rest period on return to neutral from cervical end range rotation. This rest period of 10 s is a feature of pre-manipulative testing protocols and guidelines and is carried out clinically in order to identify any latent effects of cervical spine positioning. No cumulative effect from repeated rotational positioning on either peak velocity at C1-2 or volume flow rate at C5-6 was found in this young asymptomatic sample. This has clinical relevance given the concerns held by some that the pre-manipulative tests themselves might have a morbid effect on the VAs.

References Arbeille P, Desombre C, Aesh B, Philippot M, Lapierre F 1995 Quantification and assessment of carotid artery lesions: degree r 2003 Elsevier Science Ltd. All rights reserved.

of stenosis and plaque volume. Journal of Clinical Ultrasound 23: 113–124 Australian Physiotherapy Association 2000 Clinical guidelines for pre-manipulative procedures of the cervical spine. Australian Physiotherapy Association, PO Box 6465, St Kilda Road Central, Melbourne Victoria 8008, Australia Australian Physiotherapy Association 1988 Protocol for premanipulative testing of the cervical spine. Australian Journal of Physiotherapy 34: 97–100 Blesh TE 1974 Measurements in Physical Education, 2nd edn. Ronald Press, New York Brown SP, Li H, Chitwood LF, Anderson ER, Boatwright D 1993 Blood pressure, hemodynamic, and thermal responses after cycling exercise. Journal of Applied Physiology 75: 240–245 Cameron I, Browning S 1982 The vertebral artery. British Osteopathic Journal 14: 11–18 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: 159–163 Faris AA, Poser CM, Wilmore DW, Agnew CH 1963 Radiologic evaluation of neck vessels in healthy men. Neurology 13: 386–396 Grant R 1987 Clinical testing before cervical manipulation—can we recognise the patient at risk? Proceedings of the Tenth International Congress of the World Confederation for Physical Therapy, Sydney, p 192 Grant R 1988 Dizziness testing and manipulation of the cervical spine. In: Grant R (ed.) Physical Therapy of the Cervical and Thoracic Spine, 1st edn. Churchill Livingstone, New York, pp 111–124 Grant R 1996 Vertebral artery testing—the Australian Physiotherapy Association Protocol after 6 years. Manual Therapy 1: 149–153 Grieve GP 1994 Incidents and accidents of manipulation and allied techniques. In: Boyling JD, Palastanga N (eds) Grieve’s Modern Manual Therapy: The Vertebral Column, 2nd edn. Churchill Livingstone, Edinburgh Hedera P 1995 Influence of extreme head rotations on brainstem auditory evoked potential. Clinical Neurology and Neurosurgery 97: 290–295 Johnson C, Grant R, Dansie B, Taylor J, Spyropolous P 2000 Measurement of blood flow in the vertebral artery using colour duplex Doppler ultrasound: establishment of the reliability of selected parameters. Manual Therapy 5(1): 21–29 Licht PB, Christensen DC, Hoilund-Carlsen PF 2000 Is there a role for premanipulative testing before cervical manipulation? Journal of Manipulative and Physiological Therapeutics 23(3): 175–179 Licht PB, Christensen DC, Hoilund-Carlsen PF 1999a Vertebral artery volume flow in human beings. Journal of Manipulative and Physiological Therapeutics 22(6): 363–367 Licht PB, Christensen DC, Hojgaard P, Hoilund-Carlsen PF 1998a Triplex ultrasound of vertebral artery flow during cervical rotation. Journal of Manipulative and Physiological Therapeutics 21(1): 27–31 Licht PB, Christensen DC, Hojgaard P, Marving J 1998b Vertebral artery flow and spinal manipulation: a randomized, controlled and observer-blinded study. Journal of Manipulative and Physiological Therapeutics 21(3): 141–144 Licht PB, Christensen DC, Svenden P, Hoilund-Carlsen PF 1999b Vertebral artery flow and cervical manipulation: An experimental study. Journal of Manipulative and Physiological Therapeutics 22(7): 431–435 Maitland GD 1968 Vertebral Manipulation, 2nd edn. Butterworths, London McGill S 1997 The biomechanics of low back injury: implications on current practice in industry and the clinic. Journal of Biomechanics 30 (5): 465–475 Meadows JTS, Magee DJ 1994 An overview of dizziness and vertigo for the orthopaedic manual therapist. In: Boyling JD, Palastanga N (eds) Grieve’s Modern Manual Therapy: The Vertebral Column, 2nd ed. Churchill Livingstone Edinburgh Refshauge KM 1994 Rotation: a valid premanipulative dizziness test? Does it predict safe manipulation? Journal of Manipulative and Physiological Therapeutics 17: 15–19 Manual Therapy (2003) 8(2), 103–109


Rivett DA, Milburn PD, Chapple C 1998 Negative pre-manipulative vertebral artery testing despite complete occlusion: a case of false negativity? Manual Therapy 3(2): 102–107 Rivett DA, Sharples KJ, Milburn PD 1999 Effect of premanipulative tests on vertebral artery and internal carotid artery blood flow: A pilot study. Journal of Manipulative and Physiological Therapeutics 22(6): 368–375 Rivett DA, Sharples KJ, Milburn PD 2000 Vertebral artery blood flow during pre-manipulative testing of the cervical spine. In: Singer KP (ed.) Proceedings of the 7th Scientific Conference of the IFOMT in conjunction with the MPAA. The University of Western Australia, Perth, Australia November 2000. Scialfa G, Ruggerio G, Salamon G, Mochotey P 1975 Post mortem investigation of the vertebrobasilar system. Acta Radiologica Suppl 357: 259–286 Spencer MP, Reid JM 1979 Quantitation of carotid stenosis with continuous-wave (C-W) Doppler Ultrasound. Stroke 10: 326–330 Stevens AJ 1984 Doppler sonography and neck rotation. Journal of Manual Medicine 1: 49–53

Manual Therapy (2003) 8(2), 103–109

Terrett AGJ 1983 Importance and interpretation of tests designed to predict susceptibility to neurocirculatory accidents from manipulation. Journal of the Australian Chiropractors’ Association 13: 29–33 Thiel AW, 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 Weintraub MI, Khoury A 1995 Critical neck position as an independent risk factor for posterior circulation stroke. A magnetic resonance angiographic analysis. Journal of Neuroimaging 5: 16–22 Zananiri FV, Jackson PC, Halliwell M, Harris RA, Hayward JK, Davies ER, Wells PNT 1993 A comparative study of velocity measurements in major blood vessels using magnetic resonance imaging and Doppler ultrasound. The British Journal of Radiology 66: 1128–1133 Zierler RE 1990 Haemodynamic Considerations in evaluation of arterial disease by doppler ultrasound. In: Taylor KJW, Strandness DE (eds) Duplex Doppler Ultrasound. Churchill Livingstone, New York


Manual Therapy (2003) 8(2), 110–116 r 2003 Elsevier Science Ltd. All rights reserved. 1356-689X/03/$ - see front matter doi:10.1016/S1356-689X(02)00156-X

Original article

Adherence to rehabilitation in patients with low back pain G. S. Koltn, J. F. McEvoyw Faculty of Health, Auckland University of Technology, New Zealand, w West Suburban Sports Medicine Centre, Australia

n

SUMMARY. This study investigated adherence to low back pain rehabilitation in the clinical setting. Adherence was assessed in 105 (71 male and 34 female) patients attending private physiotherapy clinics for rehabilitation of low back pain. Three aspects of adherence were measured over the 4-week study period: attendance at clinic-based rehabilitation sessions, adherence to a home exercise component of rehabilitation, and adherence to activities and advice during clinic-based rehabilitation. Rehabilitation outcome was measured using the Patients’ Measure of Perceived Rehabilitation (McDonald & Hardy 1990) and the Physiotherapists’ Measure of Perceived Rehabilitation (McDonald & Hardy 1990). It was found that patients attended 87.7% of their scheduled physiotherapy rehabilitation appointments and reported completing 71.6% of their prescribed home exercises. In relation to adherence to clinic-based rehabilitation activities (as measured by the Sport Injury Rehabilitation Adherence Scale, Brewer et al. 2000), patients scored an average of 11.6/15. Although no gender differences were found, compensable patients adhered significantly less to clinic-based rehabilitation activities than did their noncompensable counterparts. Further, it was found that higher levels of adherence to clinic-based activities significantly predicted both the patients’ and physiotherapists’ perception of degree of rehabilitation at the end of the 4-week rehabilitation period. These findings are discussed in relation to rehabilitation strategies for physiotherapists. r 2003 Elsevier Science Ltd. All rights reserved.

