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

VOLUME 9 NUMBER 4 PAGES 183– 246 NOVEMBER 2004 Editors International Advisory Board Ann Moore PhD, GradDipPhys, FCSP,...

Author: Editors: Ann Moore and Gwen Jull

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VOLUME 9 NUMBER 4 PAGES 183– 246 NOVEMBER 2004

Editors

International Advisory Board

Ann Moore PhD, GradDipPhys, FCSP, CertEd, MMACP Clinical Research Centre for Healthcare Professions University of Brighton Aldro Building, 49 Darley Road Eastbourne BN20 7UR, UK

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

Gwendolen Jull PhD, MPhty, Grad Dip ManTher, FACP Department of Physiotherapy University of Queensland Brisbane QLD 4072, Australia Editorial Committee Karen Beeton MPhty, BSc(Hons), MCSP MACP ex o⁄cio member Department of Allied Health Professions—Physiotherapy University of Hertfordshire College Lane Hat¢eld AL10 9AB, UK Je¡rey D. Boyling MSc, BPhty, GradDipAdvManTher, MAPA, MCSP, MErgS Je¡rey Boyling Associates Broadway Chambers Hammersmith Broadway London W6 7AF, UK Darren A. Rivett PhD, MAppSc (ManiPhty) GradDip ManipTher, BAppSc (Phty) Discipline of Physiotherapy Faculty of Health The University of Newcastle Callaghan, NSW 2308, Australia Kevin P. Singer PhD Centre for Musculoskeletal Studies Department of Surgery The University of Western Australia, Royal Perth Hospital Level 2, MRF Building, 50 rear, Murray Street Perth,WA 6000, Australia Raymond Swinkels MSc, PT, MT (Book Review editor and NVMTex o⁄cio member) Ulenpas 80 5655 JD Eindoven The Netherlands

Visit the journal website at http://www.elsevierhealth.com/journals/math doi: 10.1016/S1356-689X(04)00089-X

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Manual Therapy 9 (2004) 183–184

www.elsevier.com/locate/math

Editorial

How to evaluate manual therapy: value and pitfalls of randomized clinical trials There are many possibilities to investigate the effects of manual therapy varying from case studies, case series, nonor quasi-experimental studies with control groups and finally the true experimental designs (in medical research approached by the design of a randomized clinical trial (RCT)). All designs are frequently used and all have their relative strengths and weaknesses. I argue that the RCT is the design of first choice in manual therapy research when it comes to answering questions like ‘is the new (or old) intervention more effective than no therapy at all, a placebo treatment or another existing therapy?’ The RCT is characterized by the use of one or more control groups and random allocation of the patients. Often blinding of therapists, patients and outcomes assessment is included. Due to its potential to control for different forms of bias, the RCT is by many people considered to be the ‘gold standard’ for intervention research. There already have been carried out and published quite a number of RCTs within the field of manual therapy. It is no secret however, that many trials carried out in the past showed important methodological shortcomings, thereby threatening the internal validity of the study and making it difficult to interpret the study results. For many manual therapeutic interventions it holds that currently there is insufficient evidence to draw conclusions regarding their effects. Clearly, there seems to be a need for more and better RCTs in this area. There exist, however, a number of potential drawbacks of RCTs. They usually are time consuming. Three to four years seem to be quite normal periods for such trials, making them quite costly. The mean costs for a (medium sized; n=100–200) randomized clinical trial will be about US$500.000. Other comments on RCTs include that randomizing patients to, for example, a placebo treatment group or a no-treatment group is unethical. However, only after the conduct of RCTs do we have valid information that the intervention under study is doing more good than harm. So, we may ask ourselves whether it is ethical to treat patients with therapies with unknown effects. Another criticism is that in previously conducted RCTs often isolated parts of a manual therapeutic intervention have been investigated which may not reflect the situation in daily clinical practice. This may indeed be a problem. However, this is 1356-689X/$ - see front matter r 2004 Published by Elsevier Ltd. doi:10.1016/j.math.2004.04.002

not a characteristic of an RCT in which it certainly is possible to investigate a ‘full’ manual therapeutic treatment for example in comparison with a drug treatment. Of course before starting a RCT one must always consider whether the research question is clinically relevant. Finally, the conduct of a randomized clinical trial is not an easy job. Frequently encountered methodological problems of randomized clinical trials in the field of manual therapy concern the following topics. 1. Prognostic homogeneous study populations In randomized clinical trials one usually attempts to include a prognostic homogeneous study group, which will likely respond to the experimental intervention(s) under study. However, in the available randomized clinical trials it appears that often rather heterogeneous study groups were included. This may hamper finding a treatment effect if, for instance, an intervention is effective only for a subset of the population. In this case the positive effect in this subgroup will be diluted due to the absence of effect in the complementary subgroups. 2. Standardization of interventions On occasions one may read that the experimental or control treatments in a study consisted of manual therapy/physiotherapy at the discretion of the participating therapist. It is obvious that, with a description like this, readers of are not well informed of the kind of therapy that was investigated in the study at issue. For generalizibility of study findings it is essential that the type, the intensity, the frequency and duration of the treatment is sufficiently described in order to make it possible to replicate the therapy elsewhere. It is not always necessary and/or feasible to develop a strict treatment protocol. In such cases, it is certainly permissable to work with some kind of treatment algorithm, in which the steps in the treatment path depend on the outcome of a previous step. In any case in the absence of a clear treatment protocol or algorithm, a clear description of the actual treatment applied in the study should be recorded and presented. 3. Blinding of patients, and therapists and outcome measurement

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Editorial / Manual Therapy 9 (2004) 183–184

Blinding at several levels is one of the important features in a randomized clinical trial. In trials in manual therapy blinding is often problematic. 3a. Blinding of patients is hampered by the fact that, from the content of the manual therapy, the patient in most cases will know which treatment he/she receives. Blinding patients by including a placebo treatment may not always be possible because a good and trustworthy placebo cannot be developed. For example, placebo exercise therapy, or placebo spinal manipulation appear to be difficult to develop. Since knowledge by the patient may influence the outcome of a trial some measures may need to be taken. During the selection process of patients, one may ask the potential participant about their treatment preferences, and may decide only to include patients with no strong preferences for or against the treatments included in the study. In the same way, patients with extensive previous experiences with one of the investigated treatments may also be excluded. 3b. Blinding of therapists will not be possible in most trials evaluating manual therapy. Due to the nature of the manual treatment the participating therapist will have actual knowledge of the treatment that he/she applies. Also in this case some attention to treatment preferences of therapist may be needed. Ideally, the therapists of the various study treatments should be equally positive, etc., regarding the delivery of the treatment. Especially, in studies in which a placebo therapy has to be convincingly delivered this may cause problems for the therapists. This delivery may have to be practised extensively before the start of the trial. 3c. Blinding of outcome measurement has also been problematic in previous randomized clinical trials. Blinding of patients and therapist is often not satisfactorily feasible as stated above. In addition, the outcome assessment often includes a subjective rating of pain and functioning. In these cases, the only available method to include at least partial blinded outcome measurement is to use a blinded independent observer. This observer should assess the patient without knowledge of the assigned therapy. In randomized clinical trials published in the last few years this method seems to have become more common. 4. Small sample sizes Although sample size deals more with the precision of the estimation of effect and not necessarily with the validity of the study, it remains an important aspect of a trial. In manual therapy, the randomized clinical trials usually include small sample sizes (i.e. less than 50 patients per study group). Because of this there might be a problem in detecting a (statistically significant) small but true treatment effect. This is sometimes called a type II-error and is caused by the low (statistical) power of small studies to detect small but clinically relevant treatment effects.

Another problem with small sample sizes is that the comparability of the study groups at baseline may be in danger. Only with increasing numbers of randomized patients do we have some assurance that known, but also unknown, prognostic factors will be evenly distributed over the study groups. 5. Drop outs/loss to follow-up The last methodological flaw relates to the description of dropouts of a study. If patient dropout occurs it is essential to know and report the reason for this dropping out. Patients may drop out because they are completely recovered or because they feel worse than ever. Knowledge of this is especially needed if the dropout rate is selective (i.e. occurs mainly in one of the study groups). Loss to follow-up may also be substantial in trials of physiotherapy. Loss to follow-up relates to the number of patients participating in the outcome assessment. It is obvious that if there are large numbers of loss to follow-up (>20%) that the outcome of the study can be much influenced. Again, this is even more problematic if the loss to follow-up is selective. It is possible, however, to deal with selective follow-up in the analysis phase of a study. Additional analysis, for example a ‘worst case analysis’ could be carried out. In conclusion, randomized clinical trials clearly have their strengths and weaknesses. They appear to be a powerful research tool for answering questions on the efficacy of interventions. Despite some problems with the conduct of randomized clinical trials, which mainly relate to problems with blinding of patients, therapists (and consequently the outcome assessment), it is certainly possible to carry out high-quality studies in this area. It will take, however, an open mind and courage of the manual therapeutic professions to go (further) into the direction of evidence-based-manual therapy and to conduct RCTs. Not all interventions, which currently are applied, will be shown to be effective. In this case the profession itself must be prepared to stop applying those treatments and focus on the interventions, which do turn out to be effective. Of course, other types of research aimed at increasing ‘the body of knowledge’ of manual therapy also should be carried out. Basic sciences, including animal studies and biomechanical work are needed to develop new therapies, improve old therapies, etc. At the end of the day however, only by conducting high-quality RCTs will we be able to collect evidence whether the new therapies are (cost-) effective or not.

Bart W. Koes (Guest editor) Department of General Practice, Erasmus MC University Medical Center Rotterdam, P.O. Box 1738 3000 Rotterdam, The Netherlands

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Manual Therapy 9 (2004) 185–196 www.elsevier.com/locate/math

Masterclass

Foot orthotics in the treatment of lower limb conditions: a musculoskeletal physiotherapy perspective Bill Vicenzino Physiotherapy Division, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland 4072, Australia Received 30 July 2004; accepted 9 August 2004

Abstract Orthotic therapy is frequently advocated for the treatment of musculoskeletal pain and injury of the lower limb. The clinical efficacy, mechanical effects, and underlying mechanism of the action of foot orthotics has not been conclusively determined making it difficult for practitioners to agree on a reliable and valid clinical approach to their application and indeed even their fabrication. This problem is compounded by evidence suggesting that the most commonly used approach for orthotic prescription, the (Biomechanical Evaluation of the Foot. Vol. 1. Clinical Biomechanics Corporation, Los Angeles, 1971) approach, has poor validity and many of the associated clinical measurements of that approach lack adequate levels of reliability. This paper proposes a new approach that is based on two key elements. One is the identification, verification and quantification of physical tasks that serve as client specific outcome measures. The second is the application of specific physical manipulations during the performance of these physical tasks. The physical manipulations are selected on the basis of motion dysfunction and their immediate effects on the client specific outcome measures serve as the basis to making an informed decision on the propriety of using orthotics in individual clients. The motion dysfunction also guides the type of orthotic that is applied. Practical case examples as well as generic and specific guidelines to the application of this clinical assessment process and orthotics are provided in this paper. r 2004 Published by Elsevier Ltd.

1. Introduction Musculoskeletal pain and injury is a negative consequence of participating in physical activities, such as walking and running, that are frequently prescribed and recommended to aid in preventing or overcoming the diseases of increasingly sedentary lifestyles. Abnormal lower limb biomechanics are often associated with lower limb musculoskeletal conditions (James et al., 1978; Tiberio, 1987, 1988) and the use of orthotics is frequently advocated in their treatment (Sobel et al., 1999). A popular clinical approach to the prescription and fabrication of orthotics is based on the Root et al. (1971) paradigm (McPoil and Hunt, 1995; Lang et al., 1997; Landorf et al., 2001), which in essence is a mechanical approach based on the premise that correct Tel.: +61-7-3365-2781; fax: +61-7-3365-2275.

E-mail address: [email protected] (B. Vicenzino). 1356-689X/$ - see front matter r 2004 Published by Elsevier Ltd. doi:10.1016/j.math.2004.08.003

mechanical alignment of the foot and lower limb is required normal function. The clinical corollary of this concept is that the mechanical approach can be used as a basis to prevent or treat musculoskeletal injuries. Interestingly, recent laboratory evidence questions the ability of orthotics to systematically alter mechanical alignment of the rearfoot (Heiderscheit et al., 2001; Nigg et al., 1999; Stacoff et al., 2000), which seriously challenges the validity of the Root et al. (1971) paradigm. McPoil and Hunt (1995) reviewed the available literature pertaining to the Root et al. (1971) scheme of evaluating and treating foot disorders. They identified serious concerns regarding the ongoing clinical application of this traditional means of prescribing orthotics. Notably, McPoil and Hunt (1995) reported that several underlying suppositions were not reliable or valid. For example, the notion that the subtalar joint neutral position is the position of the rearfoot during mid-stance


B. Vicenzino / Manual Therapy 9 (2004) 185–196

(Root et al., 1971, 1977) was not evident when evaluated in a gait laboratory (McPoil and Cornwall, 1994). In addition, the physical measurements recommended by Root et al. (1977) to evaluate the foot structure and function were found to be unreliable and hence of little utility to the clinician (McPoil and Hunt, 1995). In response to this mounting evidence against the Root et al. (1971) schema for assessment and treatment of foot disorders, McPoil and Hunt (1995) proposed an alternative model for evaluating and managing foot and ankle problems, which they termed the ‘tissue-stress model’. In utilizing this ‘tissue-stress model’ in the assessment and management of foot and ankle problems, they suggested that the objective of the clinical examination was to identify symptomatic tissues that were undergoing excessive stress and then, in a complimentary manner, to include strategies to alleviate this stress in the treatment program. The inclusion of strategies to alleviate the stress in the identified tissues would be in addition to the conventional physical therapy modalities of exercise to treat impaired muscles and electrophysical agents to reduce inflammation and pain. The strategies that are usually used to reduce stress in symptomatic tissues in the lower limb are external physical devices such as orthotics, strapping tape and braces. A recent survey of podiatrists, a profession that is widely associated with the prescription of foot orthotics, has shown that despite the evidence reported by McPoil and Hunt (1995), the majority of podiatrists still utilize the Root et al. (1971, 1977) schema when prescribing orthotics (Landorf et al., 2001). The recent survey of Landorf et al. (2001) indicates that the ‘tissue-stress model’ has not been widely adopted in clinical practice. Indeed, a 1997 Masterclass on the static biomechanical evaluation of the foot referred to the Root et al. (1971) scheme as the basis of the physical examination (Lang et al., 1997). One possible reason for this apparently low uptake of the ‘tissue-stress model’ is that it may not have provided the practitioner with a conveniently pragmatic approach to the prescription and application of foot orthotics that may be viewed as superior to that proposed by Root et al. (1971, 1977). Furthermore, orthotics often impose an additional significant financial burden onto the client. If for no other reason, it would seem that there is a need for a practical and simple approach to the prescription of orthotics by which both the practitioner and client can readily make an informed decision on their application. A practical, simple yet seemingly effective approach that we have employed in clinic, termed the treatment direction test (TDT), seeks to overcome the impasse that was highlighted in the preceding section. In brief, the TDT is part of the physical examination that addresses specifically the propriety of prescribing and applying orthotics not only for foot and ankle problems, but also

for any lower limb musculoskeletal disorder for which there is a putative biomechanical aetiological basis. It is adjunctive and complimentary to the ‘tissue-stress model’ of McPoil and Hunt (1995), in that it is an additional physical examination procedure. This Masterclass outlines the TDT by describing it in detail and presenting case studies that provide practitioners with exemplars from which to develop and apply the approach in their clinics.

2. Treatment direction test for foot orthotic therapy: generic overview The TDT consists of a number of iterations of physical activity performed by the client as well as physical manipulations performed on the client by the practitioner. The express aim is to determine the suitability of orthotic devices in the management of the lower limb musculoskeletal condition (Fig. 1). The central feature of the TDT is the identification of physical activities or tasks with which the client has difficulties, particularly tasks that provoke pain and discomfort. Identification of these tasks occurs in the

Fig. 1. Flowchart overview of the treatment direction test (TDT) concept designed to enhance the decision making process in orthotic therapy. Note that the key elements are the Client Specific Outcome Measure and the application of a Physical Manipulation. The Client Specific Outcome Measure is usually a physical task that exacerbates the symptoms and is responsible for the client seeking help from the health care professional. The practitioner assesses both the quality of motion and the quantity of motion to the first onset of symptoms. Then by selecting and applying Physical Manipulations (e.g. tape, felt padding), which is specific to the observed motion impairment, the practitioner makes a decision on the basis of this flow chart. Note that to be improved by 75% means that the change from baseline is 75% larger than the baseline measure. For example, if on first assessing the Client Specific Outcome Measure the client could jog for 50 m to first onset of pain, for a positive TDT then the client would have to jog for 87.5 m (i.e. 50+(75% of 50)) with the specific Physical Manipulation in situ. In practice, the Client Specific Outcome Measure is usually either markedly improved with the Physical Manipulation applied (i.e. no pain with 1000 m jogging) or not.

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interview and then verification that the physical activity reproduces symptoms occurs in the physical examination, in most cases at the outset of the physical examination. Following verification that the physical activity is provocative of the client’s symptoms, it is essential that the practitioner quantifies the amount of physical activity that is required to bring about the first onset of pain (i.e. a pain threshold test). While doing this, the practitioner also observes the motion of the foot during the physical activity to identify any aberration from normal or ideal motion patterns. In the event that there are aberrant motion patterns, the practitioner then applies specific physical manipulations, which are based on the observed aberrant motions. The foot is, the area of the lower limb to which the TDT will be applied in this Masterclass (noting that TDT concept can be applied to all motion segments of the lower limb). The physical manipulations usually take the form of adhesive strapping tape or temporary felt orthotics. Then, with the physical manipulations in situ, the client is asked to perform the specific pain-provoking physical activities that were previously identified and verified. The TDT is deemed to be positive if there is an improvement in the motion pattern and more importantly if there is a substantial increase of the quantity of physical activity to the first onset of pain (Fig. 1). A positive TDT implies that there will be a positive outcome to orthotic therapy. If there is no change in the amount of physical activity taken to first bring on the pain with the physical manipulation in place, then the TDT is deemed to be negative, meaning that an orthotic is not likely to be successful in this instance. In a practical sense, anecdotal evidence suggests that the likelihood of success with subsequent application of an orthotic is most probably greatest if the improvement in the quantity of physical activity is in the order of 75% of baseline or higher (i.e. substantial improvements). Certainly it would appear logical that if there was only about a 50% change from baseline level (or lower) during the application of the physical manipulation in the TDT it would be likely that there will be a lower level of success with any subsequent application of orthotics.