(Goldby 1997). A further report indicated that up to 80% of all adults will have significant back pain over the course of their lives (Lanes et al. 1995). These statistics are further amplified by estimates of recurrence of low back pain being as high as 85% (Binkley et al. 1993). Therefore, establishing the efficacy of treatment for such conditions is paramount. Therapeutic exercise, as part of the rehabilitation for patients with low back pain, is one of the treatment modalities most commonly used by physiotherapists (Martin et al. 1986; Schneiders et al. 1998). The effectiveness of physiotherapy, however, is reliant on the adherence of patients to its various components. Research has demonstrated a positive relationship between adherence to rehabilitation programs and recovery from a variety of musculoskeletal conditions (Derscheid & Feiring 1987; Rives et al. 1992; Hawkins & Switlyk 1993; Ettinger et al. 1997; Rejeski et al. 1997; Treacy et al. 1997; Brewer et al. 2000). Only a small literature, however, has focused on adherence to rehabilitation for low back

INTRODUCTION Physiotherapy is primarily concerned with the rehabilitation of people from injury. Physiotherapists, it has been estimated, spend 40% of their professional time treating patients with low back pathology (Goldby 1997). This is not surprising, given that that low back pain is a pathology that is endemic to the Western world, and is experienced by an estimated 60% of people at some time in their lives Received: 12 June 2002 Revised: 16 October 2002 Accepted: 11 December 2002 Gregory S. Kolt, PhD, BSc, BAppSc(Phty), GradDipEd, GradDipBehavHlthCare, Professor and Associate Dean (Research), Faculty of Health, Auckland University of Technology, New Zealand, Justin F. McEvoy, BAppSc(Phty), GradDipSportsPhysio, MSportsPhysio, Physiotherapist and Director, West Suburban Sports Medicine Centre, Melbourne, Australia Correspondence to: GK, Faculty of Health, Auckland University of Technology, Private Bag 92006, Auckland 1020, New Zealand. Tel: +64-9-917-9999 ext. 7774; Fax: +64-9-917-9706; Email: [email protected] . 110

Adherence to rehabilitation 111

pain (Jackson 1994; Freidrich et al. 1996, 1998; Linton et al. 1996; Schneiders et al. 1998). A recent investigation by Schneiders et al. (1998) assessed the adherence to exercise therapy over a 14-day period by 96 patients with acute or subacute low back pain. Schneiders and his colleagues reported that patients who received their exercise instructions verbally, but reinforced with written and illustrated material, adhered to a significantly higher level than their control counterparts who received verbal instructions alone. Freidrich et al. (1998) assessed the effect of a combined exercise and ‘motivation’ program (including the use of an exercise diary) on adherence, disability, and pain in 93 patients with chronic and recurrent low back pain. They reported that, compared to patients in the standard exercise program, those in the combined exercise and motivation program were significantly more likely to attend their exercise therapy appointments, and reported significantly lower disability and pain scores 4 and 12 months after the commencement of the study. Of note, there was no difference in self-reported adherence with long-term exercise (i.e. after the face-to-face exercise sessions had ceased) between the groups. The investigation by Linton et al. (1996) found that participants with back pain who adhered to an exercise program over a 6-month period had increased aerobic levels when compared to nonadherers. There was, however, no significant difference in pain improvement between adherers and non-adherers. Given the dearth of research on adherence to low back pain rehabilitation, the current study was carried out. The aims of this study were: (1) To establish adherence rates to treatment attendance and physiotherapy home exercise programs in patients with low back pain. (2) To establish physiotherapists’ perceptions of adherence of patients with low back pain to exercise and advice when at clinic-based treatment sessions. (3) To investigate gender and patient type (i.e. compensable and non-compensable) differences in home exercise adherence rates, attendance rates, and adherence to exercise and instructions during clinic-based treatment sessions in patients with low back pain. (4) To examine the relationship between adherence rates to home exercise programs, attendance rates to clinic-based treatment sessions, and adherence to exercise and instruction during physiotherapy treatment sessions in patients with low back pain. (5) To examine the relationship between adherence to home exercise programs, attendance rates to physiotherapy treatment sessions, adherence to exercise and instruction during clinic-based Manual Therapy (2003) 8(2), 110–116

treatment sessions, and perceived rehabilitation outcome in patients with low back pain. Due to the largely exploratory nature of this investigation, and the inconsistent findings of previous research, no directional hypotheses were tested.

METHOD Participants The participants were 105 (71 male and 34 female) patients recruited from three private physiotherapy clinics in the North-western suburbs of Melbourne, Australia. All participants had a significant lumbarrelated pain episode requiring physiotherapy treatment and rehabilitation. Significant lumbar pain was defined as a level of lumbar pain that was severe enough to warrant the participant to seek treatment. The participants were all volunteers who had either been referred to the clinics by a medical practitioner, or self-referred for treatment of their low back injury. The age of the participants ranged from 15 to 71 years with a mean of 39.7 years (SD=13.4). The mean age of the male participants was 38.8 years (SD=12.5), while for females, the mean was 39.7 years (SD=15.2). Of the 105 patients in the sample, 43 were either injured at work or in motorcar accidents, and were, therefore, financially covered by a third-party insurance company. The remaining 62 participants were injured through other means, and were either uninsured or privately insured in terms of medical expenses. It should be noted that although 50 participants had not reported any previous episodes of lumbarrelated back pain (i.e. this was their first episode), 33 had reported one previous episode, 16 indicated two prior episodes, five had three previous episodes, and 1 participant had experienced four previous episodes. The length of time that participants had their significant lumbar-related pain before presenting for physiotherapy rehabilitation was varied but appears to represent the normal population of patients attending a private physiotherapy practice for treatment of their condition. There were 55 participants (52.4% of the study population) with lumbar related pain of less than 1 week duration, 22 (20.9%) participants who reported having their lumbar related pain for greater than 1 week but less than 4 weeks, 12 participants (11.4%) who reported that they had their pain for between 4 weeks and 6 months, and 16 (15.2%) participants who reported that their lumbar related pain was present for greater than 6 months prior to attending for physiotherapy treatment. r 2003 Elsevier Science Ltd. All rights reserved.

112 Manual Therapy

Test instruments Adherence measures Three instruments were used in this study to assess adherence to various aspects of the rehabilitation program. The Home Exercise Compliance Assessment (HECA) was administered weekly (over a 4week period) to assess the proportion of the participants’ prescribed home exercises they had completed during the week prior to assessment. Participants were requested to record the number of exercise sessions completed of the 14 prescribed sessions (i.e. 2 sessions per day) during the previous week. Although no previous reports of the psychometric properties of this adherence measure could be found in the literature, this self-report method of assessment of adherence to home exercise has been used in several previous investigations (Noyes et al. 1983; Almekinders & Almekinders 1994; Brewer et al. 1994; May & Taylor 1994; Taylor & May 1996). The second measure of adherence to rehabilitation was attendance scores (i.e. the proportion of rehabilitation appointments attended compared to those scheduled). This method has been reported extensively in the literature as a measure of adherence to rehabilitation (see reviews by Brewer 1998; Spetch & Kolt 2001). The final adherence test instrument used in this study was the Sport Injury Rehabilitation Adherence Scale (SIRAS: Brewer et al. 2000), utilized to assess adherence during rehabilitation sessions. The SIRAS requires the physiotherapist to rate the participant on three indicators of adherence on a 5-point likert-type scale ranging from 1 (not at all adherent) to 5 (very adherent). The three items are the intensity with which the participant completed their exercises during treatment, the frequency with which the participant followed instructions, and the degree to which the participant was receptive to progressions or changes in the program. The SIRAS has demonstrated psychometric properties (Brewer et al. 2000; 2002). Outcome measures Two rehabilitation outcome measures were used. The Patients’ Measure of Perceived Rehabilitation (PMPR: McDonald & Hardy 1990) is a measure of each patient’s perceived percentage of improvement (from 0=not at all rehabilitated to 100=fully rehabilitated to their pre-injury level). This measure was initially used by McDonald and Hardy (1990) in a study of affective response patterns of injured athletes. The second rehabilitation outcome measure was the Physiotherapists’ Measure of Perceived Rehabilitation (PTMPR: McDonald & Hardy 1990). The PTMPR measures physiotherapists’ ratings of perceived rehabilitation (from 0%=not at all rehabilir 2003 Elsevier Science Ltd. All rights reserved.

tated to 100%=fully rehabilitated to the patients’ pre-injury level). Exercise instruction sheets Exercise instruction sheets (produced using the ‘Physiotools’ computer program, Chattanooga Group) were used to encourage adherence to home exercise programs. Each home exercise program consisted of three exercises selected by the treating physiotherapist thought to be most appropriate for each patient’s back pain condition. The exercise sheets included clear diagrams and standard instructions. The exercises were selected from a set of 10 commonly used back rehabilitation exercises that were generated by a team of six physiotherapists experienced in the management of low back pain (mean experience=8.2 years). Pilot work indicated that any combination of 3 of the 10 possible exercise) would take approximately 12 min to complete. Procedure The five treating physiotherapists involved in the study attended a 2-h information session with the investigators where the aims of the project were described, the recruitment procedures outlined, and the methodological aspects of the research discussed. The physiotherapists had between 3 and 10 years experience (mean=6.3), with two of them holding postgraduate qualifications in musculoskeletal physiotherapy. Patients with low back pain were recruited on initial presentation to any of the three physiotherapy clinics involved in the investigation. All participants read and completed an informed consent form. The appropriate institutional Ethics Committee approved the project. Participants were advised that this investigation had no bearing on any compensation claims that may be in progress. At the initial consultation, the treating physiotherapist recorded whether the participants’ episode of low back pain was their first, or whether they had experienced low back pain previously. Further, details of the length of time that they had the presenting pain prior to the commencement of the study were recorded, as were the participants’ perceived percentage of improvement since onset of the symptoms (Week 0 PMPR). During the initial consultation, the physiotherapists assessed the patients (in line with usual clinical practice) to establish a diagnosis and treatment plan. The patient was administered the treatment deemed most appropriate by the treating physiotherapist and three exercises were prescribed for the participant to complete at home, twice per day, 7 days per week. The participants returned for further physiotherapy sessions including treatment and progression of Manual Therapy (2003) 8(2), 110–116


exercise programs as requested by the treating physiotherapists, and in line with the physiotherapists’ usual procedures for rehabilitation of that particular pathology. At the end of each week (for a maximum of 4 weeks), participants, when attending for physiotherapy treatment, completed the HECA and the PMPR (administered by the administration staff of the clinics), and the treating physiotherapist completed the SIRAS and the PTMPR immediately after the rehabilitation session. Those participants who were discharged from rehabilitation prior to the end of the 4-week treatment period (10 patients at less than 2 weeks, three at greater than 2 weeks but less than 4 weeks), completed the test instruments only for the time that they were undergoing rehabilitation, and were excluded from the data analysis. Of the 120 patients with low back pain that were invited to participate in the study, only two did not want to be included: an initial response rate of 98.3%.

RESULTS Descriptive statistics The mean and standard deviation scores for Attendance, HECA, SIRAS, week 0 PMPR, week 4 PMPR, week 1 PTMPR, and week 4 PTMPR are shown for the total sample, males, females, and compensable and non-compensable participants in Table 1. As some scores (attendance, HECA, Week 4 PMPR, and Week 4 PTMPR) were negatively skewed, an inverse and square root transformation was employed to establish a more normal distribution. Also, a logarithmic transformation was used on week 0 PMPR scores due to the high level of kurtosis

(Tabachnick & Fidell 1996). These transformed values were used in subsequent analyses.

Correlations among variables Correlations were carried out among age, average attendance, HECA, SIRAS, Week 4 PMPR, and Week 4 PTMPR scores. Significant correlations were found between average HECA and average SIRAS scores for the total sample (r=0.64, n=105, Po0.01), compensable participants (r=0.58, n=43, Po0.01), and noncompensable participants (r=0.71, n=62, Po0.01). This indicates that participants who reported that they performed their home exercise routine in an adherent manner were also more likely to receive high SIRAS ratings by their physiotherapist. As well, significant correlations between Week 4 PMPR and Week 4 PTMPR scores were found for the total sample (r=080, n=105, Po0.01), compensable participants (r=0.82, n=43, Po0.01), and noncompensable participants (r=0.78, n=62, Po0.01). This indicates a match between both the patients’ and physiotherapists’ perception of the degree of rehabilitation achieved by the end of the 4-week rehabilitation period. The final correlations of note were between average SIRAS and Week 4 PMPR scores for the total sample (r=0.34, n=105, Po0.01) and for the compensable participants (r=0.45, n=43, Po0.01), and between average SIRAS scores and Week 4 PTMPR scores for the total sample (r=0.34, n=105, Po0.01) and the compensable patients (r=0.39, n=43, Po0.01). This suggests that those patients who were rated high on the SIRAS throughout the 4-week rehabilitation intervention were also more likely to rate their own level of rehabilitation highly at week 4, and were more likely to be rated as highly rehabilitated by their treating physiotherapist at week 4.

Table 1. Mean scores and standard deviations for adherence and outcome variables for the total sample, males, females, compensable, and non-compensable participants

Variable

Total sample n=105

Males n=71

Females n=34

Compensable patients n=43

Non-compensable patients n=62

Mean (SD)

Mean (SD)

Mean (SD)

Mean (SD)

Mean (SD)

Adherence variables Average attendance (%) Average HECA (%) Average SIRAS (out of 15)

87.7 (13.7) 71.6 (23.4) 11.6 (2.3)

87.2 (27.3) 69.5 (23.9) 11.2 (2.3)

88.7 (26.2) 76.1 (21.9) 12.3 (2.2)

85.8 (14.9) 70.0 (25.7) 10.8 (2.2)

89.0 (12.7) 72.8 (21.7) 12.2 (2.2)

Outcome variables Week 0 PMPR (%) Week 4 PMPR (%) Week 1 PTMPR (%) Week 4 PTMPR (%)

8.5 75.5 56.4 80.8

9.5 74.9 55.1 80.9

6.5 76.7 59.0 80.8

14.5 68.4 53.7 75.8

4.4 80.4 84.4 84.4

(17.2) (23.6) (20.6) (19.1)

(18.4) (24.0) (20.4) (19.8)

(14.3) (22.9) (21.1) (18.0)

(21.5) (25.4) (19.3) (19.3)

(12.0) (21.1) (18.0) (18.0)

HECA=Home Exercise Compliance Assessment; SIRAS=Sport Injury Rehabilitation Adherence Scale. Score (out of 15) represents the sum of the physiotherapists’ responses to the three items of the SIRAS; PMPR=Patients’ Measure of Perceived Rehabilitation; PTMPR=Physiotherapists’ Measure of Perceived Rehabilitation. Manual Therapy (2003) 8(2), 110–116


114 Manual Therapy

Gender and patient type differences To examine gender and patient type differences (i.e. compensable compared to non-compensable patients) a two-way MANOVA (gender patient type) was performed using average attendance, average HECA, average SIRAS, week 4 PMPR scores, and week 4 PTMPR scores as dependent variables. The results showed that there was a significant effect for patient type, F (5, 97)=2.27, P=0.05. However, there was no significant effect for gender, F (5, 97)=0.37, P=0.87, and no interaction effect, F (5, 97) =0.97, P=0.78. Specifically, there was a significant difference between the groups (i.e. compensable patients and noncompensable patients) on SIRAS scores, F (1, 101)=8.23, P=0.004. In this case, post hoc analyses (using Sheffe! tests) showed that for patient type, compensable patients scored significantly lower on the SIRAS than did their non-compensable counterparts (P=0.001). Prediction of outcome measures To determine whether the perceived outcome measures (Week 4 PMPR and Week 4 PTMPR scores) could be predicted by other variables such as SIRAS scores, HECA scores, age, gender, length of pain, patient type, and attendance, two hierarchical regression analyses were performed. As there was a significant correlation between HECA and SIRAS scores, the HECA scores were removed from each analysis in an attempt to increase the predictive power of the regression equations (Tabachnick & Fidell 1996). The outcome of the first hierarchical regression analysis was significant, F (7, 97)=9.53, Po0.0001, indicating that two variables [length of pain prior to attending for physiotherapy rehabilitation (Po0.01), and average SIRAS scores (Po0.01)], were predictive of Week 4 PMPR scores. The second hierarchical regression analysis was performed to assess the predictive power of the same variables assessed in the first analysis on week 4 PTMPR scores. The regression equation was significant, F (7, 97)=9.74, Po0.0001, and two of the variables assessed [Week 1 PTMPR (Po0.001) and length of pain prior to attending for physiotherapy (Po0.001)], were predictive of Week 4 PTMPR scores.

DISCUSSION Adherence to rehabilitation The findings of the present study indicated that patients with low back pain who sought physiotherapy treatment attended 87.7% of their scheduled physiotherapy appointments, with no significant r 2003 Elsevier Science Ltd. All rights reserved.

differences between males and females or compensable and non-compensable patients. This high level of attendance compares favourably with rates found in other studies on a variety of musculoskeletal conditions. For example, Friedrich et al. (1998) reported that patients with chronic low back pain attended 86–96% of scheduled rehabilitation sessions. Rehabilitation attendance rates for other musculoskeletal conditions have ranged from 85% to 92% (Lampton et al. 1993; Brewer et al. 1994; Daly et al. 1995; Laubach et al. 1996). The present findings also indicated that compensable and noncompensable patients’ attendance rates were similar, as were those for males and females. Participants reported completing 71.6% of their prescribed home exercise sessions over the 4-week rehabilitation period. This supports the earlier findings of Schneiders et al. (1998) that patients with acute low back pain adhered to 77.4% of their prescribed home exercises over a 2-week intervention. As these rates tend to be higher than those in studies where supplementary printed material is not used to support exercise programs (May & Taylor 1984; Spelman 1984; Schneiders et al. 1998;), physiotherapists should consider this approach more strongly. Contrary to earlier findings (Hazard et al. 1989; Leavitt 1992; Gallagher et al. 1995), this study indicated no differences between compensable and non-compensable patients in relation to adherence to home exercise completion. Treating physiotherapists reported that patients were generally adherent to clinic-based rehabilitation activities (the average SIRAS score for the overall sample was 11.6/15, 77.4%). Although there were no significant differences between males and females on SIRAS scores, compensable patients scored significantly lower than their non-compensable counterparts. This indicates the practical need of educating compensable patients on the importance of the clinicbased physiotherapy sessions in their overall rehabilitation program. The physiotherapist may need to spend a greater amount of time with the compensable patient to do this, and could utilize adherence enhancement techniques such as positive reinforcement and education of the patient (Jackson 1994; Friedrich et al. 1996). Relationship among adherence measures Contrary to the findings of Brewer et al. (1994), significant correlations were found between average HECA and average SIRAS scores, indicating that the physiotherapists’ judgement of a patient’s adherence during rehabilitation sessions (SIRAS) was related to the patient’s report of adherence to his or her home exercises. Given the present findings, physiotherapists may be able to get an indication of home exercise adherence levels by looking at what patients do Manual Therapy (2003) 8(2), 110–116


during clinic-based sessions. It could be that if patients are not adhering adequately to home exercise sessions, the physiotherapist might reduce the emphasis on this component of rehabilitation and increase the supervision of exercises during clinicbased rehabilitation sessions. Further, physiotherapists could utilize other adherence enhancement techniques such as positive reinforcement, goal setting, and contracting between therapist and patient. It is noteworthy that there was a significant correlation between the average SIRAS scores and week 4 PTMPR scores, suggesting that the physiotherapists’ judgments of a patient’s adherence during rehabilitation sessions was related to their perception of the patient’s level of rehabilitation at week 4. Therefore, if the physiotherapist thought that adherence to usual clinic-based rehabilitation was inadequate, they could adopt a change of focus that might involve closer supervision of exercise. The present study also found significant correlations between patients’ and physiotherapists’ perceptions of the degree of rehabilitation that had been achieved by the end of the 4-week study period. This finding is important clinically in that it suggests that physiotherapists and patients perceive similar outcomes, indicating agreement of treatment expectations between the two parties. The findings of the present study indicated no relationship between attendance at physiotherapy sessions and SIRAS scores. With these findings in mind, physiotherapists in the clinical setting cannot rely simply on using patients’ attendance rates as an indicator of how likely they are to be adherent to advice, instruction, and intensity during clinic-based physiotherapy sessions.