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3. Treatment direction test for foot orthotic therapy: specific application In dealing with the specific application of the TDT, the following sections will deal with the assessment of patterns of foot motion during gait. The identification of some commonly seen aberrant foot motion patterns and several physical manipulations specific to these aberrant motion patterns will be outlined. Guidelines for orthotic prescription and application, as well as a description of several case studies that will highlight various aspects of the practical application of the TDT will be presented. 3.1. Assessing quality and quantity of the client specific physical activity To demonstrate a specific application of the TDT, this paper will restrict the physical activity to a walking task. Quantification of the load to pain threshold could then be distance walked, number of steps taken and/or time taken to the first onset of pain. Thus quantification of the task to pain threshold is reasonably simple. The identification of aberrant foot motion during gait is somewhat more difficult and requires a developed observational skill, and if possible, the assistance of a digital video camera by which the motion may be captured and then observed within a slower timeframe. In cases of lower limb musculoskeletal pain in which abnormal pronation has been suggested as a causative factor (Sobel et al., 1999), it is important to observe gait for any deviation from the ideal pattern of motion. A textbook on gait analysis such as that of Perry (1993) is of considerable help when developing higher-level observational skills of motion during gait. The use of movement diagrams (e.g. Figs. 2–5), in which the x-axis represents time expressed as a proportion of the total gait cycle and the y-axis represents motion, is of considerable value in communicating concepts regarding the identification of aberrant motions. An ideal pattern of motion of the foot during stance phase is shown in a movement diagram in Fig. 2, in which the foot strikes the floor on the posterolateral heel region in a relative neutral position before

Fig. 2. Movement diagram for the ideal rearfoot motion pattern in the frontal plane (supination-pronation movement of the calcaneum relative to the leg shown on the y-axis representing inversion–eversion, respectively) across time (x-axis, showing temporal characteristics displayed as a percent of total cycle). Adapted from Wright DG, Desai SM, Henderson WH. Action of the subtalar and ankle-joint complex during the stance phase of walking. Journal of Bone and Joint Surgery 1964;46A:361–82.



Fig. 3. Movement diagram example of an excessive pronator (continuous line) demonstrating differences from the ideal gait motion pattern of the rearfoot (dotted line). Diagram A shows an ideal contact posture with an initial excessive amount of pronation whereas diagram B shows excessive pronation at contact.

Fig. 4. An example of a supinator pattern of foot motion (continuous line) demonstrating contact in a supinated position followed by a small quick increase in supination soon after. Pronation occurs somewhere later in stance phase and is small and quick. Notice the distinct contrast to the ideal foot motion pattern (dotted line).

Fig. 5. An example movement diagram of a prolonged pronation motion pattern (continuous line) in which the early stages of stance phase are normal but there is no re-supination during mid-stance. Dotted line is ideal pattern.

undergoing rapid pronation of approximately 3–51 in the first 5–10% of the gait cycle (Perry, 1993). The foot then remains in this position for another 5–10% of the gait cycle before re-supinating towards the middle and end of stance phase. For lower limb musculoskeletal conditions with a putative genesis in abnormal foot pronation, the identification of non-ideal gait patterns involves observation of the stance phase of gait for both the quantity of pronation (excessive or lack thereof) and

also the timing of pronation (early, late). A commonly described abnormality of pronation is excessive pronation, so labelled because the rearfoot undergoes an increased range of pronation during the first part of the stance phase, notably at contact and weight acceptance (Fig. 3). This may or may not be preceded by pronation occurring in terminal swing phase usually observed as floor contact on the medial aspect of the heel. Another, not so widely described pattern of abnormal pronation is one in which there is not only a lack of


pronation but also a markedly different pattern of motion during stance phase. This foot motion pattern during gait is termed a supinator pattern (Fig. 4). This pattern involves a slight but rapid supination (inversion) as its first movement on ground contact and loading such that at foot flat, the rearfoot is relatively inverted to the distal leg and also usually to the floor. This position remains for much of the early part of mid-stance. In those who have some flexibility in their foot, the foot then undergoes a rapid and small amount of pronation in the last part of stance phase, usually at around heel off. The reader will recognize that this is almost opposite to the ideal gait pattern described above and normal patterns reported from kinematic studies. The previously described motion patterns involve both the initial contact and loading part of stance phase as well as mid-stance through to terminal stance phases of gait. There is also a motion aberration that occurs in mid-stance through to terminal stance, known as prolonged pronation or mid-stance pronation. In this gait pattern the foot motion in contact and loading phases were as for the ideal pattern, but instead of undergoing re-supination the foot remains pronated in mid- to late-stance phase of gait (Fig. 5). This pattern of motion is not to be confused with that which occurs in mid- to late-stance phase of gait in the excessive pronator or supinator patterns of motion, in which there will also be a degree of pronated posture observed. 3.2. TDT for excessive pronator motion patterns There are two basic types of physical manipulations for TDT of excessive pronators, one involving adhesive strapping tape (Hadley et al., 1999; Vicenzino et al., 1997, 2000) and the other utilizing orthopaedic felt (Hadley et al., 1999; Vicenzino et al., 2000). The adhesive strapping tape technique consists of a number of distinct taping techniques that are frequently combined. The most comprehensive form of adhesive strapping tape technique is the augmented low dye, which consists of a modified low dye technique strengthened by addition of reverse sixes and calcaneal slings (Fig. 6 and Table 1). In brief, the augmented low dye is used when there is a requirement to control vertical navicular height (i.e. medial longitudinal arch height), an indirect but reliable and valid measure of pronation (Williams and McClay, 2000), during activities such as jogging for longer than 10 min (Vicenzino et al., 1997). Usually this is restricted to a TDT in the field in which the practitioner has been unable to find an activity that brings on the pain in the clinic (see Table 1: Variations). It is common practice to use as the physical manipulation in the clinic, the minimum amount of tape, such as, 3 reverse sixes or 2 calcaneal slings. Low dye taping may be used where there is localized foot pain, particularly in the arch and heel region where it

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may be uncomfortable to have the reverse sixes and calcaneal slings passing plantar to the sole of the foot. Full details of this taping technique including indications, contra-indications, research findings summaries and some possible technical variations are shown in Table 1. The temporary orthotic, constructed of orthopaedic felt or foam, is performed when the taping technique has been shown to relieve pain and improve function. This next stage in the decision making process for orthotic prescription is to evaluate the effectiveness of an in-shoe orthotic device to ascertain if it is as effective as the tape. See Table 2 and Fig. 7 for complete descriptions of the temporary orthotic. In the event that an orthotic, which usually incurs a significant financial burden on the client’s behalf, is required in the physiotherapy management of a musculoskeletal condition, it is advantageous to first have demonstrated to the client’s satisfaction that an in-shoe device will in practice have the same effect as that of the anti-pronation taping technique. This in-shoe device is usually constructed of a relatively inexpensive orthopaedic felt material, which is easy to customize to the individual. As shown in Fig. 7 the orthopaedic felt is attached to the innersole of the shoe. Key technical points of application of the temporary orthotic are that the distal end of the medial padding should end 5–8 mm proximal to the metatarsal phalangeal joint line. All edges of the padding should be bevelled for comfort and the ‘D-shaped’ sustentaculumtali-navicular support pad should commence just proximal to the level of the medial malleolus and extend well past the navicular. It should not be placed in the arch, as this is not an effective location to control pronation. A laboratory study has demonstrated that an anti-pronation temporary in-shoe device was capable of similar mechanical effects, as measured by changes in vertical navicular height, to that of the augmented low dye taping technique described above (Vicenzino et al., 2000). There is another circumstance in which the temporary felt orthotics may be used and that is when the taping technique produces discomfort or pain at its point of contact with the skin. For example, it is not uncommon for a person who has limited dorsiflexion or a marked forefoot varus to experience pain at the skin–tape interface on the anterior shin region where the reverse sixes and the calcaneal slings anchor. 3.3. Anti-pronation orthotic application guidelines In the excessive pronator foot motion type, it is usual practice to use orthotics that are somewhat inverted (i.e. the angle of the superior surface that contacts the plantar foot surface to the inferior surface of the orthotic that sits on the shoe), often referred to as being varus wedged or posted on the medial side of the device.



Fig. 6. Sequential images of the augmented low-Dye tape for excessive or prolonged pronator patterns of foot motion, See Table 1 for further detail; (A) Spur tape commences on the medial forefoot proximal to the metatarsophalangeal joint line, wraps around the heel and finishes on the lateral side of the forefoot. This is the first part of the low-Dye technique. (B) Spur and 3 mini-stirrups. The mini-stirrups arise from the lateral side of the spur and end up on the medial side, with each individual mini-stirrup being laid down in a distal to proximal fashion. Usually 4–6 mini-stirrups are required to extend coverage in a distal to proximal manner, to approximately the region of the sustentaculum tali (not shown here). (C) Completed low-Dye taping technique consisting of a spur, 5 mini stirrups and a locking off spur. If an anchor across the forefoot dorsal surface is required, make sure that this is applied in weight bearing. (D) Reverse sixes (2) which start at about the medial malleolus or proximal to it (not distal to it) that courses over the anterior ankle, distally down the lateral foot, under the plantar mid-foot and wrapping up under the region between sustentaculum tali and navicular before being laid down on the distal leg to anchor onto the anchor strip located some one third to one quarter the way up the leg. (E) Calcaneal sling commences on the anterior leg at the level of the anchor strip, then courses obliquely distally and across the Achilles tendon and heel region, wrapping under the plantar heel and mid foot regions to then pass up by the sustentaculum tali-navicular regions to anchor off at or close to its origin much like the end part of a reverse six. (F) Augmented low-Dye taping technique consisting of a low-Dye, three (3) reverse sixes and two (2) calcaneal slings.

An example of a pre-fabricated type of an antipronation orthotic is the three-quarter length shown in Fig. 8. Pre-fabricated anti-pronation orthotics usually have some degree of varus posting built into the device (e.g. 2–6 degrees) that can be modified by heating (lessen the amount of inversion) or the addition of external rearfoot and forefoot postings (to increase the inversion in the device). The current best level of evidence, which is largely based on laboratory work and not on clinical trials evaluating the efficacy of these types of devices, indicates that it is perhaps the comfort fit of the device and the improvement in performance rather than the effect on the motion that should guide the fitting of the devices (Nigg et al., 1999). Thus, when fitting prefabricated orthotics (or custom made orthotics) the practitioner should first fit the orthotic to an acceptable

level of comfort and then, once comfortable, the orthotics should be tested in a similar fashion to the TDT explained above. All modifications, whether heating or adding external posts to the device, should be guided by this principle and if it is impossible to make the device comfortable and ameliorate pain and dysfunction, then the client should not be prescribed the orthotic. There are several standard issues to consider in improving the comfort of the device, such as correct sizing (e.g. leading edge ends 5–8 mm proximal to the metatarsophalangeal joint line, lateral border edge) and excessive pressure in the arch areas of the orthotic. The latter is usually remedied by either heat moulding the device and/or by the addition of rearfoot varus or forefoot varus wedges. Once the orthotic is comfortable then the TDT approach of re-evaluating


191

Table 1 Anti-pronation taping technique. The augmented low dye technique that may be used as a physical manipulation in the Treatment Direction Test. See Fig. 6 for images of tape Indication: Pain and dysfunction that exists in a client with an abnormal pronation, either excessive or prolonged. Purpose and Intent: To determine if a transient correction of abnormal pronation is associated with a marked amelioration of symptoms and function. Positioning: Client Foot Therapist

Supine with distal half of lower limb extending off end of treatment table. Moderately supinated at the rearfoot with neutral forefoot–rearfoot alignment. The client actively holds this Position. Standing at end of foot with head and torso overhanging the foot.

Taping Techniques and Application Guidelines: Material: Rigid adhesive strapping tape 38 mm in width will suit most feet sizes. Low Dye: 1. Spur: commences on the medial side of the forefoot just proximal to the metatarsal phalangeal joint line, while maintaining the rearfoot and forefoot position in the frontal plane, the therapist exerts a slight amount of adduction of the forefoot and plantar flexion of the first ray while laying the tape down on the medial side of the foot and around the heel. The spur then concludes by being laid down on the lateral side of the foot, finishing proximal to the metatarsal phalangeal joint. 2. Mini-stirrups: commence on the lateral side of the foot over the spur and course underneath the foot, being careful not to wrinkle the plantar skin, before finishing on the medial side of the foot at the level of the spur. The last portion of the mini-stirrup is laid down while the therapist applies an inversion force to the medial side of the foot with the hand that is not holding the tape. The exception to this is the first mini-stirrup, during which the therapist plantar flexes the first ray. A series of some 4–6 mini-stirrups are applied, commencing distally at a level just proximal to the metatarsal phalangeal joints and moving more proximally with successive stirrups overlapping each previous one by about a half tape width. 3. Spur lock off: this tape is exactly like the first one but is used to lock in the ends of the mini-stirrups.

Reverse sixes 4. Anchor strip applied obliquely to a point on the leg approximately one quarter to one third the way proximal to the ankle. 5. Reverse six: starts at the medial malleolus or proximal to it (not distal to it) and runs across the front of the ankle distal to the lateral midfoot, under the plantar aspect of the midfoot before coursing up the medial side of foot, ankle and leg to anchor on the anchor strip. It is important to have the final part of the reverse six cover the navicular and sustentaculum tali areas of the mid and rearfoot.

Calcaneal sling 6. Commences on the anterior aspect of the distal leg at the level of the anchor strip, courses distally and posteriorly to wrap obliquely about the Achilles tendon and heel before wrapping underneath the foot (plantarlly).

Lock off tape 7. 3–4 lock of tapes that are exactly the same as the anchor strip but overlay each other by approximately half extend from the anchor strip distally. Comment: Technical issues—It is very important that the position of the foot and ankle is initially obtained and more importantly maintained during the taping technique as failure to do so often results in an inefficient attempt at correcting pronation during gait. Ensure that the forefoot is not abducted but rather slightly adducted throughout the taping technique. We have shown in a number of studies that this taping technique is superior to others in its effects on arch height, not only immediately after application but also after jogging for 20 min. Risk of either allergic reactions to the tape, or excessive skin stress usually as a result of excessive traction, or compression or injury to underlying soft tissues due to excessive compression must be considered during and after the application of the tape, especially if the taping technique is to be in situ for a protracted period of time. Always follow contour of underlying body part and soft tissues such that there is even pressure visible under both sides of the tape (widthwise) as failure to do so increase the risk of compression injury to underlying tissues. Do not place excessive traction on the tape during its application as this will result in traction stress and possibly injury to the skin. Variations: In some instances, notwithstanding the data in the literature, it appears advantageous to only apply some components of this technique in order to obtain optimal outcomes. For example, is not at all uncommon to use solely reverse sixes or calcaneal slings or low-Dye taping to achieve the desired pain relieving effects. If the client is unable to nominate a physical activity that can be reasonably measured in the clinic (e.g., in a runner who runs for 20 min to pain onset), then the anti-pronation taping will need to be applied before the client goes for a run. Contra-indications: Allergic reaction to tape. Increased pain with tape in situ


192

Table 2 Temporary anti-pronation orthotic. See Fig. 7 for illustrations of this technique Indication: Pain and dysfunction that exists in a client with an abnormal pronation, either excessive or prolonged. Purpose and Intent: To determine if a transient correction of abnormal pronation is associated with a marked amelioration of symptoms and function. Positioning: Client Foot Therapist

Prone with distal half of lower limb extending off end of treatment table. In Fig. 4 position to allow the following foot position to be assumed. Foot perpendicular to floor surface. Sitting at end of foot with head and torso overhanging the foot.

Materials: Orthopaedic felt with adhesive backing. A thickness of about 5–8 mm seems best to work with. If greater height is needed it can be achieved by layering. Application Guidelines: 8. Medial footpad (Fig. 7A)

Approximately measure and cut out a piece of orthopaedic felt length of the foot and approximately one third the width of the foot. Ensure it is oversize. Trim the heel end of the pad to the shape of the posterior heel. Cut a crescent shape recess into the lateral side of the heel end of the pad to accommodate the heel. Trim the length of the pad at its distal end so that it is some 5–8 mm shy of the first metacarpophalangeal joint line. Bevel the lateral side of the pad and the distal end for comfort. Adhere the pad to the innersole of the shoe. Sustentaculum tail–navicular pad (Fig. 7B): Cut a ‘D’ shaped bit of orthopaedic felt out making sure it is long enough to cover the area from the medial malleolus to the cuneiforms and wide enough to cover from the medial side of the foot to the cuboid. At the heel end of the pad, it is necessary to flatten the curved shape of the ‘D’’ to accommodate the heel to ensure comfort. Lay the pad on the innersole on top the medial footpad so that the lateral extent may be determined and then trim accordingly. Make sure that the finished product does not cover the cuboid. Bevel for comfort fir the lateral part of this pad and then adhere it to the innersole over the medial footpad.

Comment:

Constructing this temporary orthotic whilst observing and fitting to the clinet’s foot (as opposed to doing it without the clinet in the room) allows for a customised product with less likelihood of adverse effect.

Once the padding is adhered to the innersole then place it up against the plantar surface of the foot to check for correct sizing and allowing for any final trimming before initial testing.

Test the temporary orthotic during gait to ascertain if it is comfortable, if not make necessary modifications by trimming or adding more padding. Research has shown that this tecnhique has a similar anti-pronation effect to that of the augmented low-Dye taping technique after 20 minutes of jogging (Vicenzino et al. 2000). Variations:

In order to gain better control of excessive pronation it may be necessary to add another medial footpad or a smaller pad on top of the sustentaculum-tali pad.

If there is only minor prolonged pronation, then the medial footpad may not be needed. Contra-indications: Increased pain with padding in situ, either the client’s symptoms or pain induced from direct pressure of the padding. Allergic reactions to felt in the past.

the client specific outcome measure is undertaken. Additional, postings may be required at this stage to ensure that the effect is at least the same as for the taping and temporary orthotic. 3.4. Case examples of the excessive pronation TDT applied Smith et al. (2004) reported a single case of a soccer player with Achilles Tendinopathy in which they

demonstrated the application of a TDT. In that case, there was a substantial improvement from 100 m jogging to onset of pain to 1200 m jogging pain free with a single application of several reverse sixes. This improvement was replicated on several occasions and was shown to mirror the improvements gained following the longerterm application of anti-pronation orthotics. This case exemplar was in distinct contrast to an unpublished case study of a triathlete who had a phase III medial tibial stress syndrome of 12 weeks duration (Roy and Irvin,


193

Fig. 8. Some examples of three-quarter length off-the-shelf orthotics that are frequently used for conditions associated with abnormal pronation, which are commercially available to practitioners.

Fig. 7. Sequential images of the components of the temporary antipronation orthotic. (A) Medial footpad component of the temporary anti-pronation orthotic constructed of orthopaedic felt adhered to an innersole. (B) Sustentaculum tali—navicular pad overlaid on to the medial footpad to form the temporary anti-pronation orthotic. See Table 2 for further detail.

1983). During jogging this case exhibited excessive pronation and first onset of pain at approximately 400 m of jogging (unpublished case report, Bissett L, O’Meara T, Vicenzino B, 2001). There was no substantial change in the distance jogged to the onset of pain despite a 20% improvement in vertical navicular height with both the application of an augmented lowdye taping technique and pre-fabricated orthotic. That is, there was no improvement following augmented lowdye anti-pronation taping and this was matched by a similar lack of efficacy of a follow up period of protracted use of the anti-pronation orthotic. The improvement in vertical navicular height is commensurate to that reported in several studies of the augmented low-dye technique and temporary orthotic (Vicenzino et al., 1997, 2000), indicating that the lack of effectiveness in influencing jogging distance to pain onset was not due to a lack of mechanical efficacy of the tape or orthotic. These two cases highlight the clinical utility of

the TDT to predict the effectiveness (or lack thereof) of orthotic therapy, but do not constitute sufficient level of evidence to be generalized to the broader clinical context. Further work is required to study the clinical utility of the TDT. Anterior knee pain of patellofemoral joint origin is another example of a condition that has been reported to be strongly associated with abnormal lower limb mechanics (Williams et al., 2001) and treatment of this condition by the correction of abnormal foot motion with orthotics has been advocated (Eng and Pierrynowski, 1993; Gross and Foxworth, 2003; Saxena and Haddad, 2003), including the use of off-the-shelf prefabricated orthotics (Eng and Pierrynowski, 1993; Sutlive et al., 2004). The ability to predict the outcome following application of orthotics in patellofemoral pain syndrome is an issue that has recently become the focus of several research groups (Gross and Foxworth, 2003; Sutlive et al., 2004). We recently completed a case study of a 30-year-old female with chronic anterior knee pain that highlights the utility of the TDT to predict orthotic outcomes in patellofemoral pain syndrome. In brief, prior to anti-pronation taping, consisting of three (3) reverse sixes and a low-Dye, the client walked down 4 stairs to the first onset of pain, whereas with taping in situ the client was able to walk 62 stairs. This substantial change in client specific outcome measure of pain and function was replicated with the subsequent application of an anti-pronation orthotic of a longer (6 week) follow up period (unpublished data, Shopka B, Yee B, Costanza A, Al-Marooqi Y, Vicenzino B, 2003). That is, the wearing of an in-shoe orthotic device over a protracted period of time ameliorated the anterior knee pain, and most importantly, this success was predicted by the application of the TDT in the physical examination of this client.



4. TDT for supinator motion pattern There is one predominant physical manipulation for the supinator pattern of foot motion during gait, termed the supinator pad. The supinator pad consists of a piece of foam or orthopaedic felt that is applied to the plantar surface of the foot such that distally it ends approximately 5–8 mm proximal to the metatarsal phalangeal joints, and proximally just distal to the cuboidmetatarsal articulation. Its lateral extent is to the lateral border of the foot and its medial side covers at least the 3rd through 5th metatarsals but not the 1st and 2nd metatarsals. It is shown in Fig. 9 and details included in Table 3. The orthotic that is frequently used in these cases, that is, in the event of a positive TDT, is one that includes the supinator pad in the orthotic. Frequently the supinator pad made of ethyl vinyl acetate (EVA) is simply attached to an innersole of the client’s shoes. Alternatively, the supinator pad may be attached to a low density EVA off-the-shelf prefabricated orthotic with only little or no built-in rearfoot varus posting.

An example of cases that frequently respond favourably to supinator pads are long term or recurrent foot and ankle pain as a result of severe or recurrent ankle sprains in which there is observed a supinator pattern of foot motion during gait. An exemplar case was a patient with diffuse mid-foot pain following several ankle sprains in a period of approximately 24 months in which the acute phase seemed to settle but resulted in the client experiencing disabling pain when walking down stairs and on uneven or sloped surfaces. Several programs of conventional physiotherapy over the preceding 18 months, consisting of sensori-motor re-training (i.e. ‘proprioceptive’), had limited impact on this pain and dysfunction, despite showing improvement in balance tasks. At the initial physiotherapy session, on using the TDT for supinator gait pattern it was noted that walking down stairs was pain free, where it had been previously disabling. A simple 41 forefoot supinator pad was fashioned from an off the shelf orthotic addition (Vasyli Forefoot Valgus wedge) and applied to the innersole of the client’s shoe with the result being a long lasting improvement in pain and function. This apparently effective management by a simple orthotic was predicted by the application of a TDT in the physical examination. The TDT provides an advantage over other skeletal alignment approaches to orthotic prescription in that it directly assures the client during the practitioner–client interaction of the propriety of applying an orthotic in this specific situation and also by guiding the practitioner in the management of the client’s problem by providing individualized data to work with from that client.

5. TDT for prolonged pronation motion pattern The TDT for prolonged pronation is similar to the excessive pronation. However it should be noted that this motion pattern is difficult to differentiate from normal gait and in some cases from mild cases of supinator type motion patterns, requiring the practitioner to first select either the anti-pronation or supinator TDT approach and then if found not to be suitable to swap to the alternative motion dysfunction TDT. Although this does seem to protract the length of the physical examination somewhat, it would leave the client and the practitioner with little doubt about the appropriateness of proceeding with orthotic therapy or not.

6. Integration of orthotic therapy approach into clinical practice

Fig. 9. Physical Manipulation and Orthotic for supinator pattern of foot motion. (A) Supinator pad adhered to the foot as a Physical Manipulation in the Treatment Direction Test. (B) Supinator pad on an innersole as a temporary orthotic. See Table 3 for further detail.

Other findings on physical examination, such as, muscle tightness and weakness (e.g. of the foot, calf, thigh and hip musculature), and reduced motion of the talocrural, sub-talar and metatarsal-phalangeal joints should also be addressed once the effect of the orthotic


195

Table 3 Supinator pad Indication: Pain and dysfunction that exists in a client with a supinator motion pattern of the foot. Purpose and Intent: To determine if a transient correction of abnormal pronation is associated with a marked amelioration of symptoms and function. Positioning: Client Foot Therapist

Prone with distal half of lower limb extending off end of treatment table. In Fig. 4 position to allow the following foot position to be assumed. Foot perpendicular to floor surface. Sitting at end of foot with head and torso overhanging the foot.

Materials: Orthopaedic felt or foam with adhesive backing. A thickness of about 5 mm seems best to work with. If greater height is needed it can be achieved by layering. Application Guidelines: Cut out a piece of material so that it fits on the lateral plantar surface of the foot, covering the 3rd–5th metatarsals, ending about 5 mm proximal to the metatarsophalangeal joints and commencing about 5 mm distal to the cuboid-metatarsal joint. Taper the proximal end of the pad in towards the cuboid (Fig. 9A), that is, so that the pad does not cover the lateral cuneiform. As a physical manipulation adhere the pad to the skin (Fig. 9A). As an orthotic, the pad is attached to the innersole or two an off-the-shelf orthotic (Fig. 9B). Comment: It is important to fashion the pad whilst being able to see and feel the foot so that accurate size of the pad is obtained. Variations: If the effect on motion and symptoms is not satisfactory then modify the length proximally of the pad and/or increase its thickness by laying on another 5 mm layer. Felt has the advantage of allowing fine adjustments through the addition or removal of small layers as the need requires. Contra-indications: Allergic reaction to felt Increased pain with tape in situ

has been ascertained. It is sometimes the case that full amelioration of all symptoms occurs only after the selective application of exercises and manual therapy is used in conjunction with orthotic therapy. Clinical examination findings and a clinical reasoning process, that is based on prioritizing physical findings and systematically addressing these findings guide the selection of the exercises and manual therapy.

7. Conclusion The TDT is a simple pragmatic and practical clinical approach to solving the dilemma that confronts the practitioner who manages clients with lower limb musculoskeletal disorders for which there is a putative aetiological basis in abnormal motion patterns of the foot during gait. It is an adjunctive process to the physical examination that seeks to guide the practitioner in deciding if an orthotic is likely to succeed. Importantly, it does not replace but rather complements the conventional comprehensive clinical examination performed by musculoskeletal physiotherapists.

Acknowledgements I would like to acknowledge the contribution to the Treatment Direction Test concept of many of my colleagues and students and specifically the following who have directly helped in aligned research in this field: Professor Thomas McPoil, Ms. Leanne Bisset, Ms. Natalie Collins, Ms. Michelle Smith, Ms. Tara O’Meara, Ms. Suzi Brooker, Mr. Bryan Shopka, Ms. Erin Smyth, Mr. Brian Yee, Mr. Adam Costanza, Mr. Yacob Al-Marooqi. References Eng JJ, Pierrynowski MR. Evaluation of soft foot orthotics in the treatment of patellofemoral pain syndrome. Physical Therapy 1993;73:62–8. Gross MT, Foxworth JL. The role of foot orthoses as an intervention for patellofemoral pain. Journal of Orthopaedic & Sports Physical Therapy 2003;33:661–70. Hadley A, Griffiths S, Griffiths L, Vicenzino B. Antipronation taping and temporary orthoses—effects on tibial rotation position after exercise. Journal of the American Podiatric Medical Association 1999;89:118–23.



Heiderscheit B, Hamill J, Tiberio D. A biomechanical perspective: do foot orthoses work? British Journal of Sports Medicine 2001;35:4–5. James SL, Bates BT, Osternig CR. Injuries to runners. The American Journal of Sports Medicine 1978;6:40–50. Landorf K, Keenan A-M, Rushworth R. Foot orthosis prescription habits of Australian and New Zealand Podiatric Physicians. Journal of the American Podiatric Medical Association 2001;91:174–83. Lang L, Volpe R, Wernick J. Static biomechanical evaluation of the foot and lower limb: the podiatrist’s perspective. Manual Therapy 1997;2:58–66. McPoil T, Cornwall MW. Relationship between neutral subtalar joint position and pattern of rearfoot motion during walking. Foot & Ankle International 1994;15:141–5. McPoil TG, Hunt GC. Evaluation and management of foot and ankle disorders—present problems and future-directions. Journal of Orthopaedic & Sports Physical Therapy 1995;21:381–8. Nigg BM, Nurse MA, Stefanyshyn DJ. Shoe inserts and orthotics for sport and physical activities. Medicine and Science in Sports and Exercise 1999;31:S421–8. Perry J. Observational gait analysis. Downey, CA: Los Amigos Research and Educational Institute; 1993. Root M, Orien W, Weed J. Biomechanical evaluation of the foot, Vol. 1. Los Angeles: Clinical Biomechanics Corporation; 1971. Root M, Orien W, Weed J. Normal and Abnormal Function of the Foot, Vol. 2. Los Angeles: Clinical Biomechanics Corporation; 1977. Roy S, Irvin R. Sports Medicine. New Jersey: Prentice-Hall; 1983. Saxena A, Haddad J. The effect of foot orthoses on patellofemoral pain syndrome. Journal of the American Podiatric Medical Association 2003;93:264–71.

Smith M, Brooker S, Vicenzino B, McPoil T. Use of anti-pronation taping to assess suitability of orthotic prescription: case report. Australian Journal of Physiotherapy 2004;50:111–3. Sobel E, Levitz SJ, Caselli MA. Orthoses in the treatment of rearfoot problems. Journal of the American Podiatric Medical Association 1999;89:220–33. Stacoff A, Reinschmidt C, Nigg BM, van den Bogert AJ, Lundberg A, Denoth J, Stussi E. Effects of foot orthoses on skeletal motion during running. Clinical Biomechanics 2000;15:54–64. Sutlive TG, Mitchell SD, Maxfield SN, McLean CL, Neumann JC, Swiecki CR, Hall RC, Bare AC, Flynn TW. Identification of individuals with patellofemoral pain whose symptoms improved after a combined program of foot orthosis use and modified activity: a preliminary investigation. Physical Therapy 2004;84: 49–61. Tiberio D. The effect of excessive subtalar joint pronation on patellofemoral mechanics a theoretical model. Journal of Orthopaedic and Sports Physical Therapy 1987;9:160–5. Tiberio D. Pathomechanics of structural foot deformities. Physical Therapy 1988;68:1840–9. Vicenzino B, Feilding J, Howard R, Moore R, Smith S. An investigation of the anti-pronation effect of two taping methods after application and exercise. Gait & Posture 1997;5:1–5. Vicenzino B, Griffiths SR, Griffiths LA, Hadley A. Effect of antipronation tape and temporary orthotic on vertical navicular height before and after exercise. Journal of Orthopaedic & Sports Physical Therapy 2000;30:333–9. Williams DS, McClay IS. Measurements used to characterize the foot and the medial longitudinal arch: reliability and validity. Physical Therapy 2000;80:864–71. Williams DS, McClay IS, Hamill J. Arch structure and injury patterns in runners. Clinical Biomechanics 2001;16:341–7.

ARTICLE IN PRESS



Original article

The flexion–rotation test and active cervical mobility—A comparative measurement study in cervicogenic headache T. Hall*, K. Robinson Curtin University of Technology, Hayman Road, Bentley, Western Australia, Australia Received 9 April 2003; received in revised form 22 March 2004; accepted 14 April 2004

Abstract A single blind, age and gender matched, comparative measurement study was designed to assess active range of cervical motion and passive range of rotation in cervical flexion in asymptomatic and cervicogenic headache subjects. Both procedures are commonly used in clinical practice to evaluate patients with cervicogenic headache. We studied 20 women and eight men with side dominant cervicogenic headache (mean age 43.3 years) matched with 28 asymptomatic subjects. Two experienced manipulative therapists, who were blind to each other’s measurement, noted active ranges of cervical motion and passive cervical rotation performed in the flexion–rotation test using the Cervical Range of Motion Device. Headache severity was assessed by a questionnaire. Additionally, one therapist prior to neck motion assessment determined the dominant symptomatic cervical motion segment. Active cervical motion in each direction was identical between the cervicogenic and control groups. In contrast, average rotation in flexion was 44 to each side in the asymptomatic group and 28 towards the headache side in the symptomatic group. C1-2 was deemed to be the dominant segmental level of headache origin in 24 of 28 subjects. In those 24 subjects range of rotation during the flexion–rotation test was inversely correlated to headache severity. r 2004 Elsevier Ltd. All rights reserved. Keywords: Cervical mobility; Cervical spine; Cervicogenic headache; Manual examination; Flexion-rotation test

1. Introduction Headache disorders affect a large proportion of the general population and represent a major health problem affecting both quality of life and work productivity (Lipton, 1994; Diener, 2001). Cervicogenic headache is one subgroup of headache arising from cervical joint dysfunction (Bogduk, 1994; Jull, 2002) that accounts for up to 20% of all headaches (Pfaffenrath and Kaube 1990; Maciel, 1997). Distinguishing cervicogenic headache from other headache forms is essentially made on the pattern of the symptoms together with the clinical physical examination findings (Mersky and Bogduk, 1994; Sjaastad et al., 1998; Vincent and Luna, 1999). The diagnostic criteria for cervicogenic headache as outlined by Sjaastad et al. (1998) and the International *Corresponding author. 81 Northwood Street, West Leederville, Western Australia 6007, Australia. Tel./fax: +61-8-9284-7112. E-mail address: [email protected] (T. Hall). 1356-689X/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2004.04.004

Headache Society (2000) are principally based on subjective characteristics. Physical criteria for cervical dysfunction in cervicogenic headache are less well established and non-specific (Jull, 2002) although there is an established link between impairment in cervical joints and cervicogenic headache pathogenesis (Jull et al., 1988; Jaeger, 1989; Treleaven et al., 1994). Zwart (1997) showed range of active cervical rotation and neck movement in the sagittal plane was less in cervicogenic headache sufferers when compared to controls. In contrast Placzek et al. (1999) found headache subjects were only limited in cervical extension range, all other movements were no different to normal controls. In that study no attempt was made to classify the headache hence the results may be misleading. A range of examination procedures, (active and passive motions test) have been described to determine the presence of upper cervical spine joint dysfunction (Greenman, 1996; Maitland et al., 2001; Monaghan, 2001). Such manual examination procedures have been shown to detect symptomatic cervical joint dysfunction


T. Hall, K. Robinson / Manual Therapy 9 (2004) 197–202

in a number of studies of cervicogenic headache (Jaeger, 1989; Jensen et al., 1990; Watson and Trott, 1993; Drefus et al., 1994; Treleaven et al., 1994; Whittingham et al., 1994; Schoensee et al., 1995). One diagnostic test in particular, the flexion–rotation test, is said to determine C1-2 dysfunction (Dvorak, 1998) and may require less skill on the part of the operator in contrast to other passive segmental mobility tests. With the subject relaxed and recumbent the cervical spine is fully flexed with the occiput resting against the examiners abdomen, in an attempt to block as much rotational movement as possible in the cervical spine above and below C1-2. The head is then rotated to the left and the right. If firm resistance is encountered, pain provoked and range is limited before the expected end range then this is said to be positive, with a presumptive diagnosis of limited rotation of the atlas on the axis (Stratton and Bryan, 1994). In the authors experience the greater the restriction the more significant will be the headache symptoms. The test is therefore used clinically as a treatment outcome after manual therapy techniques to the upper cervical spine as well as in the initial diagnosis. However there are no studies to justify these inferences. The cervical flexion–rotation test is used extensively in clinical practice but it has not been studied adequately in the literature. The aim of this study was to investigate active cervical mobility and the cervical flexion–rotation test to compare these ranges of movement in cervicogenic headache subjects with asymptomatic controls. It was hypothesized that range of active cervical movement in the cardinal planes and range of cervical rotation in flexion would be reduced in those subjects with cervicogenic headache in comparison to asymptomatic controls. In addition it was hypothesized that range of rotation, during the flexion–rotation test, would be inversely proportional to the severity of the headache in the cervicogenic headache group.

included in the cervicogenic headache group based on the following inclusion and exclusion criteria: 2.3. Inclusion *

*

*

*

*

Unilateral or side dominant headache without sideshift (Sjaastad et al., 1990). Associated neck pain or stiffness (Bogduk, 1994; Sjaastad et al., 1990). Neck symptoms preceded or were a co-existent feature in onset of headache (Sjaastad, et al., 1989). Headache frequency of at least an average of one per week. History of episodic semicontinuous or continuous headache for at least the previous three months.

2.4. Exclusion *

*

* *

Headache not of cervical origin-based on subjective screening criteria developed by the International Headache Society (2000). Autonomic, dizziness or visual disturbance symptoms. Inability to tolerate the flexion–rotation test position. Known congenital conditions of the cervical spine (e.g. congenital fusion).