Adherence and rehabilitation outcomes The findings of this study indicated that average SIRAS scores over the 4-week rehabilitation period were a significant predictor of week 4 PMPR and week 4 PTMPR scores. This suggests that if the physiotherapist’s judgement of a patient’s adherence to in-clinic physiotherapy has been high it is likely that the patient will have a higher outcome at 4-weeks than for a patient who was judged by the physiotherapist as less adherent to clinic-based physiotherapy. The length of time with low back pain prior to starting the physiotherapy program was also predictive of week 4 PMPR and week 4 PTMPR scores. Therefore, physiotherapists may be able to justify early intervention for back pain patients. The findings of the present study should be viewed in relation to four potential limitations. First, as the participants were aware that they were part of a study assessing adherence to home exercise, this might have Manual Therapy (2003) 8(2), 110–116

affected their normal behaviour. Second, the measure of adherence to home exercise was dependent on the patient’s honesty and their ability to remember the number of exercise sessions that they performed in the prior week. Despite the widespread use of this approach, it is prone to recall and bias problems. Further, although the patients included in this study all had low back pain, there would have been diverse pathologies responsible. It could be that people with more severe pathologies have different adherence rates and progress rates than those with less severe pathologies. Therefore, future research should consider injury severity and specific pathology in the study design. Finally, the non-exercise treatment received by each patient was not standardized. For example, some patients may have been taking nonsteroidal anti-inflammatory drugs that affect pain and their ability to perform exercise, while others may have had more ‘effective’ manual treatment. However, in a clinically based study, and considering the lack of evidence of the efficacy of any particular standardized programs, it would be unethical to standardize a treatment program for a group with a diverse range of low back pathologies.

CONCLUSION Notwithstanding the potential concerns outlined above, the current investigation of adherence to rehabilitation was successful in assessing adherence within a clinical physiotherapy setting. In line with the recommendation by Spetch and Kolt (2001) this study has built on previous research by using a range of adherence measures that focus on different aspects of rehabilitation. As there have been very few studies of adherence to exercise rehabilitation, this study provides a basis for the future assessment of adherence to the exercise components of low back pain management. Further investigation of adherence should utilize improved and objective measures of exercise adherence (e.g. hidden counters attached to exercise video programs) and should endeavour to assess adherence rates to all aspects of rehabilitation utilizing a double blind study design. The present research has implications that are important to the physiotherapy clinician and, in turn, could assist in the effectiveness of the treatment of their patients with low back pain.

Acknowledgements We wish to thank Dr Britton Brewer for his initial input into study design, Dr Jeremy Adams for his advice on statistical analyses, and the physiotherapists and administrative staff who assisted with data collection. This study was carried out as part of Justin McEvoy’s Master of Sports Physiotherapy program. r 2003 Elsevier Science Ltd. All rights reserved.

116 Manual Therapy

References Almekinders LC, Almekinders SV 1994 Outcome in the treatment of chronic overuse sports injuries: A retrospective study. Journal of Orthopaedic and Sports Physical Therapy 19: 157– 161 Binkley J, Finch E, Hall J, Black T, Gowland C 1993 Diagnostic classification of patients with low back pain: report on a survey of physical therapy experts. Physical Therapy 73: 138–450 Brewer B W 1998 Adherence to sport injury rehabilitation programs. Journal of Applied Sport Psychology 10: 70–82 Brewer BW, Avondoglio JB, Cornelius AE, Van Raalte JL, Brickner JC, Petitpas AJ, Kolt GS, Pizzari T, Schoo AMM, Emery K, Hatten SJ 2002 Construct validity and interrater agreement of the Sport Injury Rehabilitation Adherence Scale. Journal of Sport Rehabilitation 11: 170–178 Brewer BW, Daly JM, Van Raalte JL, Petitpas AJ, Sklar JH 1994 A psychometric evaluation of the rehabilitation adherence questionnaire. Paper presented at the Annual Meeting of the North American Society for the Psychology of Sport and Physical Activity, Clearwater FL Brewer BW, Van Raalte JL, Petitpas AJ, Sklar JH, Pohlman MH, Krushell RJ, Ditmar TD, Daly JM, Weinstock J 2000 Preliminary psychometric evaluation of a measure of adherence to clinic-based sport injury rehabilitation. Physical Therapy in Sport 1: 68–74 Daly JM, Brewer BW, Van Raalte JL, Petitpas AJ, Sklar JH 1995 Cognitive appraisal, emotional adjustment, and adherence to rehabilitation following knee surgery. Journal of Sport Rehabilitation 4: 23–30 Derscheid GL, Feiring DC 1987 A statistical analysis to characterize treatment adherence of the 18 most common diagnoses seen at a sports medicine clinic. Journal of Orthopaedic and Sports Physical Therapy 9: 40–46 Ettinger WH, Burns R, Messier SP, Applegate W, Rejeski WJ, Morgan T, Shumaker S, Berry MJ, O‘Toole M, Monu J, Craven T 1997 A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis: The Fitness Arthritis and Seniors Trial (FAST). Journal of the American Medical Association 277: 25–31 Friedrich M, Cermack 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: 1082–1088 Freidrich M, Gittler G, Halberstadt Y, Cermak T, Heiller I 1998 Combined exercise and motivation program: Effects on the compliance and level of disability of patients with chronic low back pain: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation 79: 475–487 Gallagher RM, Williams RA, Skelly J, Haugh LD, Rauh V, Milhous R, Frymoyer J 1995 Workers’ compensation and return to work in low back pain. Pain 61: 299–307 Goldby LJ 1997 Low back pain: The evidence for physiotherapy. Physical Therapy Reviews 2: 7–11 Hawkins RJ, Switlyk P 1993 Acute prosthetic replacement for stress fractures of the proximal humerus. Clinical Orthopaedics and Related Research 289: 156–160 Hazard RG, Fenwick JW, Kalisch SM, Redmond J, Reeves V, Reid S, Frymoyer JW 1989 Functional restoration with behavioral support: a one year prospective study of patients with chronic low back pain. Spine 14: 157–161


Jackson LD 1994 Maximizing treatment adherence among back-pain patients: an experimental study of the effects of physician-related cues in written medical messages. Health Communication 6: 173–191 Lampton CC, Lambert ME, Yost R 1993 The effects of psychological factors in sports medicine rehabilitation adherence. Journal of Sports Medicine and Physical Fitness 33: 292–299 Lanes TC, Gauron EF, Spratt KF, Wernimont TJ, Found EM, Weinstein JN 1995 Long term follow up of patients with chronic back pain treated in a multidisciplinary rehabilitation program. Spine 20: 801–806 Laubach WJ, Brewer BW, Van Raalte JL, Petitpas AJ 1996 Attributions for recovery and adherence to sport injury rehabilitation. Australian Journal of Science and Medicine in Sport 28: 30–34 Leavitt F 1992 The physical exertion factor in compensable work injuries. A hidden floor in previous research. Spine 17: 307–310 Linton SJ, Hellsing A, Bergstrom G 1996 Exercise for workers with musculoskeletal pain: does enhancing compliance decrease pain? Journal of Occupational Rehabilitation 6: 177–189 Martin P, Rose M, Nichols P, Russell P, Hughes I 1986 Physiotherapy exercises for low back pain: process and clinical outcome. International Rehabilitation Medicine 8: 261–287 May S, Taylor AH 1994 The development and examination of various measures of patient compliance, for specific use with injured athletes. Journal of Sports Sciences 12: 180–181 McDonald SA, Hardy CJ 1990 Affective response patterns of the injured athlete: an exploratory analysis. The Sport Psychologist 4: 261–274 Noyes FR, Matthews DS, Mooar PA, Grood ES 1983 The symptomatic anterior cruciate-deficient knee. Part II : the results of rehabilitation, activity modification, and counseling on functional disability. Journal of Bone and Joint Surgery (Am) 65A: 163–174 Rejeski WJ, Brawley LR, Ettinger W, Morgan T, Thompson C 1997 Compliance to exercise therapy in older participants with osteoarthritis: implications for treating disability. Medicine and Science in Sports and Exercise 29: 977–985 Rives K, Gelberman R, Smith B, Carney K 1992 Severe contractures of the proximal interphalangeal joint in Depuytren’s disease: results of a prospective trial of operative correction and dynamic extension splinting. Journal of Hand Surgery 17A: 1153–1159 Schneiders AG, Zusman M, Singer KP 1998 Exercise therapy compliance in acute low back pain patients. Manual Therapy 3: 147–152 Spelman MR 1984 Back pain: how health education affects patient compliance with treatment. Occupational Health Nursing 32: 649–651 Spetch LA, Kolt GS 2001 Adherence to sport injury rehabilitation: implications for sports medicine providers and researchers. Physical Therapy in Sport 2: 80–90 Tabachnick BG, Fidell LS 1996 Using multivariate statistics, 3rd edn. Harper Collins, New York Taylor AH, May S 1996 Threat and coping appraisal as determinants of compliance with sports injury rehabilitation: an application of the protection motivation theory. Journal of Sports Sciences 14: 461–482 Treacy SH, Barron OA, Brunet ME, Barrack R 1997 Assessing the need for extensive supervised rehabilitation following arthroscopic ACL reconstruction. American Journal of Orthopedics 26: 25–29

Manual Therapy (2003) 8(2), 110–116


Professional issue

Validating clinical reasoning: a question of perspective, but whose perspective? A. M. Downing, D. G. Hunter School of Allied Health Professions, Faculty of Health & Social Care, University of the West of England, Bristol, UK