53 subjects were interviewed and of these, 28 were suitable for inclusion in the study. This group then included 20 females and 8 males with a mean age of 43.3 (SD 11.5) years. Each symptomatic subject was matched for age and sex with 28 asymptomatic subjects with a mean age of 43 (SD 13.5) years. None of the asymptomatic subjects had a significant history of episodic headache, neck pain or neck stiffness. All subjects were required to provide informed consent prior to taking part in the study. The rights of the subjects were protected at all times. 2.5. Measurement

2. Methods 2.1. Study design A single blind age and gender matched comparative measurement design was used to determine differences between asymptomatic subjects and those with subjective features of cervicogenic headache. 2.2. Subjects This study had ethical approval by Curtin University’s Human Research Ethics Committee. Subjects were recruited from private physiotherapy clinics and through advertisements placed in a local community newspaper. Volunteers were interviewed and were

Two, experienced manipulative physiotherapists carried out measurements of active cervical mobility and the flexion–rotation test. Both examiners were blinded to the subject’s group allocation and to each other’s measurement. Measurement of headache severity was determined by a questionnaire developed by Niere and Robinson (1997). This questionnaire has been shown to be reliable (Niere and Robinson 1997) and enables an index of headache severity to be calculated based on headache intensity, frequency and duration of attack. Cervical range of motion in the cardinal planes was measured using a Cervical Range of Motion Device (CROM) (Performance Attainment Associates. 958 Lydia Drive, Roseville, Minnesota, USA. 55113). This

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device has been shown to have good intra- and intertester reliability (Capuano-Pucci et al., 1991; Rheault et al., 1992). The CROM was modified slightly to assess range of rotation with the cervical spine in end range flexion. Prior to examination of neck movement, one examiner determined the dominant symptomatic cervical motion segment by manual examination. This consisted of passive accessory and passive physiological intervertebral motion tests (Maitland et al., 2001; Monaghan, 2001). 2.6. Procedure The procedure was first explained to the subject before the CROM device was fitted. The two examiners performed active cervical movement tests and the flexion–rotation test. To measure active cervical motion the subject was seated with a neutral spine posture, with the spine supported against a high back chair. The subject was instructed to move their head and neck through all cardinal planes, in turn, as far as they could within comfortable limits. The range was recorded and the movement repeated three times in each direction. For the flexion–rotation test the subject lay supine on a physiotherapy treatment couch. The subject was asked to relax while their neck was moved to end range cervical flexion by the examiner. In this flexed position the head and neck was passively rotated as far as possible within comfortable limits. The range was recorded and the movement repeated three times in each direction. Immediately following the flexion–rotation test the examiner was required to state whether the test demonstrated significant restriction of motion and the direction of restriction. This interpretation was based upon the range of motion (restriction greater than 10 ), pain provocation and resistance to movement during the test. The second examiner was asked to determine, by way of manual examination, the segmental level and side from which the headache symptoms predominated. This was carried out prior to neck range of motion assessment. Each examiner was blinded to the other’s findings. 2.7. Reliability To determine intra- and inter-examiner reliability, of range of motion measures and manual examination procedures, the first 10 subjects (5 from the asymptomatic group and 5 from the symptomatic group) were tested according to the above protocol on two occasions by both examiners with a 10-min resting period between each occasion. During the resting period the CROM

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device was removed and the subject was allowed to move freely around the room. 2.8. Data analysis In all cases statistical significance was accepted at the 0.05% level of confidence. Inter- and intra-therapist reliability was determined by an average measure intra-class correlation coefficient (ICC). Range of motion in the seated and supine position was compared over the three repeated trials using a repeated measures analysis of variance (general linear model). An independent samples t-test, compared active range of movement between the two groups, and a w2 analysis was used to determine whether the headache group had more subjects with restriction of the flexion– rotation test when compared to the control group. Range of rotation with the cervical spine in flexion was correlated with the headache severity index as calculated from the headache questionnaire using a Pearson’s correlation analysis. Scores for headache frequency (Freq ¼ number of headaches over 4 week period, 0–28 scale), duration (Dur ¼ hours per day, 0–24 scale) and intensity (Int ¼ visual analogue, 0–25 scale) were standardized then added to give an overall score: Headache index ðH1 Þ ¼ Fre=28 þ Dur=24 þ Int=25 (Niere and Robinson, 1997)

3. Results Symptomatic subject demographics were as follows. The mean history of headache was 8.9 (SD 9) years. In addition, 20 had right side and eight had left side dominant head pain. On a rating scale from zero to 25 the mean pain intensity reported during a headache attack was 14.3 (SD 4.8), the mean duration of headache was 22.2 (SD 18) h and the mean frequency of headache was 13.8 (SD 9) per month. Intra-class correlation coefficients for intra- and interexaminer reliability of range of movement measures ranged between 0.92 (flexion) and 0.99 (extension), indicating high reliability. Analysis of repeated measures revealed no significant change in range of motion with repeated trials for any measurement apart from rotation to the left in cervical flexion that showed a variation of only 1.6 over the three trials. This change is clinically insignificant. All further analysis is undertaken with the average of the three trials taken for each movement. According to the examiners assessment 24 subjects were deemed to have C1-2 as the dominant symptomatic cervical motion segment. In addition all 24 had a positive flexion–rotation test. In contrast the remaining


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four symptomatic subjects were assessed as having C2-3 as the dominant cervical segment and all had a negative flexion–rotation test. This indicates that there was complete agreement between the results of the flexion– rotation test and the segmental diagnosis determined by manual examination. 3.1. Active movements in cardinal planes The results indicate that mean cervical spine active movement in the cardinal planes was no different in the symptomatic group compared to the asymptomatic group (all p > 0:05). Table 1 represents the average of the three repeated trials and standard deviations for each cervical cardinal plane movement in each group.

Table 2 Means, standard deviations and standard error of means for range of cervical rotation in flexion towards the headache side, away from the headache side and comparative ranges in the asymptomatic group Variable

Mean (deg)

SD (deg)

SEM (deg)

Range of rotation towards headache side Control Range of rotation away from headache side Control

27.6 44.7 42.6 43.4

6.6 7.2 6.7 7.8

1.64 1.35 1.68 1.47

rotation in flexion (rð14Þ ¼ 0:8; Po0:001). This indicates that the more severe the headache, based on headache frequency, duration and intensity, the greater the restriction will be of the flexion–rotation test.

3.2. Cervical rotation in flexion 4. Discussion The following results relate to range of rotation in cervical flexion. A w2 analysis showed a significantly greater proportion of the symptomatic group had a positive flexion–rotation test compared to the asymptomatic group, w2 ½1; N ¼ 56 ¼ 35:71; po0:001 (continuity correction). In the symptomatic group 86% of individuals had a positive test, in contrast to the asymptomatic group where this test was negative in all cases. Furthermore all subjects with C1/2 deemed to be the symptomatic cervical motion segment were positive on this test. Mean range of rotation in flexion was significantly less towards the headache side, in the symptomatic group when compared to the asymptomatic group (tð32Þ ¼ 7:8; po0:001). The difference was 17.1 . Furthermore there was no difference in range of rotation towards the non-dominant headache side in comparison to the control group (tð32Þ ¼ 0:325; P ¼ 0:747). Table 2 shows the means, standard deviations and standard error of mean for all these measurements. A Pearson’s correlation analysis showed a significant correlation between headache severity and range of

Table 1 Means, standard deviations and standard error of measurements for cervical movement Movement

Flexion Extension Rotation left Rotation right Side flexion left Side flexion right

Mean range (SD, SEM) (deg) Asymptomatic group

Symptomatic group

51 (9.4, 1.8) 60 (9.3, 1.8) 66 (10.1, 1.9) 64.9 (8.2, 1.5) 35.7 (7.8, 1.5) 35.2 (8, 1.5)

49.1 (9.8, 1.9) 58 (15.6, 2.9) 65 (9.3, 1.8) 65.5 (10.5, 2) 36.9 (11, 2.1) 33.3 (9.5, 1.8)

The results of this study indicated that active cervical spine movement in the cardinal plane was not significantly different in subjects with side dominant cervicogenic headache when compared to asymptomatic individuals. In fact, the mean ranges were, for all purposes, identical in both groups. Measurements were consistent over repeated trials with excellent intra- and inter-tester reliability. Mean cervical range of motion found in this study was consistent with values reported by Youdas et al. (1992) but less than that reported by Dvorak et al. (1992) where the mean age of subjects where much less. The failure to find a difference in range of active movement between groups is surprising if one considers that painful articular structures in the upper cervical region are frequently the source of the headache symptoms (Bogduk, 1994) and that reduced cervical range of motion is one of the diagnostic criteria for cervicogenic headache (International Headache Society, 2000). It is the opinion of Edeling (1988), an expert in cervicogenic headache, that even in severe cervicogenic headache limitation of physiological cervical movement is not always apparent. Our study chose inclusion criteria as per criteria developed by Sjaastad et al. (1989, 1990) (apart from response to local anaesthetic block). To avoid selection bias we did not include restricted active cervical motion in our inclusion criteria, however a manual examination revealed upper cervical spine joint involvement in all subjects in the cervicogenic headache group. In contrast to our study Zwart (1997) found cervical rotation and neck movement in the sagittal plane to be less in cervicogenic headache sufferers when compared to controls. Other studies have found active cervical movement examination not to be sensitive in distinguishing subjects with and without a neck complaint


where articular dysfunction is also a feature (Treleaven et al., 1994; Sandmark and Nisell, 1995). Another explanation for normal range of movement, found in cervicogenic headache sufferers, may be that the total range of neck motion is not the arithmetic sum of the segmental ranges (Mercer and Bogduk, 2001). Hence adjacent cervical levels may compensate for a loss of movement at a hypomobile cervical segment. However, it is unsure as to how much movement can be compensated by other levels. Further investigations are required to determine the reason for the inconsistency between active movement assessment and the flexion– rotation test. This study found a positive flexion–rotation test in 24/28 subjects with side dominant cervical headache. All those subjects found positive, were deemed to have had C1/2 as the most symptomatic segment as determined by a skilled manipulative therapist using manual assessment. Additionally, of those found negative to the flexion–rotation test, none had C1-2 as the symptomatic segment. Further studies are currently underway to determine the specificity and sensitivity of the flexion– rotation test. In this small sample of subjects with side dominant cervical headache C1-2 was considered to be by far the most frequent symptomatic cervical motion segment. Previous studies of neck involvement in cervical headache have reported variously, C0-1 (Watson and Trott, 1993), C1-2 (Jull et al., 1997; Treleaven et al., 1994) and C2-3 (Jull, 1986; Schoensee et al., 1995) to be the predominant dysfunctional segment. Larger studies are required to determine the frequency of cervical motion segment involvement in cervicogenic headache. Mean normal range of rotation with the cervical spine in flexion was recorded in the asymptomatic group as 44 to each side. This is very similar to that reported by Amiri et al. (2003). In contrast range of rotation towards the headache side in the present study was 16 less. Dvorak et al. (1992) reported an average 38 of rotation during the flexion–rotation test in asymptomatic subjects. Perhaps the difference in range can be accounted for by the fact that in the study of Dvorak et al. (1992) the test was performed in a seated position and in the present study the subjects were tested in supine. Dvorak (1998) postulates that the flexion–rotation test primarily tests the C1-2 segment. It is interesting that mean range of rotation recorded during the flexion– rotation test was the same as reports of normal C1-2 mobility (Dvorak and Panjabi, 1987). The unique anatomy of the C1-2 segment may account for its ability to rotate in a flexed posture in contrast to other cervical levels. In the present study, range of rotation as measured in the flexion–rotation test was inversely correlated with an index of headache severity. Hence the flexion–rotation test, in contrast to active cervical range of motion, may

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be considered a useful additional measure of specific physical impairment in side dominant cervicogenic headache. This finding is unusual, as other studies have found little association between measures of cervical movement impairment and pain (Olson et al., 2000; Riddle and Stratford, 1998). To the authors knowledge this is the first time the flexion–rotation test has been investigated in this way.

5. Conclusions This study has shown no difference in cervical spine cardinal plane motion between asymptomatic subjects and subjects with side-dominant cervicogenic headache. In contrast the flexion–rotation test was positive and significantly reduced in range in all subjects considered to have C1/2 segmental dysfunction but not when other cervical levels were primarily symptomatic. These results indicate a role for the flexion–rotation test in cervicogenic headache evaluation.

Acknowledgements We grateful acknowledge Dr. Marie Blackmore, statistician at Curtin University of Technology, for her advice on the statistical analysis for this paper.

References Amiri M, Jull G, Bullock-Saxton J. Measuring range of active cervical rotation in a position of full head flexion using the 3D Fastrak measurement system: an intra-tester reliability study. Manual Therapy 2003;8(3):176–9. Bogduk N. Cervical causes of headache and dizziness. In: Boyling J, Palastanga N, editors. Grieves modern manual therapy. 2nd ed. Edinburgh: Churchill Livingstone; 1994. p. 317–32. Capuano-Pucci D, Rheault W, et al. Intratester and intertester reliability of the cervical range of motion device. Archives of Physical Medicine and Rehabilitation 1991;72:338–40. Diener I. The impact of cervicogenic headache on patients attending a private physiotherapy practice in Cape Town. South African Journal of Physiotherapy 2001;57(1):35–9. Drefus P, Rogers J, Dreyer S, Fletcher D. Atlanto-occipital joint pain. A report of three cases and description of an intraarticular joint block. Regional Anesthesia 1994;19:344–51. Dvorak J. Epidemiology, physical examination and neurodiagnostics. Spine 1998;23(24):2663–73. Dvorak J, Panjabi MM. Functional anatomy of the alar ligaments. Spine 1987;12:183–9. Dvorak J, Antinnes JA, Panjabi MM, Loustalot D, Bonomo M. Age and gender related normal motion of the cervical spine. Spine 1992;17(10S):S393. Edeling J. Manual therapy for chronic headache. London: Butterworths; 1988. Greenman PE. Principles of manual medicine. Philadelphia: Lippincott, Williams and Wilkins; 1996. p. 175. International Headache Society. Member’s handbook. Scandinavian University Press: Oxford; 2000.


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Jaeger B. Are cervicogenic headaches due to myofascial pain and cervical spine dysfunction? Cephalalgia 1989;9:157–64. Jensen OK, Nielsen FF, Vosmar L. An open study comparing manual therapy with the use of cold packs in the treatment of post concussional headache. Cephalalgia 1990;10:241–9. Jull GA. Headaches associated with the cervical spine. In: Grieve GP, editor. Modern Manual Therap. Edinburgh: Churchill Livingstone; 1986. p. 322–9. Jull G. Management of cervicogenic headache. In: Grant R, editor. Physical therapy of the cervical and thoracic spine. 3rd ed. New York: Churchill Livingstone; 2002. p. 239–72. Jull GA, Bogduk N, Marsland A. The accuracy of manual diagnosis for cervical zygapophyseal joint pain syndromes. Medical Journal of Australia 1988;148:233–6. Jull G, Zito G, Trott P, Potter H, Shirley D, Richardson C. Interexaminer reliability to detect painful upper cervical joint dysfunction. Australian Journal of Physiotherapy 1997;43:125–9. Lipton RB. An overview of epidemiology of common primary headaches. Headache 1994;34(1 Supplement):1–5. Maciel Jr JA. Cervicogenic headache. A study of 203 cases. The First Pan American Headache Congress. Book of Abstracts, 1997. Maitland GD, Hengeveld L, Banks K, English K. Maitland’s vertebral manipulation, 6th ed. Oxford: Butterworth-Heinemann; 2001. Mercer SR, Bogduk N. Joints of the cervical vertebral column. Journal of Orthopaedic and Sports Physical Therapy 2001;3194:174–82. Mersky HN, Bogduk N. Classification of chronic pain, 2nd ed. Seattle: IASP Press; 1994. Monaghan M. Spinal manipulation: a manual for physiotherapists. Aesculapius Ltd, Nelson, 2001. p. 14. Niere K, Robinson P. Determination of manipulative physiotherapy treatment outcome in headache patients. Manual Therapy 1997;2(4):199–205. Olson SL, O’Connor DP, Birmingham G, Broman P, Herrera L. Tender point sensitivity, range of motion, and perceived disability in subjects with neck pain. Journal of Orthopaedic and Sports Physical Therapy 2000;30:13–20. Pfaffenrath V, Kaube H. Diagnostics of cervicogenic headache. Functional Neurology 1990;5(2):159–64. Placzek J, Pagett B, Roubal P, et al. The influence of cervical spine on chronic headache in women: a pilot study. The Journal of Manual and Manipulative Therapy 1999;7(1):33–9.

Rheault W, Albright B, et al. Intertester reliability of the cervical range of motion device. Journal of Orthopaedic and Sports Physical Therapy 1992;15(3):147–50. Riddle D, Stratford P. Use of generic versus region-specific functional status measures on patients with cervical spine disorders. Physical Therapy 1998;78:951–63. Sandmark H, Nisell R. Validity of five common manual neck pain provocation tests. Scandinavian Journal of Rehabilitation Medicine 1995;27:131–6. Schoensee H, Jensen G, Nicholson G, Gossman M, Katholi C. The effect of mobilisation on cervical headaches. Journal of Orthopaedic and Sports Physical Therapy 1995;21:181–96. Sjaastad O, Fredriksen TA, Sandt ST, Antonaci F. The localisation of the initial pain of attack: a comparison between classic migraine and cervicogenic headache. Functional Neurology 1989;6:93–100. Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria. Headache 1990;30:725–6. Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria. Headache 1998;38:442–5. Stratton SA, Bryan JM. Dysfunction, evaluation, and treatment of the cervical spine and thoracic inlet. In: Donatelli R, Wooden MJ, editors. Orthopaedic physical therapy. 2nd ed. New York: Churchill Livingstone; 1994. p. 77–122. Treleaven J, Jull G, Atkinson L. Cervical musculoskeletal dysfunction in post-concussional headache. Cephalalgia 1994;14(4):273–9. Vincent MB, Luna RA. Cervicogenic headache: a comparison with migraine and tension-type headache. Cephalalgia 1999;19(Supplement 25):11–6. Watson DH, Trott PH. Cervical headache. An investigation of natural head posture and upper cervical flexor muscle performance. Cephalalgia 1993;13:272–84. Whittingham W, Ellis WB, Molyneux TP. The effect of manipulation (toggle recoil techniques) for headaches with upper cervical joint dysfunction: a pilot study. Journal of Manipulative and Physiological Therapeutics 1994;17:369–75. Youdas JW, Garrett TR, Suman VJ, Bogard CL, Halman HO, Carey JA. Normal range of motion of the cervical spine: initial goniometric study. Physical Therapy 1992;72:770–80. Zwart JA. Neck mobility in different headache disorders. Headache 1997;37(1):6–11.

ARTICLE IN PRESS


Original article

Anatomical relationships between selected segmental muscles of the lumbar spine in the context of multi-planar segmental motion: a preliminary investigation R.S. Jemmett, D.A. MacDonald, A.M.R. Agur Department of Surgery, Division of Anatomy, University of Toronto, Canada Received 22 May 2003; received in revised form 14 January 2004; accepted 8 July 2004

Abstract In the last decade, concepts regarding spinal stability have been redefined. Whereas traditional stability models considered only the integrity of the intervertebral disc and spinal ligaments, mechanisms contributing to spinal stability are now thought to include neural and muscular elements. Lumbar muscles capable of generating intersegmental stiffness are considered necessary for the control of multi-planar segmental spinal motion. The transversus abdominis, psoas, quadratus lumborum and multifidus have each been described functionally as contributing to segmental motion control in the lumbar spine. However, the fundamental anatomy of these muscles has not been fully established nor have their architectural characteristics as a functional group been explored. A dissection of the lumbar spine was undertaken to document the attachments of the deep vertebral muscles and illustrate their group architectural characteristics in the context of multi-planar segmental motion. The transversus abdominis, psoas, quadratus lumborum and multifidus were each noted to have segmental attachment patterns in the lumbar spine. As a group, they surround the lumbar motion segments from the anterolateral aspect of a vertebral body to the spinous process. A hypothetical role for this muscle group in maintaining lumbar spine stability is discussed as are suggestions for future research. r 2004 Elsevier Ltd. All rights reserved.

1. Introduction The traditional model of spinal biomechanics considered the intervertebral disc, spinal ligaments and osseous elements to be the structures solely responsible for stabilization of the vertebral column (Knuttson, 1944; White and Panjabi, 1978). However, in vitro studies have shown the non-pathologic osseoligamentous spine to be incapable of tolerating normal physiological loads (Lucas and Bresler, 1961). While the spinal loads associated with occupational and recreational activities have been described as ranging Corresponding author. 5595 Fenwick Street, PO Box 27069, Halifax, Nova Scotia, Canada B3H 4M8. Tel.: +1-902-423-4344; fax: +1-902-423 3477. E-mail address: [email protected] (R.S. Jemmett).

1356-689X/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2004.07.006

from 6000 to 18,000 N (Cholewicki and McGill, 1996) in vitro studies of the osseoligamentous lumbar spine have found that disc, ligamentous and osseous pathology develops at loads between approximately 20 and 90 N (Lucas and Bresler, 1961; Crisco, 1989). Further biomechanical research has demonstrated that lumbar motion segments exhibit bi-phasic stiffness properties across the physiological range of motion (ROM) (Fig. 1) (Panjabi, 1992a). These phases, or partitions of the physiological ROM, are known as the neutral zone (NZ) and the elastic zone (EZ) and exist through each of the sagittal, coronal, and transverse planes of segmental motion (Fig. 2a). Normal in vitro lumbar segmental motion is inherently unstable early in range, through the NZ where stiffness is characteristically low, and is only relatively stable later in range, through the EZ where stiffness is greater (Crisco, 1989;


R.S. Jemmett et al. / Manual Therapy 9 (2004) 203–210

Fig. 1. Plot of segmental ROM and stiffness (resistance to motion) for a typical lumbar motion segment demonstrating the bi-phasic nature of segmental motion. The segment experiences little resistance to motion early in range and sharply increased resistance later in range. These phases or partitions of the overall ROM are known as the neutral zone (NZ) and elastic zone (EZ).

Fig. 2. A hypothetical illustration of the bi-phasic, multi-planar ROM characteristics typical of lumbar motion segments: (a) this model assumes a symmetrical and equal amplitude for each of the NZ and EZ in each motion plane; (b) with the onset of osseoligamentous pathology, NZ amplitude is markedly increased relative to EZ amplitude and overall ROM; in this example, pathology has resulted in a larger NZ, primarily in the posterior direction.

Panjabi, 1992a). With the onset of experimentally induced osseoligamentous pathology, NZ amplitudes are markedly increased in comparison to EZ amplitudes (Fig. 2b) (Oxland and Panjabi, 1992; Panjabi et al., 1998). Such findings have led to the development of a more comprehensive model of spinal function in which skeletal muscle, the central nervous system, and osseoligamentous structures are considered to be interdependent components of a spinal stabilization system (Panjabi, 1992b). The primary function of this stabilization system is the control of segmental motion and the maintenance of normal NZ amplitudes. Given the inability of the osseoligamentous spine to tolerate the loads associated with normal activities, spinal muscles are now considered critical to the maintenance of adequate spinal stability.

The evolution of the spinal stability model from one in which osseoligamentous structures were considered primary to one in which muscular control is seen as crucial has prompted much research. Given the relationship between controlled segmental motion and the maintenance of normal NZ amplitudes, deep muscles with segmental patterns of attachment may be more architecturally capable of developing the intersegmental stiffness required for spinal stability (Bergmark, 1989; Quint et al., 1998; Hodges et al., 2003). Functionally, the transversus abdominis, psoas, quadratus lumborum and lumbar multifidus have each been described as contributing to the control of lumbar segmental motion via either the maintenance of spinal equilibrium or the development of intersegmental stiffness. A number of studies have reported on the anatomical, biomechanical or neurophysiological characteristics of these muscles in the context of spinal stability (McGill, 1991; Wilke et al., 1995; Andersson et al., 1996; Penning, 2000; Hodges et al., 2003). Despite this significant body of work, the segmental anatomy of these muscles has not, in all cases, been fully established. For example, our review of the literature failed to identify any peer reviewed dissection study detailing the origins and insertions of the quadratus lumborum muscle. Research regarding the posterior fascial attachments of the transversus abdominis muscle has been limited to descriptions of the middle and posterior layers of the thoracolumbar fascia (TLF) (Bogduk and MacIntosh, 1984; Barker et al., 2001a). We were unable to find any study reporting on the transversus abdominis and any continuity it might have with the anterior layer of the TLF. Finally, fundamental architectural relationships between the deep lumbar muscles have yet to be described nor have they been explored in the context of multi-planar segmental motion. The current study is based on our hypothesis that the intersegmental stiffness required for stability of the lumbar spine is developed by a functional set of muscles whose architecture, both individually and as a group, is suited to the control of segmental multi-planar motion. Thus, the objective of this preliminary investigation was to describe and illustrate both the individual and group architectures of these muscles, and to discuss these findings in the context of multi-planar segmental spinal motion.

2. Materials and methods Adult male or female embalmed cadavers without evidence of previous injury, deformity or prior surgery were considered appropriate for the purposes of this study. The dissection was carried out in the Division of Anatomy, Department of Surgery, University of Toronto following the guidelines for use of cadaveric

ARTICLE IN PRESS R.S. Jemmett et al. / Manual Therapy 9 (2004) 203–210

material in research as set forth by the Chief Coroner of the Province of Ontario. The lumbar spine was carefully dissected in a serial fashion. Skin and sub-cutaneous tissues were removed from the distal sacrum to the mid-thoracic levels and as far laterally as the mid-axillary line. The latissimus dorsi and the posterior layer of the TLF were then resected exposing the erector spinae and its caudal fascia. The lateral incisions were then extended to fully expose the abdominal oblique muscles. The external and internal oblique muscles were then reflected and the lumbar erector spinae removed, creating posterior and posterolateral exposures of the multifidus, quadratus lumborum and transversus abdominis. Next, the skin and sub-cutaneous tissues were removed from the anterior abdominal wall. The abdominal aponeurosis, rectus abdominis muscle and the remaining attachments of the external and internal oblique muscles were then resected. Removal of the abdominal viscera and cleaning of the abdominal cavity permitted anterior and anterolateral exposures of the psoas major and quadratus lumborum. Each of the psoas, quadratus lumborum and multifidus muscles were dissected from superficial to deep to determine the segmental and multi-segmental attachments of these muscles. Observations of the fundamental architectural relationships between the lumbar vertebrae and the multifidus, transversus abdominis, quadratus lumborum and psoas muscles were noted. Special attention was paid to the axial attachments of these muscles in terms of their physical relationships to one another and to the lumbar vertebral column. Further note was made of the transversus abdominis and its fascial attachment to the TLF. Photographs were obtained using a digital camera and processed on a personal computer using a commercially available software program.

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3. Results One male embalmed cadaver, aged 44 years, was selected for this study. There was no evidence of structural abnormality, injury or prior surgery. The musculature of the specimen, in general, was of impressive bulk. 3.1. Psoas major The axial attachments of the psoas muscle spanned the T12/L1 motion segment to the L4/5 intervertebral disc. Its most cranial elements blended with the crus of the diaphragm. Blunt dissection of psoas major demonstrated several distinct fascicles with each fascicle having a consistent pattern of attachment across a given motion segment. Two distinct components of each fascicle were demonstrated upon complete dissection, a vertebral head and a discal head. The most superficial fibers of the vertebral head attached along an arch spanning adjacent superior and inferior vertebral margins (Fig. 3a). As fibers of the vertebral head became progressively deeper they attached along the superior half of the vertebral body as far posteriorly as the pedicle. Fibers of the discal head formed a broad attachment along the lateral aspect of the intervertebral disc from its anterolateral to posterolateral margins (Fig. 3b). The most posterior fibers of the discal head had further and more lateral attachments to the anterior layer of the TLF and the inferior edge of the transverse process superior to the disc, along its medial two-thirds. This deepest attachment of the discal head thus filled the intertransverse interval. Distally, each of the fascicles of psoas terminated in a common tendon within the psoas muscle proximal to the point at which psoas merged with iliacus.

Fig. 3. (a) Psoas dissection—anterior view demonstrating the superficial discal and vertebral fibers relative to the fibrous arch at the L3 vertebrae. (b) Psoas dissection—anterolateral view demonstrating the deep attachments of the discal and vertebral heads.



3.2. Quadratus lumborum The most medial component of the quadratus lumborum spanned adjacent transverse processes from L1 to L4. Segmentally, these were observed to attach along the superolateral third of an inferior transverse process and the inferolateral third of the adjacent superior transverse process. The more lateral components of the quadratus lumborum were noted to be multi-segmental (Fig. 4a). When viewed posteriorly, two distinct patterns of attachment were evident. The first, between the transverse processes of L1–L4 and the iliac crest, was oriented in an inferolateral direction. The second, between the twelfth rib and the iliac crest, was more vertically oriented (Fig. 4b). When viewed anteriorly only the vertically oriented fibers of the lateral component were visible.

Between the S1 and the L4 level this obliquity lessened with no further progression beyond the L3 level (Fig. 5).

3.3. Lumbar multifidus The lumbar multifidus was observed to span from the S4 to the L1 spinal levels. The general orientation of the muscle varied in both the sagittal and coronal planes from caudal to cranial; the majority of this variation existed between S4 and L4. In the sagittal plane, fascicles originating from the S4 level maintained a purely axial orientation with subsequently more cranial fascicles becoming progressively more oblique from anterior to posterior. In the coronal plane the most caudal fascicles of multifidus originating from the sacrum were essentially vertical. As the sacral component of multifidus became more cranial, a more superomedial fascicular orientation was observed with this obliquity becoming maximal at the level of the L5/S1 motion segment.

Fig. 5. Posterior view of the partially dissected lumbar multifidus muscle. Individual fascicles are seen on the right side following blunt dissection; these are numbered as F1, F2, F3, F4 and F5, (SP, spinous process; TVP, transverse process; PSIS, posterior superior iliac spine).

Fig. 4. (a) Quadratus lumborum dissection—anterolateral view demonstrating the muscle’s segmental and multi-segmental fibers. (b) Quadratus lumborum dissection—posterolateral view demonstrating the muscle’s vertically and obliquely oriented multi-segmental fibers.


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Fig. 6. (a) Multifidus dissection—lateral view demonstrating the superficial structure of the first and second fascicles, F1 and F2. (b) Deep dissection of the F1 fascicle demonstrating the fascicle’s central tendon and deep architecture (SP, spinous process; TVP, transverse process; PSIS, posterior superior iliac spine).

Upon blunt dissection five distinct fascicles of the multifidus were apparent, with each appearing to originate distinctly from the caudolateral tip of a lumbar spinous process (Fig. 6a). Sharp dissection of each fascicle revealed a more complex architecture. The first and second fascicles were each comprised of superficial and deep fibers which arose in a bi-pennate fashion from a common central tendon (Fig. 6b). The more superficial fibers of each fascicle attached at the caudolateral tip of a spinous process. The deeper fibers from the same central tendon attached at the caudolateral base of the spinous process one level lower. Thus the superficial fibers of the first fascicle of the lumbar multifidus originated at the caudolateral tip of the L1 spinous process. The deep fibers of the first fascicle originated from caudolateral base of the L2 spinous process. This first fascicle inserted at the mamillary process and lamina of L4 as well as the capsule of the L4/5 zygapophysial joint and the most cranial aspect of the posterior superior iliac spine (PSIS). The second fascicle originated in the same manner from the L2 and L3 spinous processes and inserted near the PSIS and just adjacent to the superior articular process of S1 (Fig. 6b).

Fascicles 3–5 originated from the base to the tip of their respective spinous processes and inserted on the posterior surface of the sacrum with fascicle three occupying the largest and most lateral area of insertion and fascicle five the smallest and most medial (Fig. 5). Laminar fibers were also observed at each level spanning adjacent segments. These deep fibers of multifidus originated at the mamillary process of the more superior vertebrae and inserted at the zygapophysial joint capsule of the more inferior vertebrae. 3.4. Transversus abdominis The transversus abdominis muscle throughout the lumbar region was observed to be muscular only at its middle one third as it encircled the trunk from anterior to posterior. The posterior edge of the transversus abdominis muscle was irregular with its most caudal fibers extending more posteriorly than its more cranial fibers (Fig. 7a). This irregular posterior edge of the transversus abdominis was continuous with a thin, membranous fascia which lay immediately posterior to the adipose capsule surrounding the kidney (Fig. 7b). We were unable to distinguish any direct attachment of this fascia



Fig. 7. (a) Right lateral view of the lumbar dissection. (b) Right posterolateral view of the lumbar dissection demonstrating the thin transversus fascia passing anterior to the quadratus lumborum muscle.

Fig. 9. Schematic representation of the basic architectural relationships between the psoas, quadratus lumborum, multifidus and transversus abdominis muscles and a lumbar vertebrae in the transverse plane.

4. Discussion

Fig. 8. Right posterolateral view of the lumbar dissection demonstrating the general architectural relationships between the multifidus, quadratus lumborum and transversus abdominis muscles. Note that the fascial sheet continuous with the transversus abdominis lies anterior to the quadratus lumborum (MF, multifidus; TVP, transverse process; QL, quadratus lumborum; TrA, transversus abdominis; GMed, gluteus medius; GMax, gluteus maximus).

to the lateral raphe and thus to the posterior or middle layers of the TLF. Instead, the transversus abdominis and its fascia occupied a plane anterior to the quadratus lumborum muscle (Fig. 8). The transversus abdominis fascia thus became continuous with the anterior layer of the TLF only, prior to attaching to the lower two ribs, the lumbar transverse processes and the lateral aspect of the lumbar vertebral bodies. 3.5. Group architecture When considered as a group, the psoas, transversus abdominis, quadratus lumborum and multifidus muscles were noted to be arranged in a continuous fashion about the spinal column beginning at the anterolateral aspect of the lumbar vertebral body and ending at the lateral aspect of the spinous processes (Fig. 9).

The results of this preliminary investigation were consistent with much of the literature regarding the attachment of the deep muscles of the lumbar spine. However, some findings were novel with respect to the existing evidence. Since the current study was limited to the examination of a single specimen, these inconsistencies may be indicative only of variation in the ‘normal’ anatomy. Conversely, this investigation may highlight a need for larger and more precise studies of these muscles; many of the recent and often referenced dissection studies of the deep lumbar muscles have been small studies utilizing 10 or fewer specimens (Bogduk and MacIntosh, 1984; MacIntosh and Bogduk, 1991; Bogduk et al., 1992; Delp et al., 2001). 4.1. Quadratus lumborum Traditional textbook descriptions of the quadratus lumborum describe its attachments as running between the iliac crest and the twelfth rib, the iliac crest and the L1 to L4 TVPs and between the twelfth rib and the L1 to L4 TVPs (Moore, 1985; Williams, 1995). Our observations failed to identify any oblique fibers running between the TVPs and the twelfth rib. However, we did note a medial segmental component of the quadratus lumborum spanning adjacent TVPs which


209

appeared distinct from the intertransversarii laterales ventrales (Bogduk, 1997a). This segmental component of the quadratus lumborum was continuous with the lateral, multi-segmental component spanning the iliac crest and twelfth rib (Fig. 4a). As there has been very little study of the architecture of this muscle, further research is certainly warranted. 4.2. Transversus abdominis The transversus abdominis has been described as having consistent attachments to the middle and posterior layers of the TLF via the lateral raphe (Bogduk and MacIntosh, 1984; Barker et al., 2001a). Neither MacIntosh and Bogduk nor Barker and colleagues (n ¼ 10 and 6, respectively) reported any attachment of transversus abdominis to the anterior layer of the TLF. In contrast, our study found no evidence of any attachment of the transversus abdominis to the lateral raphe; instead, the transversus abdominis became continuous only with the anterior layer of the TLF. In our single specimen, this anterior layer appeared quite thin and fragile (Fig. 8). The transversus abdominis has been shown to be capable of transmitting loads of up to 30 N through the middle layer of the TLF (Barker et al., 2001b). It appeared unlikely that this thin anterior layer would be capable of tolerating tensile forces of this magnitude. Our finding that in some individuals, transversus abdominis attaches only via the anterior layer of the TLF, may well be indicative of simple variation in the normal anatomy. However, given the recent clinical emphasis on motor re-education of the transversus abdominis in patients with low back pain (Richardson et al., 1999), an understanding of the extent of this variation may be important from a therapeutic perspective. The lack of large studies which comprehensively detail the attachments of this important muscle represents a gap in the existing literature. 4.3. Psoas and multifidus The results of the current study are in keeping with much of the existing literature regarding the multifidus and psoas muscles. Our findings regarding the complex attachments of these multi-fasicular muscles are consistent, for the most part, with those of MacIntosh and colleagues who reported on the lumbar multifidus (MacIntosh et al., 1986) and Bogduk and colleagues (Bogduk et al., 1992) who studied the psoas major. Our results deviate from those of Bogduk with regard only to the most caudal attachments of psoas; the current investigation failed to identify any axial attachment of psoas to the L5 vertebral body or transverse process. Neither the current study (n ¼ 1) nor Bogduk’s (n ¼ 3) studied a large number of cadavers thus, further work in this regard is warranted.

Fig. 10. The architectural relationships between the psoas, quadratus lumborum, multifidus and transversus abdominis muscles superimposed over the hypothetical neutral zone:elastic zone model (NZ, neutral zone; EZ, elastic zone).