SUMMARY. This paper explores the notion of validity from different perspectives and addresses its integration with clinical reasoning. Whilst valuing the evidence-based practice (EBP) perspective in our quest for validation of practice, the authors posit that other perspectives may provide added value through their potential for offering validity in differing circumstances. The reality of the EBP aspiration is discussed and nuances within the evolved term ‘research-enhanced practice’ are shared. Validity theory applied through different perspectives may, it is argued help to get to grips with the balancing act of validating manual therapy practice. r 2003 Elsevier Science Ltd. All rights reserved.

universal acceptance. As a consequence of EBP, a culture may be developing whereby those clinicians seen not to be assessing the validity of their assumptions and actions by EBP criteria are deemed to lack credibility. However, are the EBP criteria solely capable of legitimizing clinical practice, or are other perspectives on evidence necessary and equally valid? EBP has pioneered the validation of clinical practice and in constructing its model it has drawn heavily on the empirical paradigm of science. By taking this perspective, EBP emphasizes a reduction in the unpredictable elements of subjectivity that are entwined in clinical reasoning. It suggests that objective evidence, which eliminates bias, is the strongest scientific evidence, and this is reflected in its hierarchies of evidence, where, for example, expert opinion is categorized as the lowest form of evidence, even superseded by methodologically flawed clinical research evidence (Tonelli 1999). Though evolving, the current model of EBP may be classified as an empirical approach to validation (Fawcett et al. 2001), whereby publicly verifiable and factual descriptions are used to make predictions about populations and can be used to exert influence on healthcare. From this empirical perspective, validity is typically defined conceptually in relation to two distinct, yet allied, dimensions known as relevancy and reliability (Safrit 1981). Relevancy refers to the ability of data to measure accurately, under specified conditions, what it is supposed to measure (Safrit

Autonomous practice provides the manual therapist with the authority and freedom to collate, interpret and act independently in response to the multitude of clinical features presenting in daily practice. This independence, however, comes with the price of accountability, whereby the assumptions, reasoning and actions of the clinician are required to be credible, efficacious and in line with the tenets of professional conduct. The notion of credibility, and related terms such as soundness and authenticity, can be embraced by one word: validity. Issues of validity pervade everyday life where they become a prominent aid to decision-making and the analysis of consequent actions. In manual therapy, issues of clinical validity are being challenged by the burgeoning evidence-based practice (EBP) movement. EBP, defined as ‘the conscientious and judicious use of current best evidence in making decisions about the care of individual patients’ (Sackett et al. 1996), offers clinicians criteria by which they can authenticate their practice. Such has been the impact of EBP, that it is likely to become the buzzword of the decade (Ingersoll 2000), and appears to have achieved almost Received: 18 June 2002 Accepted: 22 July 2002 Angela M. Downing, MSc, MCSP, DipTP, Cert. Ed., D. Glenn Hunter, MSc, MCSP, SRP, Cert. Ed., Senior Lecturers in Physiotherapy, School of Allied Health Professions, Faculty of Health & Social Care, University of the West of England, Bristol, UK. Correspondence to: AMD. Tel: +44 117 344 8417; Fax: +44 117 344 8408; E-mail: [email protected] 117

118 Manual Therapy

1981), whereas reliability relates to the notion of freedom from measurement error and to the consistency of scores over repeated testing (Safrit 1981). In this approach, the claimant of validity must be able to demonstrate evidence for both relevancy and reliability. For example, in the assessment of subacromial impingement, a therapist may produce reliable positive results from the use of the Hawkins Kennedy impingement test (Hawkins & Hobeika 1983) and claim that the positive test indicates subacromial impingement. However, the low specificity of this test indicates that a positive result has little meaning (Calis et al. 2000). Hence, the therapist’s reasoning would only be substantiated by reliable not relevant evidence, and reliability alone does not presuppose validity. The flagships of the empirical approach are the randomized controlled trial (RCT) and meta-analysis. While the RCT provides potentially valuable information about the effectiveness of interventions, in reality the predictions made pertain to average effects, thus making the transference of outcomes to individual patients tenuous. Also, the emphasis on RCTs appears to have focused practitioners on validating the treatment component of clinical reasoning by providing evidential hierarchies of clinical effectiveness (Moore et al. 1995). It appears to have had less influence on addressing the equally important issues of data collection and analysis in clinical reasoning (Delitto & Snyder-Mackler 1995) and on integrating qualitative issues into the process (Greenhalgh & Worrall 1997). It does not address how decision-making may have to vary from circumstance to circumstance and from patient to patient within the same circumstances (Haynes et al. 2002). With incomplete categorization and classification of clinical features and varying patient perspectives, how does the clinician decide what evidence to integrate into the clinical reasoning process with an individual patient? On this basis it could be viewed that the expectations of EBP are inflated (Naylor 1995) and possibly unattainable (Clemence 1998). Indeed, the current EBP model has not only been challenged over its relevance to individual patients, but also over issues surrounding its time-consuming nature, the lack of and quality of evidence, and its threats to clinical autonomy (Herbert 2001) and the art of patient care (Naylor 1995). Any comfort drawn from the RCT may be spurious considering the arguable inadequacy of this method in validating many aspects of manual therapy practice. Even guidelines, soundly based upon meta-analyses, may result in good to average outcomes – accepted by politicians and health care managers; but, as Grimley-Evans (1995) questions, could some patients actually be harmed by such mandatory guidelines? Moore & Petty (2001) elaborate this point by implying that there is a temptation r 2003 Elsevier Science Ltd. All rights reserved.

to ignore other evidence perceived from the EBP perspective to be lower down the evidentiary ladder (authors’ italics), but which may be potentially useful in the management of each unique patient. In acknowledging the benefits of empirical evidence, we need to acknowledge the warts of the EBP aspiration so far. But, what are the alternatives to EBP in its current form? It seems that in a clinical environment, given a single patient, no control group, and the absence of the opportunity to apply single-case study method, the clinician cannot validate the claim that a particular treatment has resulted in patient’s improvement. Does this, however, completely invalidate the clinical process? The answer to this question may lie in considering different perspectives on validating evidence. If we consider the EBP perspective as the only legitimate provider of criteria with which practice can be validated, then many claims of therapeutic efficacy in individual patients will have weak validity. But are other perspectives equally credible in legitimizing clinical practice? In addressing this question, guidance may come from using broader models of evidence. One such model, initially presented by Carper (1978) and later extended by Chinn & Kramer (1999), acknowledges the importance of empirically derived theoretical knowledge, but also recognizes with equal importance the knowledge gained through clinical practice. This approach categorizes evidence as empirical, ethical, personal and aesthetic. Using this model, during a patient encounter the clinician could validate actions by emphasizing an ethical perspective, focusing on the analysis and justification of values and beliefs held by individuals. Alternatively, the emphasis may take a personal perspective whereby the clinician, with a deep knowledge of personal ‘self’, reflects on the patient/therapist relationship to authenticate actions and through so-doing permits the ‘therapeutic use of self’ (Carper 1978) within the encounter. Or, emphasizing an aesthetic perspective, the clinician in unique situations may validate actions or assumptions through the skilful artistry of patient engagement and intuition. In using such broad yet interrelated perspectives, the clinician would be acknowledging that the manual therapy encounter is value laden. Treatment is human based and must be guided by values and theoretical principles, rather than simply be driven by an empirical endeavour. Haynes et al. (2002) remind us how EBP was developed to encourage the ‘paying of due respect— no more, no less—to current best evidence in decision making’. Their notion of research-enhanced health care permits these other perspectives and perhaps we would be wise to consider the alternative term ‘research-enhanced practice’ (REP) for manual therapy. Manual Therapy (2003) 8(2), 117–119

Validating clinical reasoning 119

While multiple perspectives on assessing validity appear to be more realistic than just relating good practice to empirical evidence, the problem remains as to how to give value to the outcome of integrated perspectives in clinical reasoning. Unlike in some branches of mathematics, within health sciences the quantification of validity is rarely a binary decision; inferences or actions can be valid to a degree or from a particular perspective and rarely will the statement of 100% validity be defendable. This notion of graded validity introduces the problem of just how to implement it. Ironically, this will require reliable and relevant criteria that are sensitive enough to discriminate between high and low levels of validity: a valid measurement tool to validate validity at each step in reasoning! In summary, validity relates to the authenticity of an inference or action and addressing validity in clinical reasoning is likely to enhance the credibility of clinical practice. However, there are many complex issues that require rigorous scrutiny and definition before the validating process can be conducted with confidence. While these problems are considerable, developing the skill of defending reasoning behind action cannot be ignored. The clinician may develop proficiency in this process by reflecting upon analogies drawn from the explicit integration of validity theory viewed from the research paradigm as well as from other perspectives. For the moment, manual therapy practice is influenced by the EBP movement and despite its imperfections, it has potentially a great value for us and for our patients. Perhaps, however, there is scope for a balancing of thought over the validity of EBP, the validity of expert opinion and of patients’ views, the validity of our clinical reasoning processes and an acknowledgement that not all epistemologies can ever stand up to scientific scrutiny. Validity theory, viewed from different

Manual Therapy (2003) 8(2), 117–119

perspectives, may help us to get to grips with the balancing act.