4.4. Potential functional implications While knowledge of muscle architecture alone is insufficient to define muscle function, muscle architecture is nonetheless a key determinant of muscle function (Lieber, 1992; Delp et al., 2001). A variety of authors have concluded that muscles with segmental patterns of attachment are architecturally suited to generating the intersegmental stiffness required to maintain stability in the lumbar spine (Bergmark, 1989; Panjabi et al., 1989; Quint et al., 1998). Individually, the multifidus, quadratus lumborum, psoas and transversus abdominis have been described as functioning to maintain spinal stability (Bogduk, 1997b; McGill, 1998; Gibbons, 2001; Hodges et al., 2003). However, Panjabi’s model of spinal stability requires a muscular system capable of controlling segmental motion and maintaining normal NZ amplitudes across multiple planes of segmental spinal motion. We have hypothesized that given the need for multiplanar control of segmental motion, certain deep lumbar muscles will function to maintain adequate segmental stability in the lumbar spine. Individually, each of the transversus abdominis, psoas, quadratus lumborum and multifidus muscles have a segmental pattern of attachment considered necessary for the maintenance of spinal stability. As a group, they surround the lumbar motion segments from the anterolateral aspect of the vertebral bodies to the spinous processes posteriorly. Based on their fundamental architecture, these muscles, when considered as a functional group, are suited to the generation of intersegmental stiffness across multiple planes of segmental motion (Fig. 10).

5. Conclusions Physiological movements of the lumbar spinal column occur as a consequence of multi-planar segmental motion. Lumbar motion segments demonstrate



bi-phasic stiffness characteristics across the physiological range of motion. Given the low critical load of the lumbar spine, coordinated muscular activity is required to prevent excessive loading of the osseoligamentous elements leading to injury and a subsequent increase in the relative amplitude of the NZ. A system of muscles with the ability to control segmental motion through multiple planes of movement is therefore necessary for the maintenance of spinal stability. Individually, the psoas major, transversus abdominis, quadratus lumborum and multifidus muscles have patterns of attachment in the lumbar region conducive to the maintenance of intersegmental stiffness. They are hypothesized to have the fundamental group architecture required to develop this intersegmental stiffness across multiple planes of segmental motion. The present study was designed to illustrate these individual and group characteristics. To varying extents, our understanding of the fundamental anatomy and architecture of the deep lumbar muscles remains incomplete. Future research should attempt to confirm, negate or expand upon the current anatomical findings which are based upon our dissection of a single cadaver. Further anatomical, biomechanical and neurophysiological studies should address the functional relationships between the psoas, quadratus lumborum, multifidus and transversus abdominis muscles as a group and in relation to the multi-segmental muscles of the lumbar spine in the context of lumbar stability. References Andersson EA, Oddsson LE, Grundstrom H, Nilsson J, Thorstensson A. EMG activities of the quadratus lumborum and erector spinae muscles during flexion–relaxation and other motor tasks. Clinical Biomechanics 1996;11(7):392–400. Barker P, Briggs CA, Lohman R. Posterior attachments of the abdominal obliques and transversus abdominis. In: Proceedings of the Fourth Interdisciplinary World Congress on Low Back and Pelvic Pain. Montreal, Canada, November 2001a. p. 360–361. Barker P, Briggs CA, Bogeski G. Muscle attachments of the lumbar fasciae. In: Proceedings of the 4th Interdisciplinary World Congress on Low Back and Pelvic Pain. Montreal Canada, November 2001b. p. 238–239. Bergmark A. Stability of the lumbar spine. A study in mechanical engineering. Acta Orthopaedica Scandinavia 1989;60(Suppl 230):1–54. Bogduk N, MacIntosh JE. The applied anatomy of the thoracolumbar fascia. Spine 1984;9(2):164–70. Bogduk N, Pearcy M, Hadfield G. Anatomy and biomechanics of psoas major. Clinical Biomechanics 1992;7:109–19. Bogduk N. Clinical anatomy of the lumbar spine and sacrum. Edinburgh: Churchill Livingstone; 1997a. p. 103. Bogduk N. Clinical anatomy of the lumbar spine and sacrum. Edinburgh: Churchill Livingstone; 1997b. pp. 108, 219. Cholewicki J, McGill SM. Mechanical stability of the in vivo lumbar spine: implications for injury and chronic low back pain. Clinical Biomechanics 1996;11(1):1–15. Crisco JJ. The biomechanical stability of the human lumbar spine: experimental and theoretical investigations [Doctoral Dissertation], New Haven, CT, Yale University, 1989.

Delp SL, Suryanarayanan S, Murray WM, Uhlir J, Triolo RJ. Architecture of the rectus abdominis, quadratus lumborum and erector spinae. J Biomech 2001;34:371–5. Gibbons S. Biomechanics and stability mechanisms of psaos major. In: Proceedings of the Fourth Interdisciplinary World Congress on Low Back and Pelvic Pain. Montreal, Canada, November 2001. p. 246–7. Hodges PW, Kaigle-Holm A, Holm S, Ekstrom L, Cresswell A, Hansson T, Thorstensson A. Intervertebral stiffness of the spine is increased by evoked contraction of transversus abdominis and the diaphragm: In vivo porcine studies. Spine 2003;28(23): 2594–601. Knuttson F. The instability associated with disk degeneration in the lumbar spine. Acta Radiologica 1944;25:593–609. Lieber RL. Skeletal muscle structure and function. Implications for rehabilitation and sports medicine. Baltimore: Williams & Wilkins; 1992. p. 1. Lucas DB, Bresler B. Stability of the ligamentous spine. Technical Report esr. 11 No. 40, Biomechanics Laboratory, University of California, 1961. MacIntosh JE, Valencia F, Bogduk N, Munro RR. The morphology of the lumbar multifidus muscles. Clinical Biomechanics 1986;1:196–204. MacIntosh JE, Bogduk N. The attachments of the lumbar erector spinae. Spine 1991;16(7):783–92. McGill SM. Kinetic potential of the lumbar trunk musculature about three orthogonal orthopaedic axes in extreme postures. Spine 1991;16(7):809–15. McGill SM. Low back exercises: evidence for improving exercise regimens. Physical Therapy 1998(78):754–65. Moore KL. Clinically oriented anatomy, 2nd ed. Baltimore: Williams & Wilkins; 1985. p. 276. Oxland TR, Panjabi MM. The onset and progression of spinal injury: a demonstration of neutral zone sensitivity. Journal of Biomechanics 1992;25(10):1165–72. Panjabi MM, Abumi K, Duranceau J, Oxland T. Spinal stability and intersegmental muscle forces. A biomechanical model. Spine 1989;14(2):194–200. Panjabi MM. The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. Journal of Spinal Disorders 1992a; 5(4):390–7. Panjabi MM. The stabilizing system of the spine. Part 1. Function, dysfunction, adaptation and enhancement. Journal of Spinal Disorders 1992b;5(4):383–9. Panjabi MM, Kifune M, Liu W, Arand M, Vasavada A, Oxland TR. Graded thoracolumbar spinal injuries: development of multidirectional instability. European Spine Journal 1998;7: 332–9. Penning L. Psoas muscle and lumbar spine stability: a concept uniting existing controversies. Critical review and hypothesis. European Spine Journal 2000;9(6):577–85. Quint U, Wilke HJ, Shirazi-Adl A, Pamianpour M, Franz L, Claes LE. Importance of the intersegmental muscles for the stability of the lumbar spine. A biomechanical study in vitro. Spine 1998; 23(18):1937–45. Richardson C, Jull G, Hodges P, Hides J. Therapeutic exercise for spinal segmental stabilization in low back pain. Edinburgh: Churchill Livingstone; 1999 [Chapter 9]. White AA, Panjabi MM. Clinical biomechanics of the spine. Philadelphia: JB Lippincott; 1978. p. 194. Wilke HJ, Wolf S, Claes LE, Arand M, Wiesend A. Stability increase of the lumbar spine with different muscle groups. Spine 1995; 20(2):192–8. Williams PL editor. Gray’s anatomy. 38th ed. Edinburgh: Churchill Livingstone; 1995.

ARTICLE IN PRESS


Original article

Spinal kinematics and trunk muscle activity in cyclists: a comparison between healthy controls and non-specific chronic low back pain subjects—a pilot investigation Angus F. Burnetta,, Mary W. Corneliusa, Wim Dankaertsb,c, Peter B. O’Sullivanb a

School of Biomedical and Sports Science, Edith Cowan University, 100 Joondalup Drive, Joondalup, 6027 Western Australia, Australia b School of Physiotherapy, Curtin University of Technology, Western Australia, Australia c Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium Received 17 July 2003; received in revised form 31 March 2004; accepted 28 June 2004

Abstract The aim of this pilot study was to examine whether differences existed in spinal kinematics and trunk muscle activity in cyclists with and without non-specific chronic low back pain (NSCLBP). Cyclists are known to be vulnerable to low back pain (LBP) however, the aetiology of this problem has not been adequately researched. Causative factors are thought to be prolonged forward flexion, flexion–relaxation or overactivation of the erector spinae, mechanical creep and generation of high mechanical loads while being in a flexed and rotated position. Nine asymptomatic cyclists and nine cyclists with NSCLBP with a flexion pattern disorder primarily related to cycling were tested. Spinal kinematics were measured by an electromagnetic tracking system and EMG was recorded bilaterally from selected trunk muscles. Data were collected every five minutes until back pain occurred or general discomfort prevented further cycling. Cyclists in the pain group showed a trend towards increased lower lumbar flexion and rotation with an associated loss of co-contraction of the lower lumbar multifidus. This muscle is known to be a key stabiliser of the lumbar spine. The findings suggest altered motor control and kinematics of the lower lumbar spine are associated with the development of LBP in cyclists. r 2004 Elsevier Ltd. All rights reserved.

1. Introduction The aim of a competitive cyclist is to produce maximal power at the pedals to propel the bike in the desired direction (Burke, 1996). To maximise bike velocity for a given power output however, the cyclist must reduce their frontal cross-sectional area to reduce aerodynamic drag (Kyle, 1994) and consequently the cyclist must bend forward from the hips in addition to flexing the thoracolumbar spine. The extent to which pelvic and spinal flexion contributes towards the cyclist reaching the handlebars determines whether the cyclists adopts a ‘‘round-back’’ or ‘‘flat-back’’ posture (Burke, 1996; Usabiaga et al., 1997). The fact the cyclist is seated Corresponding author. Tel.: +61-8-6304-5860; fax: +61-8-63045036. E-mail address: [email protected] (A.F. Burnett).

1356-689X/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2004.06.002

increases the tendency towards a kyphotic lumbar spine posture (Lord et al., 1997; Salai et al., 1999; Bressel and Larson, 2003) unless there is well-developed flexibility of the hamstrings and hips. Cyclists are known to be vulnerable to low back pain (LBP) (Weiss, 1985; Mellion, 1991; Brier and Nyfield, 1995; Wilber et al., 1995; Callaghan and Jarvis, 1996; Manninen and Kallinen, 1996) however, there is little evidence of radiographic abnormality in the majority of back pain disorders resulting in them being diagnosed with non-specific chronic low back pain (NSCLBP) (Dillingham, 1995). Because of this there is a growing emphasis upon sub-classifying LBP patients on criteria other than radiological abnormality. Patients that present with NSCLBP have been reported to show distinctly different clinical patterns although this notion has not been well scientifically validated (Delitto et al., 1995; O’Sullivan, 2000). A proposed sub-group of


A.F. Burnett et al. / Manual Therapy 9 (2004) 211–219

NSCLBP patients have been classified on the directional basis of back pain provocation and their individual clinical presentation. One of these groups has been classified as a ‘‘flexion pattern’’ pain disorder (O’Sullivan, 2000). Flexion strain pain disorders are clinically characterised by LBP, which is reproduced by sustained and repeated flexion of the lumbar spine and is relieved by extension of the lumbar spine. This clinical pattern is reported to be associated with no spinal mobility impairment but a loss of lower lumbar lordosis with associated dysfunction of the lumbar multifidus muscles and a compensatory upper lumbar lordosis and increased tone in the thoracic erector spinae muscles (O’Sullivan, 2000). Flexion pattern pain disorders are thought to result from a loss of neutral zone control of the spinal motion segment with resultant repetitive strain of the spinal segment at the end of range of flexion (O’Sullivan et al., 2003). Cyclists with LBP are thought to commonly represent subjects with a flexion strain pain disorder of the lumbar spine. As cyclists spend a large amount of time training on their bikes to elicit a physiological training effect this may increase the chance of low back injury via three mechanisms. Firstly, the flexion–relaxation phenomenon, which manifests itself as myoelectrical silence of the erector spinae at the end of range of forward flexion (Floyd and Silver, 1955; McGill and Kippers, 1994; Kaigle et al., 1998; Callaghan and Dunk, 2002) may be problematic as it has been found that when muscle forces are reduced in lifting, passive structures such as the ligaments and intervertebral discs are placed at higher risk (Kong et al., 1996). A study of non-cycling athletes by Juker et al. (1998) suggested that flexion–relaxation may occur in certain cycling postures. Secondly, NSCLBP in cyclists may result from the generation of excessive activation of the spinal extensors resulting in increased tissue strain across the lower lumbar spine. This mechanism has been previously suggested as a basis for NSCLBP (Indahl, 1999). Thirdly, prolonged forward flexion may be an important etiological factor towards LBP as the posterior annulus may develop accumulated micro-damage (Callaghan and McGill, 2001). Loading of the passive structures of the lumbar spine which leads to LBP as discussed above, may be further exacerbated by two factors. Firstly, mechanical creep may increase the stretch on the posterior structures (McGill and Brown, 1992) however, this is questionable as a portion of the cyclist’s mass is supported by the handlebars (Bolourchi and Hull, 1985) and therefore, is different to the open-ended system that is typically evident in occupational settings (McGill and Brown, 1992). Secondly, intersegmental joint reaction forces and moments are generated by the lower limbs and must be transferred through the thoracolumbar spine whilst the trunk is in a flexed, and sometimes rotated position.

As there is little data pertaining to the development of LBP in cyclists, the aim of this pilot study was to examine whether differences in trunk muscle activity and spinal kinematics existed in cyclists with and without NSCLBP. It was hypothesised that cyclists with NSCLBP develop a flexion pattern pain disorder due to repeated strain of the lower lumbar spine into end range of flexion/axial rotation and altered motor control of their spinal stabilising muscles.

2. Methods 2.1. Sample Eighteen (8 male and 10 female) middle-level to highlevel cyclists/triathletes, aged between 18 and 57 years were recruited for this study. Cyclists were matched as closely as possible by specific criteria (see below) into a non-pain and a pain group. The non-pain group contained nine cyclists (mean age 37.677.9 years, weight 67.277.0 kg, height 1.7070.07 m, body mass index 23.472.0) with no history of LBP. The pain group contained nine cyclists (mean age 42.379.7 years, weight 67.077.0 kg, height 1.7070.07 m, body mass index 22.971.7) that had a history of NSCLBP. The details of this group are outlined in Table 1. Two experienced manipulative physiotherapists independently assessed the NSCLBP group, and only the cyclists presenting with a flexion pattern pain disorder, that was considered directly attributable to the activity of cycling, were selected (O’Sullivan, 2000). The pain group had a baseline Visual Analog Score (VAS) for the level of pain of 2.371.7. This VAS score was determined by the subject’s average pain over the week prior to clinical investigation. Cyclists with known structural pathology such as spondylolisthesis of the spine were excluded from the study. Ethical clearance for the study was provided by the Edith Cowan University Human Research Ethics Committee and informed consent was obtained from subjects prior to testing. Subjects were instructed not to partake in any heavy training or physical activity 24 h prior to their clinical assessment or testing day. 2.2. Data collection Subjects rode their own road bicycles on an indoor wind trainer and were instructed to remain seated as much as possible and to ride on either their tri-bars or drop bars (Fig. 1). Subjects were also instructed to ride at 75% of their age-predicted maximum heart rate and at a cadence between 90 and 100 rpm until the onset of LBP (pain group—total ride time was 38.5712.7 min) or until the general discomfort was too great (non-pain group—total ride time was 54.5712.3 min). The cycling

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Table 1 Non-specific chronic low back pain (NSCLBP) group subject general details, pain characteristics and level of pain measured by a Visual Analog Scale (VAS) Subject (pain duration)

Sex

Age (yrs)

Baseline pain (VAS)

Level of pain

Side of pain

Cycling pain (VAS)

JV (3 months) JP (14 years) NC (2 years) SM (10 years) DW (7 months) MM (18 months) DB (4 months) DM (3 years) AK (6 years)

M M F F F F M F M

28 57 30 40 44 49 45 48 36

5/10 3/10 2/10 5/10 2/10 2/10 2/10 0/10* 0/10*

L5/S1 L4/L5 L2/3, L3/4, L5/S1 L4/5, L5/S1 L4/5, L5/S1 L4/5, L5/S1 L4/5, L5/S1 L4/5, L5/S1 L4/5, L5/S1

R4L L=R L=R L=R L=R L=R R4L L L=R

5/10 5/10 4/10 5/10 5/10 6/10 6/10 6/10 7/10

*—Denotes pain was experienced whilst cycling only.

of back muscles. The muscles that were investigated (with their abbreviations in brackets) and their electrode placements were as follows:

Fig 1. The experimental set up.

positions were utilised to accelerate the onset of LBP in the pain group. Based on the similarity in the mean age of the pain and non-pain groups there would be little difference between the resulting power output between these two groups (Grazzi et al., 1999). The VAS scores at the end of the ride for the pain group were 5.470.9. Subjects in the pain group were matched to subjects in the non-pain group by three criteria, they being; total ride time (data were collected every 5 min and the files corresponding to the time where the LBP occurred were eventually analysed in both the pain and non-pain groups), ride position (tri-bars and drop bars) and subject height. Subjects were not matched for physical activity level as training activities outside cycling could not be controlled for however, all subjects were all very physically active. Synchronised trunk muscle electromyography (EMG) and spinal kinematics data were collected at the beginning of each trial and then every 5 min throughout the duration of the ride. Six pairs of trunk muscles were investigated in this study; three pairs of abdominal muscles and three pairs

Left and Right Rectus Abdominis (LRA, RRA)— approximately 3 cm lateral to the midline, half way between the tip of the xyphoid process to the umbilicus (Ng et al., 1998); Left and Right External Oblique (LEO, REO)—at the approximate edge of the lateral border of the 8th rib (Ng et al., 1998); Left and Right Internal Oblique (LIO, RIO)— approximately 1 cm lateral to the border of the anterior superior iliac crest (Ng et al., 1998); Left and Right Lumbar Multifidus (LLM, RLM)— approximately 2–3 cm lateral to the midline of the L4/ 5 level of the spinous process (De Foa et al., 1989); Left and Right Erector Spinae Thoracic 12 (LEST12, REST12)—approximately 5 cm lateral of the midline of the vertebral column at the level of the T12 spinous process (Danneels et al., 2001a); Left and Right Erector Spinae Thoracic 9 (LEST9, REST9)—approximately 5 cm lateral of the midline of the vertebral column at the level of the T9 spinous process (Callaghan et al., 1998).