References Calis M, Akgun K, Birante M et al. 2000 Diagnostic value of clinical diagnostic tests in sub acromial impingement syndrome. Annals of Rheumatic Disease 59: 44–47 Carper BA 1978 Fundamental patterns of knowing in nursing. Advances in Nursing Science 1(1): 13–23 Chinn PL, Kramer MK 1999 Theory and Nursing: Integrated Knowledge and Development, 5th edn. Mosby, St Louis, MO Clemence ML 1998 Evidence-based physiotherapy: seeking the unattainable? British Journal of Therapy and Rehabilitation 5(5): 257–260 Delitto A, Snyder-Mackler L 1995 The diagnostic process: Examples in orthopedic physical therapy. Physical Therapy 75: 203–211 Fawcett J, Watson J, Neuman B et al. 2001 On nursing theories and evidence. Journal of Nursing Scholarship 33(2): 115–119 Greenhalgh T, Worrall JG 1997 From EBM to CSM: The evolution of context sensitive medicine? Journal of Evaluation in Clinical Practice 3(2): 105–108 Grimley-Evans J 1995 Evidence-based and evidence-biased medicine. Age and Ageing 24: 461–463 Hawkins RJ, Hobeika PE 1983 Impingement syndrome in the athletic shoulder. Clinics in Sports Medicine 2(2): 391–405 Haynes RB, Devereaux PJ, Guyatt GH 2002 Physicians’ and patients’ choices in evidence based practice. Evidence does not make decisions, people do. British Medical Journal 324: 1350 Herbert RD, Sherrington C, Maher C et al. 2001 Evidence based practice—imperfect but necessary. Physiotherapy Theory and Practice 17: 201–211 Ingersoll GL 2000 Evidence based nursing: What it is and what it isn’t. Nursing Outlook 48: 151–152 Moore A, McQuay H, Gray JAM (eds) 1995 Evidence-based everything. Bandolier 1(12): 1 Moore A, Petty N 2001 Evidence-based practice—getting a grip and finding a balance. Manual Therapy 6(4): 195–196 Naylor CD 1995 Grey zones of clinical practice: Some limits to evidence-based medicine. The Lancet 345: 840–842 Sackett DL, Rosenberg WM, Gray JA et al. 1996 Evidence based medicine: What it is and what it isn’t. British Medical Journal 312(7023): 71–72 Safrit MJ 1981 Evaluation in Physical Education, 2nd edn. Prentice-Hall, Engelwood Cliffs, NJ Tonelli MR 1999 In defense of expert opinion. Academic Medicine 74(11): 1187–1192


Manual Therapy (2003) 8(2), 120–127 r 2003 Elsevier Science Ltd. All rights reserved. 1356-689X/03/$ - see front matter doi:10.1016/S1356-689X(02)00111-X

Case report

False-negative extension/rotation pre-manipulative screening test on a patient with an atretic and hypoplastic vertebral artery M. D. Westawayw,*, P. Stratfordz, B. Symonsy Faculty of Kinesiology, University of Calgary, Alberta, Canada, w Private Practice, LifeMark Health, Calgary, Alberta, Canada, z School of Rehabilitation Science and Department of Clinical Epidemiology and Biostatistics, Hamilton, Ontario, Canada, y Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Alberta, Canada

n

The combined physiological extended and rotated cervical spine position has been postulated to affect vertebral artery (VA) blood flow based on mechanically occlusive haemodynamic constructs. This test is classically described as placing the patient’s cervical spine in an extreme (end-range) physiological combined extended and rotated position. Occlusion of the vertebral artery in this position is thought to occur when compressive forces exceed the blood flow pressure force through the vessel. The vertebral artery is divided into four zones; Zone I is most caudal extending from the subclavian artery to C6; Zone II is regarded as the length extending cranially from the C6 foramen tranversaria to C2; Zone III extends from the C2 foramen transversaria to the point where the artery punctures the tectorial membrane, and finally Zone IV is regarded as the length that is intracranial and ultimately communicates with the basilar artery. There is a general impression that the contralateral vertebral artery is stretched and the ipsilateral compressed in the extended/rotated position. Altered blood flow may be due to either of these morphological changes in Zone III of the vertebral artery (Symons & Westaway 2001). Theoretically, with a mechanically induced blood flow alteration, there is decreased perfusion to the brainstem manifesting vertebrobasilar signs and symptoms. This positive response cues the practitioner into making an informed decision on the utility and application of a manipulative intervention. This case report documents a false-negative extended/rotated screening outcome of a patient with an atretic (lacking in normal lumen patency) right vertebral artery and a radiologically confirmed atlantoaxial instability. This case highlights issues with respect to a pre-manipulative screening test and its clinical construct and utility.

INTRODUCTION The use of vertebral manipulation in the medical and paramedical community is a common treatment approach. Various practitioners use the modality of low-amplitude, high-velocity impulse (thrust) techniques on the cervical spine to improve vertebral range of motion and function, whilst reducing cervicogenic headaches and pain (Hurwitz et al. 1996). Delivery of a high-velocity, low-amplitude rotatory thrust to the cervical spine has been reported in the literature as a possible mechanism for vertebral artery dissection and sequelae (Hufnagel et al. 1999). Although this hypothesized mechanism of arterial injury is documented as rare in occurrence (Haldeman et al. 2002), there is a clinical tenet to implement valid premanipulative screening techniques to reduce this potential risk. Since being reported in the literature by DeKleyn and Nieuwenhuyse (1927), the combined extended/rotated position of the cervical spine has been employed as a clinical pre-manipulative screening maneuver. The validity and positive predictive value of this screening test has been challenged (Cote et al. 1996).

Received: 31 May 2002 Revised: 15 August 2002 Accepted: 10 September 2002 M. D. Westaway, BSc, PT, FCAMT, Faculty of Kinesiology, University of Calgary, 2500 University Drive NW, Alberta, Canada, Private practice, LifeMark Health, Calgary, Alberta, Canada, P. Stratford, MSc, PT, School of Rehabilitation Science and Department of Clinical Epidemiology and Biostatistics, Hamilton, Ontario, Canada, B. Symons, MSc, DC, Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Alberta, Canada Correspondence to: MDW. Tel.: +1403 246 4059; Fax: +1 403 280 7168; E-mail: [email protected] 120

Vertebral artery and a pre-manipulative screening test

METHODS The subject was a 38-year-old female with an 8-year diagnosis of rheumatoid arthritis. She was referred to our research group from a community rheumatologist due to an atlantodental interval (ADI) greater than 3 mm. Of interest, the patient did not report neck pain or symptoms. This subject was initially a candidate for a larger study investigating atlantoaxial rotation and vertebral artery deformation. The patient met the following inclusion criteria (Table 1). Ethics approval was obtained from the Office of Medical Bioethics, Faculty of Medicine, University of Calgary. The patient signed an informed consent document to participate in this study.

121

tion. Symptoms and nystagmus were monitored in this end-range position for 45 seconds. The subject was asymptomatic, and no apparent (cardinal or cranial nerve) signs were manifested from the bilateral extended/rotated positions (Fig. 2).

Table 1. Inclusion criteria

Age 18–55 Male and female subjects Atlantodental interval greater than 3 mm defined as unstable Mild to moderate symptoms Minimal dental fillings in the molars Small pannus formation Serum creatinine levels (60–120 mmol/l) No contraindications to contrast medium injections Hepatic, renal and cardiopulmonary status stable Able to tolerate extended/rotated position for 80 s with or without signs or symptoms Lack of significant osteophytic/degenerative changes

The subject was asymptomatic on standard orthopaedic and neurological clinical testing. An ADI of 5 mm in flexion was exhibited on conventional flexion/extension lateral radiographs (Fig. 1). In a supine position, the subject was carefully and sequentially placed in right and then left extended and rotated cervical spine positions and lastly, combined end-range craniovertebral extension/rota-

Fig. 1—Conventional lateral cervical spine radiograph in flexion: the short horizontal line between the two longer vertical lines represents the ADI measurement. In this subject, the ADI measured a displacement of 5 mm between the anterior cortex of the odontoid to the posterior cortex of the anterior arch of the atlas.

Fig. 2—Representation of the subject in the left extended/rotated pre-manipulative screening position with combined craniovertebral left rotation and extension. Manual Therapy (2003) 8(2), 120–127


122 Manual Therapy

A venous puncture blood sample (5 ml) was taken. Normal blood extraction procedures were adhered to using sterile technique. A serum creatinine level of 51 mmol/l (reference range 45–100 mmol/l) enabled the subject to advance to the computed tomography (CT) scanning phase. Two contrast medium injections were done at the CT scan site: one in the neutral position and one with the patient in the left extended/ rotated position. Due to the large contrast medium boluses and the repetitive nature of the injections, it was imperative to know the renal status of the patient to investigate the potential of excreting the medium; hence the serum creatinine analysis. The subject was well hydrated and had omitted the meal preceding the examination. While the subject was in a supine neutral position within the CT scanner gantry, a preliminary enhanced 1:1 pitch (scout) scan was conducted from our defined projected region (superior to the transverse process of C3 to the inferior-most line of the occiput). Once the scout scan was completed, a digital blood pressure and heart rate monitor was affixed to the subject’s left index finger. Blood pressure and heart rate were measured before and after the CT examination to check for haemodynamic stability. The right brachial artery was prepared for injection using standard hospital procedures. A power injector was used to administer the Omnipaque-300s contrast medium administered at a rate of 3 ml/s. A volume of 100 ml was injected over a 33-second time span. An 18-second scan delay was imposed to allow for ascent of the contrast medium bolus to achieve optimal enhancement of the vertebral arteries. The neuroradiologist determined the contrast medium dosage. The actual scan time took approximately 30 seconds to the Zone III region of the vertebral artery, while the subject was in a supine neutral position. The subject was allowed to rest for 5 minutes before the second contrast medium injection was given. Procedures for the second scan were the same as those in the first scan. The subject was placed in the left extended/rotated position (both cervical and craniovertebral region) by a trained clinician. The clinician was protected with lead gloves and chest shield while holding the head of the subject in the required position. The subject was then returned to a neutral position after the injection and scan phase was completed. The subject underwent transcranial Doppler sonography (TCD) upstream from the C1 transverse process window: first in the neutral, and then in the extended rotated position for the contralateral artery (i.e. if the subject’s neck was rotated/extended left, then the right vertebral artery was insonated). The subject was sitting in an upright chair for the TCD examination. An ultrasound machine (256 digital channels; Siemens Sonoline Elegra Siemenss Issaquah, WA, USA) with a 5-MHz linear probe was r 2003 Elsevier Science Ltd. All rights reserved.

used by an experienced neurosonographer (Neurologist with a Fellowship in TCD). The peak flow velocity was recorded in the contralateral vertebral artery in the axial center of the artery. Peak flow velocity was calculated from automatic tracing after operator-controlled angle correction. While the sound-head probe was manually placed at the C1 window, the neurologist determined the angle of insonation. The midline of the occiput was used as the initial insonation point (foramen magnum access). The probe was aimed left or right of the midline to be certain the appropriate vertebral artery was insonated. The VA was insonated at a depth of 50 mm from the cranial window, whereas the basilar artery was captured at approximately 80 mm.

RESULTS The subject was asymptomatic on both right and left extended/rotated positions during the preliminary neurological and orthopaedic assessment. There was no evidence of cardinal sign provocation or clinical neural compromise while in the screening positions. These bilateral extended/rotated pre-manipulative screening positions were held for 80 s. Right vertebral artery TCD revealed a baseline peak flow velocity of 57 cm/s in the neutral position and 0 cm/s in the left rotated/extended position. (Figs. 3 and 4). The right vertebral artery was insonated intracranially at a depth of 60–62 mm. Figure 3 reveals a solid right vertebral artery signal at 62 mm exhibiting a distinct diastolic and systolic flow profile. Color imaging reveals normal upstream flow. With the subject in the left pre-manipulative position and insonated at a depth of 62 mm, a flow signal was not detected in the right VA (Fig. 4). Color imaging (Fig. 4) of the right VA reveals a reversal of blood flow. The subject did not present with symptoms during the neutral or the left extended/rotated positions for right vertebral artery sonographic investigation. Left vertebral artery sonographic investigation was not done in the extended/rotated position due to the fact that this patient was intended for a larger associated study and only the right VA was being insonated. The patient did not present with significant changes in heart rate or systolic blood pressure during both CT scan positions. During the CT scan axial image analysis and on three-dimensional reconstruction, the right vertebral artery was shown to be hypoplastic throughout Zone II (Figs. 5 and 6) and atretic at the Zone III region leading to non-union at the Zone IV (intracranial) region (Fig. 7). The average cross-sectional area of the right and left VA’s was 1.55 and 3.60 mm, respectively. Manual Therapy (2003) 8(2), 120–127


123

Fig. 3—Transcranial Doppler ultrasonographic image of the right vertebral artery at Zone III with the subject in neutral. The top graph shows a solid line representing the depth (61 mm) of penetration of ultrasound wave at the vertebral artery level. The bottom graph shows a wave that represents the peak flow velocity spike (systolic: 57 cm/s) and diastolic flow (30 cm/s).

Fig. 4—Transcranial Doppler ultrasonographic image of the right vertebral artery in the left extended/rotated position. The top graph reveals that the ultrasound probe is detecting minimal flow (solid white line) at a depth of 62 mm. Flow of the right vertebral artery is not detectable in this position.

DISCUSSION Vertebral artery blood flow velocity studies originated on the premise that cervical spine rotation had a direct mechanical occlusive effect on a vertebral artery; therefore, manifesting vertebrobasilar insufficiency symptomology due to ischemia via ‘pinching’ of that artery. Based on anatomic and cadaveric studies, early researchers postulated that instantaneous blood flow compromise in the vertebral artery, Manual Therapy (2003) 8(2), 120–127

via combined extension/rotation of the cervical spine, could elicit vertebrobasilar symptoms. Tatlow and Bammer (1957) in their postmortem angiographic study of the atlantoaxial joint noted that the vertebral artery could be occluded on rotation. Toole and Tucker (1960) concurred with this single premise of contralateral VA occlusion, as did Brown and Tatlow (1963) in their classic cadaveric study. In their in vivo investigation of functional haemodynamic impairment associated with neck rotation, Weintraub and r 2003 Elsevier Science Ltd. All rights reserved.

124 Manual Therapy

Fig. 5—CT three-dimensional reconstruction anterior image of the cervical spine in neutral comparing the left vertebral artery to the right hypoplastic vertebral artery.

Fig. 6—CT three-dimensional lateral reconstruction image of the right vertebral artery exhibiting a hypoplastic artery. The subject is in the pre-manipulative (left rotation and extension) position. Vertebral artery: small arrows. Mechanical deformation of the VA: large arrow.

Khoury (1995) utilized dynamic magnetic resonance angiography. They demonstrated that head rotation consistently produced compression and occlusion of the contralateral VA at the atlantoaxial segment. They concluded that such compression and associated occlusion was a cause for arterial damage, and that the majority of the VA impingement was the result of a downward shift of the contralateral atlas while the vertebral artery was fixed. This impingement of the artery, with the neck in a rotated and r 2003 Elsevier Science Ltd. All rights reserved.

hyperextended position lead to profound VA occlusion leading to hypoperfusion. One poignant question remains: is this subject more at risk of a vertebrobasilar insufficiency episode by performing the screening test and in doing so, mechanically/ traumatically compromising the contralateral artery regardless of blood flow alteration? Symons et al. (2002) investigated the strains sustained by the vertebral arteries with the use of piezoelectric sonographic crystals sutured on the Manual Therapy (2003) 8(2), 120–127


Fig. 7—Axial intracranial CT inferior image of the left vertebral artery as it initially punctures the tectorial membrane before it anastomoses to the basilar artery (large cursor arrow). Note there is no comparable right vertebral artery in the image due to its’ atretic nature at C1.

cephalad/distal (C0–C1) and caudad/proximal (C6subclavian) loops of the vertebral artery. In their novel approach, they studied in situ cadaveric vertebral arteries when placing the cervical spine in cardinal plane positions and in combined extension/ rotation. Generally, they found that the strains experienced by the vertebral artery contralateral to the side subjected to testing were greater than the ipsilateral VA. The distal (C0–C1) loop was typically subjected to more strain during the same procedure than the proximal segment. They found the greatest strains, which were calculated as a percentage elongation of the mean length of the vertebral artery with the neck in a neutral position, was rotation (12.5%). Vertebrobasilar testing (extension/rotation) resulted in strains of 11.8% in the distal loop of the contralateral VA; comparable to strains generated in extreme rotation. Based on the TCD results, this study tends to support direct contralateral vessel occlusive strain in the extreme extended/rotated position. Of interest in this case report is the lack of symptom provocation when the subject was placed in a right rotated/extended position. Due to the subject’s right atretic artery, one would anticipate vertebrobasilar insufficiency symptoms when positioned in right rotation/extension. Theoretically, the contralateral (left, in this case) vertebral artery is mechanically occluded and the right vertebral artery does not anastomose intracranially. One possible explanation for this false-negative result is due to collateral circulation pathway compensation. AnManual Therapy (2003) 8(2), 120–127

125

other reason could be that although the VA is atretic, it could anastomose to the collaterals such as the anterior and posterior communicating arteries and therefore, still supply the intracranial structures. The internal and external carotid arteries are also main vessels for brain perfusion. The anterior and posterior communicating spinal arteries are tributaries that nourish the brainstem and communicate with the vertebral arteries. In addition, the cervical and radicular branches form anastomoses between the vertebral arteries and the external carotids. Theoretically, the brainstem and brain will be continuously fed if one of these arteries is compromised in any way. If both vertebral arteries were compromised in the right rotated/extended position, and theoretical constructs support they should, one would expect vertebrobasilar insufficiency. This was not, however, observed in this subject. Rivett et al. (1998), in their case report of an asymptomatic subject with a completely occluded VA in right rotation/extension, support the premise of compensatory collateral circulation. Their subject was placed in the right pre-manipulative position for 60 s and duplex Doppler was conducted on the contralateral vertebral artery extracranially. The left VA displayed complete occlusion on repeated sonographic investigations. However, they noted a progressive decrease in flow of the left internal carotid artery with successive positions of rotation. They concluded that the pre-manipulative tests were evaluating the status of the collateral arterial network in the presence of a compromised contralateral vertebral artery. Intracranial and extracranial arterial autoregulation may be the mechanism that maintains adequate brainstem perfusion. Budgell and Sato (1997) suggest that autoregulation and compensatory blood flow through the collateral branches make it unlikely that occlusion of a vertebral artery would compromise flow to the brain. Autoregulation can alter the diameter of cerebral vessels, and may be used as a mechanism to maintain a relatively constant blood flow over a wide range of mean arterial pressures. Blood vessel autoregulation is most likely achieved by a combination of metabolic, myogenic and neurogenic mechanisms. This being said, Symons and Westaway (2001) in their discussion of a revised Virchow’s Triad model, state that abnormal blood flow is a potential thrombogenic factor. The premanipulative position gives evidence that there is a change in blood flow in the contralateral VA and by progressively occluding the vessel may manifest turbulent flow. Is the subject (patient) at risk of possible vertebrobasilar ischemia through this turbulent blood flow and thus, activating the clotting process? In this case report, the subject remained asymptomatic either because the collateral circulation network supplied enough blood to the brain as the r 2003 Elsevier Science Ltd. All rights reserved.