Excess body hair was removed and the area was abraded, then cleaned with an alcohol swab. Ag/AgCl disposable electrodes (30-mm diameter, 20-mm interelectrode distance), were adhered to the skin along the muscle fibre orientation. An impedance meter was then used to ensure an impedence reading less then 5 KO. To ensure that normal cycling movement was not compromised, two portable patient units and two receiving units (Bortec Electronics, Ont., Canada) received the left and right-sided EMG signals. Prior to data collection on the bicycle, subjects performed a maximum voluntary isometric contraction (MVIC) for all trunk muscles. All MVICs were collected for 5 s and three trials were performed. MVICs for all



back muscles were generated using the one test. From the prone position with hands behind their head subjects then pushed maximally against a maximal manual isometric resistance. To generate MVIC for the abdominal muscles three tests were used (Danneels et al., 2001b; Dankaerts et al., 2004). The subject was positioned supine with the legs straight and strapped with a belt. A resisted curl-up with maximal manual isometric resistance applied in a symmetrical manner through the shoulders of the subject by the investigator (standing at the head end of the couch) was used for left and right rectus abdominis (RA). A resisted crossed curl-up, with the right shoulder moving towards the left and maximal manual isometric resistance applied through the right shoulder by the investigator (standing at the left side) for left internal oblique (LIO) and right external oblique (REO) muscles. For the right internal oblique (RIO) and the left external oblique (LEO) the same procedure was repeated to the right with the investigator standing at the right side applying resistance to the left shoulder. The highest generated contraction from each muscle during the three normalisation trials was deemed to be the MVIC. This calculation of maximum activity was based upon a 25 ms moving window. This approach of normalisation of trunk muscles has previously been shown to exhibit excellent within-day reliability for both healthy controls and patients with NSCLBP (Dankaerts et al., 2004). Spinal kinematics data were recorded using an electromagnetic tracking device (3-Space Fastrak, Polhemus Navigation Sciences Division, Vermont, USA). The device consists of an electromagnetic source (transmitter), a systems electronic unit and four receivers (each of which have a three-dimensional coordinate system embedded). A validity study of the Fastrak system in the presence of metal (from EMG electrode studs, bike seat posts and bike wheel spokes) was carried out prior to data collection. This preliminary study showed that the accuracy of the Fastrak system was not compromised in the testing environment as the static variation was less than 0.11. The magnetic source was securely fixed to a wooden frame and the four receivers were placed on the subject’s back as follows:

Sensor 1—spinous process of the 2nd sacral vertebrae (S2); Sensor 2—spinous process of the 3rd lumbar vertebrae (L3); Sensor 3—spinous process of the 12th thoracic vertebrae (T12); Sensor 4—spinous process of the 6th thoracic vertebrae (T6).

To obtain a neutral posture for the spinal kinematics analysis subjects were required to sit upright on their

bike seats with their legs hanging unsupported. Three trials of five seconds were recorded. A digital switch (710 V) was positioned to synchronise the collection of the EMG and Fastrak signals and to identify top dead centre (TDC). Raw EMG and spinal kinematics data were saved to file for latter analysis. 2.3. Data analysis The files at the initiation and completion of the ride were analysed. A customised software program written in LabVIEW V6.1 (National Instruments Inc., Texas, USA) was used to process the raw data. EMG data from five continuous crank revolutions (TDC to TDC) were generated during each trial of interest. Each of these sub-samples was full wave rectified and low pass filtered at 4 Hz to generate a linear envelope. Data was then amplitude normalised to the previously recorded MVC values for each muscle. To allow comparison between subjects, data was time normalised to 0–1000 via a cubic spline. To reduce within-subject variability, an ensemble average was then calculated from the five crank revolutions for each muscle. EMG activity was quantified by obtaining the average activation, during this period. The calculation of the three-dimensional relative rotations of one electromagnetic sensor to another whilst subjects were cycling was based upon the Joint Coordinate System of Grood and Suntay (1983). The output of the Fastrak data was changed from a lateral bending, flexion/extension and axial rotation sequence of rotation to a flexion/extension, lateral bending axial rotation order of rotation as recommended by McGill et al. (1997) then all data were calculated with reference to the neutral position. The matrix algebra procedures for these calculations are outlined by Burnett et al. (1998). Flexion and axial rotation angular displacement values were then defined for the following spinal regions:

Pelvis—S2 relative to the magnetic source; Lower lumbar—L3 relative to S2; Upper lumbar—T12 relative to L3; Lower thoracic—T6 relative to T12.

2.4. Statistical analysis Independent sample t-tests were performed to determine whether differences existed between the non-pain and pain groups at the start and finish of the ride and whether differences existed in EMG activation of the left and right sides of the selected trunk muscles. Prescreening of the data revealed the assumptions of the normality and equality of variance could be made in the vast majority of cases. If the assumption of equality of group variance could not be made, the degrees of


freedom were altered according to the results of a Levene’s test. All statistical testing was carried out using the Statistical Package for Social Sciences Version 10.0 (SPSS V10.0) software. Differences were considered statistically significant at po0.05. Due to the small sample size, effect sizes were also calculated and values greater than 0.8 were considered as large (Cohen, 1988).

3. Results Statistical significance was not reached for a number of the variables measured in this pilot study due to two reasons. Firstly, a limitation in the study was the small sample size due to the requirement of the study to maintain the homogeneity of the NSCLBP group. This affected the ability to make definite conclusions however, there were trends in the data that were worthy of consideration. Secondly, the cyclists in this study adopted two differing postures (riding on their tri-bars and drop bars) as it was considered more clinically relevant that the cyclists adopt the riding posture that

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provoked their back pain. However, this resulted in large SD values for the spinal kinematics data (see paragraph below), which in turn, decreased the size of the effect between the non-pain and pain groups. However, trends were observed in the data that appear clinically significant which may provide insight into the possible mechanisms contributing to LBP in cyclists. Variables that displayed statistical significance or a large effect size were considered for discussion. There was minimal change in the pelvic and spinal angles across the duration of the ride (maximal difference for any angle was 1.11) therefore, an average value was calculated from the start and finish of the ride for each variable (Table 2). Spinal flexion and range of axial rotation data for the regions of the spine (pelvis, lower lumbar, upper lumbar and lower thoracic) are shown in Tables 2 and 3, respectively. There were no statistically significant differences found between the non-pain and pain groups for these variables. However, large effect sizes which suggested a trend towards increased spinal flexion in the lower thoracic region at the start and finish of the ride (d=0.96 and 0.80,

Table 2 Spinal kinematics in the sagittal plane at the start and finish of the ride and the resulting differences (1)

Pelvic flexion—start Pelvic flexion—finish Pelvic flexion—difference Lower lumbar flexion—start Lower lumbar flexion—finish Lower lumbar flexion—difference Upper lumbar flexion—start Upper lumbar flexion—finish Upper lumbar flexion—difference Lower thoracic flexion—start Lower thoracic flexion—finish Lower thoracic flexion—difference

Non-pain (n=9)

Pain (n=9)

p-value

Effect size

23.2 23.4 0.1 25.3 24.9 0.5 26.8 27.2 0.4 2.7 3.8 1.1

16.1 15.0 1.1 38.6 38.6 0.0 19.3 18.9 0.4 10.8 11.0 0.2

0.40 0.30 0.32 0.16 0.17 0.71 0.39 0.34 0.29 0.07 0.13 0.39

0.44 0.51 0.49 0.69 0.68 0.22 0.43 0.48 0.55 0.96 0.80 0.46

(16.6) (17.4) (1.6) (19.3) (20.2) (1.8) (13.5) (13.5) (1.9) (5.9) (5.7) (1.8)

(15.4) (15.4) (3.3) (19.0) (19.9) (2.7) (21.6) (20.9) (1.0) (10.9) (12.2) (2.5)

Table 3 Range of axial rotation relative to the magnetic source at the start and finish of the ride and the resulting differences (1) Non-pain (n=9) Pelvic axial rotation—start Pelvic axial rotation—finish Pelvic axial rotation—difference Lower lumbar axial rotation—start Lower lumbar axial rotation—finish Lower lumbar axial rotation—difference Upper lumbar axial rotation—start Upper lumbar axial rotation—finish Upper lumbar axial rotation—difference Lower thoracic axial rotation—start Lower thoracic axial rotation—finish Lower thoracic axial rotation—difference

5.6 6.4 0.9 2.2 1.6 0.6 3.4 7.8 4.4 2.5 4.2 1.7

(1.9) (4.0) (3.5) (0.9) (3.0) (3.2) (1.2) (7.1) (7.7) (2.1) (4.7) (4.5)

Pain (n=9)

p-value

Effect size

8.1 5.2 2.9 3.4 3.4 0.0 5.3 5.1 0.2 5.0 3.5 1.5

0.30 0.47 0.19 0.08 0.15 0.68 0.19 0.40 0.11 0.25 0.69 0.19

0.56 0.33 0.71 0.89 0.77 0.21 0.73 0.41 0.89 0.61 0.20 0.65

(7.0) (3.2) (7.5) (1.8) (1.7) (1.5) (4.0) (5.9) (2.7) (6.1) (2.4) (5.7)



respectively) and increased range of axial rotation in the lower lumbar spine for the pain group at the start of the ride (d=0.89) were evident. Although there was not a large effect size evident for the lower lumbar flexion angle, the mean for the pain (38.61719.91) and non-pain (24.91720.21) groups suggest clinically significant variation in the thoracolumbar flexion posture between these two groups when the difference in the lower thoracic flexion angle is also considered. Average muscle activation data are presented for the start and finish of the ride (Tables 4 and 5, respectively). Table 6 presents the differences between the left and right sides of the muscle examined in this study at the start and finish of the ride. These data suggest there were trends evident between the non-pain and pain groups and across the cycling period which may provide evidence of altered motor control of the lumbar spine in the pain group. The pain group exhibited greater levels of activation of the REST9 (d=0.83), LLM (1.24), RRA (d=0.81) and reduced levels of activation of the LIO (d=0.81) at the end of the ride (Table 5). Furthermore, trends for asymmetrical activation of the

lower portion of the lumbar multifidus (LM) were observed in the pain group both at the beginning (d=0.81) and end (d=0.99) of the ride (Table 6).

4. Discussion The aim of this pilot study was to examine whether differences in spinal kinematics and trunk muscle activity existed in cyclists with and without NSCLBP whilst performing a continuous bike ride. A longitudinal study would have been a preferable design to determine the natural history of LBP in cyclists (specifically development of a flexion pattern disorder) however, in this study, two independent groups were analysed. In selecting the subjects for the two groups in this study, two considerations were important. Firstly, the pain group was homogeneous as possible by selecting NSCLBP subjects with a classification of a flexion pattern pain disorder with the clinically determined symptomatic level being either of the two lower spinal levels. Secondly, subjects were matched between groups

Table 4 Average trunk muscle activation at the start of the ride (%MVC)

Left multifidus Left erector spinae (T12) Left erector spinae (T9) Left internal oblique Left rectus abdominus Left external oblique Right multifidus Right erector spinae (T12) Right erector spinae (T9) Right internal oblique Right rectus abdominus Right external oblique

Non-pain (n=9)

Pain (n=9)

p-value

Effect size

5.6 6.3 15.6 20.6 10.5 13.1 5.1 7.1 12.3 16.8 3.4 7.5

9.4 4.6 18.8 16.2 5.7 11.0 4.8 4.5 19.6 17.7 8.6 5.3

0.19 0.36 0.35 0.58 0.30 0.69 0.82 0.53 0.25 0.90 0.04 0.44

0.78 0.46 0.47 0.27 0.55 0.19 0.11 0.35 0.61 0.06 1.20 0.40

(1.8) (4.7) (7.9) (16.7) (12.4) (12.3) (2.3) (11.7) (7.1) (14.6) (2.2) (7.0)

(8.0) (2.7) (5.7) (16.1) (5.1) (10.4) (3.3) (3.2) (16.9) (16.6) (6.5) (4.0)

Table 5 Average trunk muscle activation at the finish of the ride (%MVC)

Left multifidus Left erector spinae (T12) Left erector spinae (T9) Left internal oblique Left rectus abdominus Left external oblique Right multifidus Right erector spinae (T12) Right erector spinae (T9) Right internal oblique Right rectus abdominus Right external oblique

Non-pain (n=9)

Pain (n=9)

p-value

Effect size

3.9 4.4 11.6 30.9 5.9 11.7 4.2 2.6 9.7 17.7 4.0 8.0

8.8 4.0 20.1 16.2 5.6 10.2 5.2 3.8 15.2 16.9 6.9 6.3

0.05 0.80 0.11 0.11 0.92 0.74 0.41 0.24 0.10 0.92 0.13 0.49

1.24 0.12 0.67 0.81 0.05 0.16 0.38 0.58 0.83 0.05 0.81 0.34

(1.1) (4.1) (11.6) (20.4) (7.8) (8.4) (2.4) (2.0) (6.7) (19.0) (2.3) (5.6)

(6.8) (2.4) (13.8) (15.8) (3.9) (10.4) (2.9) (2.1) (6.6) (14.4) (4.9) (4.4)


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Table 6 Differences in left and right side muscle activation at the start and finish of the ride (%MVC) Non-pain (n=9) Multifidus—start Multifidus—finish Erector spinae (T12)—start Erector spinae (T12)—finish Erector spinae (T9)—start Erector spinae (T9)—finish Internal oblique—start Internal oblique—finish Rectus abdominus—start Rectus abdominus—finish External oblique—start External oblique—finish

0.5 0.3 0.8 1.7 3.4 1.9 3.8 22.9 7.1 1.8 5.7 0.6

(3.0) (2.2) (12.3) (3.2) (12.5) (9.8) (23.8) (17.1) (10.5) (8.1) (8.5) (3.6)

for cycling position (i.e. drop bars and tri-bars). A discussion of the spinal kinematics, the trunk muscle activation and the clinical implications is outlined below. 4.1. Spinal kinematics The magnitude of the spinal angles measured in this study were higher than those obtained in a previous study which examined spinal posture in cyclists using Xray methods (Usabiaga et al., 1997). The reason for this is that the electromagnetic tracking system used in this study was a skin-mounted measuring system therefore, skin distraction over the underlying vertebrae is being measured which consequently overestimates the true thoracolumbar spine motion (Pearcy and Hindle, 1989; Pope et al., 1992; McGill et al., 1997). However, as the same measuring system was used to compare both the non-pain and pain groups this was not considered to be detrimental to the design of the study. The findings of this pilot study clearly showed that the spinal kinematics for both the non-pain and pain groups were remarkably stable across the cycling period which dismissed the concept that spinal creep occurred as the cyclists developed back pain, nor did the cyclists alter their spinal posture in response to the development of pain during cycling. Usabiaga et al. (1997) stated that hip flexion rather than lumbar spine flexion changed with cycling position or bicycle. This study however, suggests that spinal posture varied between asymptomatic and symptomatic patients. The pain group displayed a trend towards greater lower lumbar spine rotation and flexion when compared to the non-pain group. Conversely, the non-pain group displayed a trend towards greater upper lumbar spine flexion and rotation compared to the pain group. These findings, although clinically significant, should be viewed with caution as they did not reach statistical significance due to the low subject numbers examined in this study.

Pain (n=9) 4.6 3.6 0.0 0.1 0.8 4.9 1.5 9.9 2.9 1.4 5.6 1.0

(7.1) (5.7) (1.8) (1.6) (18.5) (14.3) (13.5) (13.4) (4.3) (5.0) (8.2) (3.0)

p-value

Effect size

0.13 0.08 0.84 0.20 0.58 0.61 0.57 0.09 0.02 0.33 0.99 0.97

0.81 0.99 0.11 0.67 0.27 0.25 0.28 0.85 1.35 0.49 0.01 0.01

Rotation of the lower lumbar spine in flexed postures has been well documented as a risk factor in the development of injury to the annulus fibrosis (Nachemson, 1999). Furthermore, end of range strain is known to increase the risk of back injury however, it was not known where these cyclists positioned their spines relative to end of range. It is possible that prolonged end of range strain into flexion and rotation was a factor in the pain group (McGill and Cholewicki, 2001). 4.2. EMG activation Lumbar multifidus is known to be a key stabiliser of the lower lumbar spine controlling both flexion and rotation moments of the spine (Bogduk, 1997). Symmetrical patterns of activation of the LM have been reported in a number of normative EMG studies when investigating the lumbar spine during flexion/rotation tasks, supporting this muscle’s stabilising role (Danneels et al., 2001b). Dysfunction of the LM has been documented in the LBP population, with a loss of symmetrical co-contraction being reported (Grabiner et al., 1992). The findings from this study suggest that the pain group presented with greater asymmetry of the superficial LM at both the beginning and end of the ride when compared to the non-pain group. This finding appears to be consistent with the trend towards increased axial rotation observed in the flexed lower lumbar spine typical of the pain group. It is unclear whether the trend towards an increase in LLM and REST (T9) and decrease in RIO at the end of the ride in the pain group represented an attempt to compensate for the flexion and rotation moments across the low back by increasing the extension moment across the spine, or whether this change was a reflex response to pain. Regardless of the mechanism involved, the spinal kinematics remained unaltered across the ride time and the pain reached a point where cycling had to cease. The reason for the trend towards an increase in the



activation of RRA for the pain group was less clear as this muscle is a powerful flexor of the spine. Previous research however, has reported dominant activation of the rectus abdominus to be associated with LBP disorders as a substitution strategy for a deficit in key stabilising muscles such as the transverse fibres of internal oblique (O’Sullivan et al., 1997). Further, this may be linked to the trend displayed for the difference in the lower thoracic spinal angle observed between the two groups. It should be acknowledged that the use of surface EMG prevented the measurement of the function of the deep spinal stabilising muscles. 4.3. Clinical implications The underlying mechanism for NSCLBP is a source of great debate due to a lack of a patho-anatomical basis for the pain disorder. It has been hypothesised that the classification of NSCLBP subjects into homogenous subgroups may enhance the understanding of the underlying basis of these disorders and enhance treatment efficacy (Rose, 1989; Atlas et al., 1996; LebouefYde et al., 1997; Fritz and George, 2000). The subject group in this study reported having a NSCLBP disorder where pain was exacerbated by flexion activities and sustained postures of the lumbar spine, especially cycling. Conversely, pain was relieved with extension postures and activities. The majority of the NSCLBP subjects had sought various treatment interventions for their pain disorders however, they were still unable to cycle without the onset of significant pain. A majority of these subjects had to cease high level cycling due to their pain disorders. The findings of this pilot study suggest that the cyclists with NSCLBP may have an underlying motor control disorder of the lumbo-pelvic region with an associated loss of co-contraction of the lower LM, and a trend towards an increase in flexion/axial rotation movement of the lower lumbar spine. This appears to represent either a maladaptive response or predisposition to a flexion/rotation strain pain disorder, as the movement pattern adopted by these subjects appears to increase the flexion/rotation strain on the lower lumbar spine already sensitised to movement and loading in these directions. Interestingly, this motor pattern preceded the onset of LBP during the cycling task, suggesting that it is an inherent movement fault rather than a reflex response to pain. Furthermore, with the onset of pain (related to flexion/rotation loading of the lower lumbar spine), there was no evidence of an effective adaptive response to pain to reduce the amount of rotation and flexion of the lower lumbar spine. These findings lend support the clinical classification of flexion related pain disorders proposed by O’Sullivan (2000). These preliminary findings are in contrast to current theories that suggest the mechanism for

NSCLBP is linked to a reflex extensor muscle response of the back extensor muscles, resulting in a loss of flexion relaxation of the back muscles and a reduction of spinal flexion resulting in secondary increased tissue strain (Indahl, 1999). In fact, the current study suggests contrary findings, they being; increased rotation movement in flexion postures of the lower lumbar spine and reduced co-contraction of the LM, which may result in increased flexion/axial rotation strain across the low back already pre-sensitised to strain in these movements. In order to test this hypothesis further, a motor learning intervention directed at facilitation of co-contraction of the lower LM to reduce the flexion/axial rotation strain at the low lumbar spine could be trialed, to assess its influence on these pain disorders. Clearly further investigations into similar populations with NSCLBP with a larger sample size are required to confirm or refute these preliminary findings.