126 Manual Therapy

vertebral arteries were occluded or the vertebral arteries were not occluded completely in the experimental position and hence perfusion to the brain was maintained. We maintained an 80-s experimental position hold on the subject to ensure there was sufficient time to allow for arterial adaptation and occlusion. One shortcoming of this case report is not having simultaneous TCD data on both internal carotid arteries and vertebral arteries to see if there is a significant change in ipsilateral and/or contralateral blood flow. Unfortunately, the TCD data were never intended for the left VA with the subject’s neck in a right rotated/extended position. Our larger study was interested in how left physiological atlantoaxial rotation effects Zone III contralateral VA deformation. Although the patient was placed in right rotation and extension on numerous occasions and presented as asymptomatic, it was not apparent to the authors that the subject was hypoplastic and atretic until 2 days later when the CT scan axial images were reconstructed three dimensionally. Cavdar et al. (1996) reported that the vertebral artery does not have a constant calibre (diameter) during its course within the foramina transversaria. The VA entering the foramina reduced its diameter and further continued to reduce until the C3 level. Above C3, the VA began to increase in caliber until at C1, it reached its largest diameter. In order to assess mean diameters and blood flow velocity of the vertebral arteries, Lovrencic-Huzjan et al. (1998) conducted color Doppler flow imaging on 596 individuals without pathology. Mean right vertebral artery diameter was 3.3770.6 mm and left, 3.5570.61 mm. The left VA is generally regarded as the dominant artery as is the case in this subject. With a right VA mean diameter of 1.55 mm, our subject is defined as hypoplastic and the left VA is considered dominant with a normative diameter of 3.60 mm. This subject could present, unbeknownst to the clinician, as somewhat of a worse case scenario if high-velocity, low-amplitude manipulation was being contemplated as a treatment option. The subject did not present with any cervical spine pain and she had a 5 mm ADI, which clinically constitutes an atlantoaxial instability (Locke et al. 1966). Instability to the atlantoaxial motion segment is contraindicated for high-velocity low-amplitude thrust techniques along with the fact that the subject is rheumatoid arthritic (Dvorak 1991). Designating specific anatomical landmarks on the C0–C3 vertebrae, three-dimensional left rotation calculation using matrix algebra revealed relative C1/2 axial rotation of approximately 38.761. Dumas et al. (1996) demonstrated with magnetic resonance imaging that atlantoaxial axial rotation greater than 351 compressed the contralateral VA. This subject presented with 391 rotation. The right vertebral artery was mechanically stressed by spinal structures evidenced by blood flow velocity change r 2003 Elsevier Science Ltd. All rights reserved.

and three dimensional CT scan imaging (Fig. 6). Therefore, it is speculated that the subject could be at risk of arterial trauma if manipulative procedures were employed, particularly those methods with endrange rotation.

CONCLUSION This case report has been presented to highlight an asymptomatic subject with a radiographically unstable atlantoaxial segment. In addition, the subject presented with a concomitant hypoplastic and atretic artery. This subject, however, tested negative on bilateral extended/rotated pre-manipulative screening positions. The lack of symptom provocation may be due to a patent collateral circulatory system or continued undetectable patency of the vertebral arteries. The predictive value of such a pre-manipulative screening test is questioned based on a falsenegative result for a subject with specific parameters that theoretically should produce vertebrobasilar insufficiency signs and symptoms.

Acknowledgements The authors would like to acknowledge the contributions made by the following individuals; Drs Andrew Demchuk MD FRCP(C), William Hu MD FRCP(C) and Mr Larry Curtis RTR. The authors would like to thank Drs Walter Herzog PhD and Murray Maitland PT PhD for their assistance. This manuscript was financially supported by LifeMARK Health, Toronto, Ontario.

References Brown BSJ, Tatlow WF 1963 Radiographic studies of the vertebral arteries in cadavers. Radiology 81: 80–88 Budgell B, Sato A 1997 The cervical subluxation and regional cerebral blood flow. Journal of Manipulative and Physiological Therapeutics 20(2): 103–107 Cavdar S, Dalcik H, Ercan F, Arbak S, Arifoglu Y 1996 A morphological study on the V2 segment of the vertebral artery. Okajimas Anatomes of Japan 73(2–3): 133–137 Cote P, Kreitz B, Cassidy D, 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): 159–164 DeKleyn A, Nieuwenhuyse P 1927 Schwindelanfaelle und nystagmus bei einer bestimmten stellung des kopfes. Acta Otolaryngology 11: 155 Dumas J-L, Salama J, Dreyfus P, Thoreux P, Goldlust D, Chevrel J-P 1996 Magnetic resonance angiographic analysis of atlantoaxial rotation: Anatomic bases of compression of the vertebral arteries. Surgical Radiological Anatomy;18: 303–313 Dvorak J 1991 Inappropriate indications and contraindications for manual therapy. Journal of Manual Medicine 6: 85–88 Haldeman S, Kohlbeck FJ, McGregor M 2002 Unpredictability of cerebrovascular ischaemia associated with cervical spine manipulation therapy: a review of 64 cases after cervical spine manipulation. Spine 27(1): 49–55 Hufnagel A, Hammers A, Schonle PW, Bohm KD, Leonhardt 1999 Stroke following chiropractic manipulation of the cervical spine. Journal of Neurology 246(8): 683–688 Manual Therapy (2003) 8(2), 120–127


Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG 1996 Manipulation and mobilization of the cervical spine. A systematic review of the literature. Spine 21(15): 1746–1755 Locke GR, Gardener JI, Van Epps EF 1966 Atlas-dens interval (ADI) in children: A survey based on 200 normal cervical spines. American Journal of Radiology 97: 135–140 Lovrencic-Huzjan A, Demarin V, Rundek T, Vukovic V 1998 Role of vertebral artery hypoplasia in migraine. Cephalgia 18(10): 684–686 Rivett DA, Milburn PD, Chapple C 1998 Negative pre-manipulative vertebral artery testing despite complete occlusion: A case of false negativity. Manual Therapy 3(2): 102–107 Symons BP, Leonard T, Herzog W 2002 Internal forces sustained by the vertebral artery during spinal manipulative therapy.

Manual Therapy (2003) 8(2), 120–127

127

Journal of Manipulative and Physiological Therapeutics 25(8): 504–510 Symons BP, Westaway M 2001 Virchow’s Triad and spinal manipulative therapy of the cervical spine. Journal of Canadian Chiropractic Association 45(4): 225–231 Tatlow WF, Bammer HG 1957 Syndrome of vertebral artery compression. Neurology 7: 331–340 Toole JF, Tucker SM 1960 Influence of head position upon cerebral circulation: Studies on blood flow in cadavers. Archives of Neurology 2: 616–623 Weintraub MI, Khoury A 1995 Critical neck position as an independent risk factor for posterior circulation stroke. A magnetic resonance angiographic analysis. Journal of Neuroimaging 5: 16–22


Manual Therapy (2003) 8(2), 128

Diary of events

Pain in Europe IV: 4th Congress of the European Federation of IASP Chapters (EFIC). Organizing Secretariat: Congress Business Travel Ltd (CBT), Sˇteˇpańska´ 6/535, 120 00 Prague 2, Czech Republic. Tel: +420-2-2494-2575; Fax: +420-2-2494-2550; E-mail: [email protected] www.pain2003.cz

Website: Our website will be continually updated as further information becomes available – please keep watching: www.uct.ac.za/depgc/pgc/ Enquiries: If you would like further information, please send an expression of interest to: Sally Elliott, Conference Management Centre, UCT Medical School, Anzio Road, Observatory 7925, Cape Town, South Africa Tel: +27 21 406-6381; Fax: +27 21 448-6263; E-mail: [email protected]

21–22 November 2003, London, UK

21–26 August 2005, Sydney, Australia

10th Anniversary Symposium on Complementary Health Care. It is an international symposium with a focus on original research and comprises two days of platform and poster presentations as well as pre-conference workshops and satellite meetings. Contact: Barbara Wider, Complementary Medicine, Peninsular Medical School, Universities of Exeter & Plymouth, 25 Victoria Park Road, Exeter EX2 4NT, UK. E-mail: [email protected] Website: www.exeter.ac.uk/FACT/sympo

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

2–6 September 2003, Prague, Czech Republic

27–30 November 2003, Sydney, Australia 13th Biennial Conference of Musculoskeletal physiotherapy Australia—Best Evidence Better Care. Includes Multidisciplinary Whiplash Symposium. Sydney Australia, Contact: Linda Phillips 2003 Conference Secretariat, GPO Box 2609 Sydney, Australia. Tel.: 61-02-9241-1478; Fax: 61-02-9251-3552; E-mail: [email protected]; Website: www.mpa2003.com

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

21–26 March 2004 8th IFOMT Congress (International Federation of Manipulative Therapy), International Convention Centre, Cape Town, South Africa. This promises to be one of the most exciting events in the history of physiotherapy in South Africa and you are encouraged to start your planning now. The theme for the conference is ‘‘Balancing the Outcome of Manual Therapy.’’ The programme will range from research based to clinical outcomes papers. Several speakers of international standing have indicated their willingness to participate. The programme will include sessions on Pain, Outcome Based Research, Community and Industrial Considerations, Musculo-Skeletal Spinal and Peripheral Dysfunctions.

Evidence-based manual therapy congress Further information: www.medicongress.com

Intensive courses in Manual Therapy Further information: http://allserv.rug.ac.be/bvthillo

If you wish to advertise a course/conference, please contact: Karen Beeton, Department of Physiotherapy, University of Hertfordshire, College Lane, Hatfield, Herts AL10 9AB, UK. There is no charge for this service.

128

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Manual Therapy Journal - Volume 9, Issue 3, Pages 123-182 (August 2004)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Manual Therapy Journal - Volume 9, Issue 3, Pages 123-182 (August 2004)

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

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

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

Recommend Documents