5. Conclusions The findings of this pilot study lend further credibility to the idea that clinical presentation of individuals suffering NSCLBP should be considered. During clinical evaluation, all subjects in this study reported that their LBP was precipitated by flexion related activities, in particular, during cycling. Cyclists in the pain group showed a trend towards increased lower lumbar rotation and flexion with associated loss of cocontraction of the muscles whose primary role is to control these movements (LM). Although these results should be viewed with caution due to the small sample size in this study, they do lend support to the presence of an underlying motor control disorder that predisposes the cyclists to flexion/rotation strain of the low lumbar spine. Further research into this group with a larger sample size is required and rehabilitation strategies to manage LBP in cyclists needs to be formerly assessed. References Atlas SJ, Deyo RA, Patrick DL, Convery K, Keller RB, Singer DE. The Quebec task force classification for spinal disorders and the severity, treatment, and outcomes of sciatica and lumbar spinal stenosis. Spine 1996;21:2885–92. Bogduk N. Clinical anatomy of the lumbar spine and sacrum. New York: Churchill Livingstone; 1997. Bolourchi F, Hull ML. Measurement of rider induced loads during simulated bicycling. International Journal of Sports Biomechanics 1985;1:308–29. Bressel E, Larson BJ. Bicycle seat designs and their effect on pelvic angle, trunk angle, and comfort. Medicine and Science in Sports and Exercise 2003;35:327–32. Brier SR, Nyfield B. A comparison of hip and lumbopelvic inflexibility and low back pain in runners and cyclists. Journal of Manipulative and Physiological Therapeutics 1995;18:25–8. Burke E. High tech cycling. Illinois: Human Kinetics; 1996.

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ARTICLE IN PRESS



Original article

Is cervical spine rotation, as used in the standard vertebrobasilar insufficiency test, associated with a measureable change in intracranial vertebral artery blood flow? Jeanette Mitchella,*, David Keeneb, Craig Dysonc, Lyndsay Harveyd, Christopher Pruveye, Rita Phillipsf a

Physiotherapy, School of Allied Health Professions, University of the West of England, Bristol, UK b United Bristol Healthcare NHS Trust, UK c Swansea NHS Trust, UK d Gloucestershire NHS Trust, UK e Homerton University Hospital NHS Trust, UK f Radiography, School of Allied Health Professions, University of the West of England, Bristol, UK Received 29 August 2003; received in revised form 2 March 2004; accepted 26 March 2004

Abstract Cervical spine rotation is used by manual therapists as a premanipulative vertebrobasilar insufficiency (VBI) test to identify patients at risk of developing VBI post-manipulation. Investigations of the effect of rotation on vertebral artery blood flow have yielded conflicting results, the validity of the test being debated. It was the aim of this study, therefore, to investigate the effects of cervical spine rotation on vertebral artery blood flow. Transcranial Doppler sonography was used to measure intracranial vertebral artery blood flow in 30 young, healthy, female subjects, with the cervical spine in the neutral position and with sustained, end-ofrange rotation. Statistically significant decreases in blood flow were demonstrated with contralateral rotation particularly, in the left (45.978.5 to 41.8711.6 cm/s) and right (27.876.9 to 25.278.2 cm/s) vertebral arteries. Despite this change in blood flow, signs and symptoms of VBI were not demonstrated in these subjects. Nevertheless, these findings are of clinical importance, especially in patients who may have underlying vascular pathology. Thus, this study supports the use of the VBI test, in the absence of a more specific, sensitive and valid test, to assess the adequacy of hindbrain blood supply to identify those patients who may be at risk of serious complications post-manipulation. r 2004 Elsevier Ltd. All rights reserved. Keywords: VBI test; Cervical spine rotation; Vertebral artery blood flow

1. Introduction Sustained end-of-range rotation of the cervical spine is a component of the physical tests recommended in the pre-manipulation guidelines for the cervical spine (Grant, 1996, 2002; Barker et al., 2000; Magarey et al., 2000) that are used by physiotherapists and other manual therapists. The objective of these tests is to aid the evaluation of whether a patient is at risk of

*Corresponding author. Department of Zoology & Physiology, University of Wyoming, Laramie, Wyoming 82071-3166, USA. E-mail address: jeanette [email protected] (J. Mitchell). 1356-689X/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2004.03.005

developing vertebrobasilar insufficiency or ischaemia (VBI) following cervical spine manipulation. Such physical tests, first described by Maitland in 1968 (Grant, 1996; Zaina et al., 2003), have been advocated as a result of reported complications post-manipulation that include paralysis, stroke and even death (Theil et al., 1994; di Fabio, 1999). A recent literature review found estimates of the risk of these serious sequelae ranging from one in 20,000 to five in 10,000,000 cervical spine manipulations (Gross et al., 2002). Despite this relatively rare occurrence, the devastating effects of these complications emphasise the importance of establishing a valid and sensitive test to identify those patients who may be at risk of developing VBI.

ARTICLE IN PRESS J. Mitchell et al. / Manual Therapy 9 (2004) 220–227

The VBI test examines the effect of the mechanical stresses on the vertebral arteries during movements of the cervical spine. The test is believed to cause stretching/compression of the arteries with contralateral/ipsilateral cervical spine rotation (Rossitti and Volkman, 1995; Haynes and Milne, 2001). This is thought to occur at the atlanto-axial vertebral level (Theil, 1991; Grant, 1996) where approximately half of cervical spine rotation occurs, or as the artery traverses the transverse foramina and posterior arch of the atlas vertebra where it is relatively fixed in position (Rossitti et al., 1992; Mann and Refshauge, 2001; Mitchell, 2003). It is suggested that these deformations of the vertebral artery may reduce the luminal cross-sectional area, thus compromising blood flow in the vessel (Mitchell, 2003). This decreased blood flow may provoke symptoms of VBI (Kuether et al., 1997) through reduced brainstem perfusion in those patients who may not posses a fully developed collateral circulation (Theil, 1991; Rivett et al., 1998). If signs and symptoms of VBI (dizziness, nausea, syncope, dysarthria, dysphagia, and disturbances of hearing or vision, paresis or paralysis) are established with this test, it is deduced that the collateral circulation is inadequate and hindbrain perfusion is not sufficiently maintained (Grant, 2002). Therefore, the patient may be at higher risk of serious complications if a cervical spine manipulation is performed (Barker et al., 2000; Mann and Refshauge, 2001). These theoretical explanations of the rationale for the use of cervical spine rotation as part of the VBI test for establishing risk have been subjected to much scrutiny, leading to the questioning of the validity of the test (di Fabio, 1999; Grant, 2002). There have been several studies conducted that measured vertebral artery blood flow velocity using, for example, pulsed-wave Doppler sonography (Trattnig et al., 1990; Brautaset, 1992; Kaps et al., 1992; Refshauge, 1994; Schoning et al., 1994; Rossitti and Volkmann, 1995; Licht et al., 1998; Li et al., 1999; Rivett et al., 1999; Scheel et al., 2000; Haynes and Milne, 2001; Mitchell, 2003). The results of such studies are controversial, however. Refshauge (1994), Rossitti and Volkmann (1995), Licht et al. (1998), Li et al. (1999), and Rivett et al. (1999), for example, found that blood flow in the vertebral artery, contralateral to the side of rotation in particular, was significantly reduced. Contrary to this, Theil et al. (1994), Haynes and Milne (2001) and Zaina et al. (2003) found no significant reduction in vertebral artery blood flow contralateral to the side of rotation. The findings of many of these studies, however, were based on samples of mixed sex and age groups (Rossitti and Volkmann, 1995; Rivett et al.,1999), and normal subjects and patients (Li et al., 1999) who may or may not have been experiencing related symptoms or pathology. As a result, the external validity of many of these studies may be questioned. The emphasis was also on measurements

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at several different levels of the extracranial part of the vertebral artery. Few studies were found that measured blood flow in the part of the vertebral artery distal to the believed point of constriction, and with both ipsilateral and contralateral rotation, thus compromising their internal validity. Another confounding factor in some of the studies was that cervical spine rotation was combined with extension (Li et al., 1999). These contradictory findings indicate that the justification of the use of cervical rotation in isolation as a pre-manipulative screening procedure is tenuous. As a result, debate has been prompted on the efficacy of endof-range cervical spine rotation as a test for VBI, and on the validity, specificity and sensitivity of this procedure as a pre-manipulative screening tool (Maher, 2001). It is apparent from such debate that further research into the effects of cervical spine rotation on vertebral artery blood flow would be of value. The aim of the present study was to provide normative, base-line data for vertebral artery blood flow, and to detect if end-of-range cervical spine rotation produces measurable and significant changes in vertebral artery blood flow in young, healthy adults. Since its development as a safe, non-invasive method of measuring blood flow (Aaslid, 1986), Transcranial Doppler sonography has been shown to enable the accurate insonation of intracranial vessels (Bazzocchi et al., 1998). Thus, with this method, it is possible to assess changes in blood flow velocities in these arteries distal to the believed points of constriction during movements of the cervical spine. Such changes in a sample of the study population would suggest that patients with underlying vascular pathology, such as atherosclerosis, would be more likely to experience compromised blood flow and suffer from VBI as a result of this movement. These findings would support the use of cervical spine rotation as a pre-manipulative screening procedure, particularly with the adjunct of Doppler sonography, to alert the therapist to patients at increased risk of developing VBI associated with manipulation. Therefore, the intention of this research is to inform physiotherapy practice and to provide some evidence on which to base the treatment of patients.

2. Materials and methods 2.1. Subjects The subjects in this study were 30 female physiotherapy students (mean height 50 400 , weight 9.5st., age 21 years) from the University of the West of England, Bristol, UK. This convenience sample size was used to support statistical analysis of data while recognising ethical considerations (Hicks, 1999). Subjects were volunteers, non-smokers, non-drug takers, with no


J. Mitchell et al. / Manual Therapy 9 (2004) 220–227

history of cardiovascular or related musculoskeletal disorders, or signs of symptoms of VBI. A further inclusion criterion was that the subject was able to actively rotate the head to at least 45 from the neutral (anatomical) position. Subjects were recruited by introducing the aims, procedure and expected results of the research to groups of students. Volunteers were given an information sheet, a consent form and a questionnaire at least 24 h prior to carrying out the blood flow measurements to enable selection of the final sample and ensure the safety of subjects to take part in the research procedures. Subjects were reassured of their right to withdraw at any time and of their anonymity at all times. Names and contact details were assigned a numerical subject code, and all records were stored securely and destroyed on completion of the research. Ethical approval was granted by the Ethics Committees of the Faculty of Health and Social Care and the University of the West of England, and of the Local Region and the United Bristol Healthcare Trust. 2.2. Instrumentation The QUL Doppler system (SCIMED, Bristol, UK) with a 2 MHz pencil probe was used for transcranial insonation of the vertebral arteries. The equipment was calibrated by the manufacturers, assuring instrument reliability and validity. The probe emitted a pulsed wave of an intensity of up to 200 mW/cm2 at a wave frequency of 80 Hz to measure the orthograde blood flow velocity. The sample volume was set to a depth of 6.2–7.2 cm and gain was varied to optimise the readings. A real-time audio-visual Doppler spectral signal was produced and data was captured for three cycles of peak Doppler shift. 2.3. Method The design of the study was quantitative: an experimental within-subject pre-test/post-test comparative study. The independent variable was sustained end-ofrange rotation of the subjects’ cervical spine. The dependant variable was vertebral artery blood flow velocity. The experimental procedure was conducted at the Bristol General Hospital, therefore ensuring onsite medical assistance if required during the measurement procedure. A protocol was established and agreed with the subject so that, if the subject reported any adverse signs or symptoms or if any vascular pathology was suspected, the experiment was stopped immediately, and details passed on to the relevant medical personnel. All experimentation was performed in the same room to minimise temperature variation. A quiet and calm environment was encouraged as this ensures accurate

recording of the Doppler signal and the highest possible quality of data collected (Haynes et al., 2000). The subject was seated and blood pressure taken manually, this being reassessed after the measurement procedure to ensure that any possible changes in blood flow were not related to general changes in the cardiovascular system. A few minutes were given to allow the subject to acclimatise and stabilise haemodynamically (Rivett et al., 1999). The intracranial vertebral arteries were insonated according to the transforaminal or suboccipital method of Aaslid (Fujioka and Douville, 1992; Bazzocchi et al., 1998), by an experienced ultrasonographer (RP) to avoid inter-rater bias and thus ensure reliability of the data. An experienced physiotherapist (JM) supervised the testing procedure and recorded captured measurements for further data analysis. The test was performed with the patient sitting, relaxed, and eyes closed to avoid stimulation of the occipital cortex (Rossitti et al., 1992). The upper cervical spine was initially in the neutral sagittal and frontal plane orientation, to allow ease of access for insonation of the intracranial vessels. This is also one of the positions outlined in the protocols for the VBI test (Barker et al., 2000). The probe was placed over the suboccipital region of the neck using an acoustic gel, aimed toward the bridge of the nose to insonate the intracranial vertebral arteries through the foramen magnum, and angled laterally and approximately 30 to the axis of the vessel. When the vertebral artery was identified, the reading was optimised to reduce interference and aliasing, and the data captured. The timeaveraged mean blood flow velocity was used. This measurement, obtained from the spectral outline, was selected as it corresponds to the maximal Doppler shift (Vmax ) (Aaslid, 1986). The data was generated from the average Vmax over three visually similar waveforms, thus reducing the influence of variations in cyclical parabolic blood flow velocities (Aaslid, 1986). After both left and right vertebral artery blood flow velocities were measured, the patient was asked to rotate the head to the maximal end-of-range position to the right. This movement was carried out slowly and guided by the radiographer, allowing the insonation of the vessel with the hand-held probe to be maintained during the movement. The end-of-range rotated position was held actively by the subject and supported by the radiographer’s free hand for B30 s and data recorded. The supervising physiotherapist checked that this position was comfortable and the normal, fully rotated position for each subject. This end-point was visually estimated to be >45 before data capture. This was done for the left and the right artery, from the neutral position, and then repeated with cervical spine rotation to the left. Finally, a post-test measurement of both vertebral arteries in the neutral position was performed.


2.4. Data analysis The mean (+SD) blood flow velocities were calculated for the right and left arteries with the cervical spine in the neutral and both rotated positions. The data for the left and right vessels, and for the various cervical spine positions in each of the arteries, were compared using the paired two-tailed t-test with a level of significance of 0.05 (Hicks, 1999; Domholdt, 2000).

3. Results No subject showed any alteration in blood pressure as a result of the experimental procedure that was considered significant in relation to our findings. The mean blood flow velocities recorded for the left and right vertebral arteries for the sample population (n ¼ 30) are shown in Table 1 and Fig. 1. On comparing the blood flow velocities in the left and right vertebral arteries, with the cervical spine in neutral,

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a statistically significant difference (t ¼ 11:68; Po0.001) was found between the sides. A similar significant difference was shown between the pre-test and post-test neutral blood flow velocities in both the left (t ¼ 2:36; P ¼ 0:03) and the right (t ¼ 3:12; P ¼ 0:01) arteries. A significant decrease in blood flow velocities with contralateral cervical spine rotation was demonstrated in both the left (t ¼ 2:39; P ¼ 0:02) and right (t ¼ 2:14; P ¼ 0:04) vessels. However, a significant decrease in blood flow velocities with ipsilateral cervical spine rotation was seen in the larger left artery only (t ¼ 4:05; Po0.001).

4. Discussion Although blood flow velocity changes may be an unreliable predictor of actual blood flow volume differences, Doppler sonography is considered to be the most accurate and validated tool for the safe and non-invasive measurement of blood flow velocity

Table 1 Mean blood flow velocities (cm/s) in the intracranial vertebral artery (n ¼ 30)

LVA RVA

Pre-test neutral

Post-test neutral

Ipsilateral rotation

Contralateral rotation

45.87+8.52 27.82+6.90

43.28+9.32 25.10+8.72

41.67+8.96 25.99+7.78

41.82+11.64 25.23+8.20

LVA=left vertebral artery; RVA=right vertebral artery.

Fig. 1. Changes in mean intracranial vertebral artery blood flow velocities following rotation of the cervical spine. LVA=left vertebral artery; RVA=right vertebral artery; N=neutral position of the cervical spine; L=rotation to the left; R=rotation to the right. NS=not significant; =significant, PX0:05; =significant, PX0:001:



(Taylor et al., 1995; Bazzocchi et al., 1998), and a reliable method of detecting relative blood flow volume changes (Aaslid, 1986; Rossitti et al., 1992) in terms of real time (Kaps et al., 1992; Schoning and Walter, 1992). In the present study using transcranial Doppler sonography, sustained, end-of-range, contralateral rotation of the cervical spine was shown to be associated with a significant decrease in mean intracranial vertebral artery blood flow velocity, irrespective of side, in this sample of healthy, young females. These results refute those of Theil et al. (1994), and Haynes and Milne (2001) who concluded that cervical rotation does not significantly reduce blood flow. Both of these research reports concern the extracranial vertebral artery which traverses the transverse foramina of the cervical vertebrae, and although superficial, is difficult to insonate accurately (Johnson et al., 2000). Theil et al. (1994) also drew conclusions from mean velocity ratios that have subsequently been criticised as being an unreliable measure of blood flow (Johnson et al., 2000). In addition, although Haynes and Milne (2001) did find reductions in blood flow velocities in 54% of their sample, statistically significant changes were not found, perhaps a result of analysing data from a sample of male and female patients aged 20–52 years. The results of the present study also conflict with the findings of Zaina et al. (2003), reporting no significant reduction in blood flow in the contralateral artery. Despite using a methodology that has been exposed to some scrutiny (Johnson et al., 2000), the use of subjects ranging in age from 20–54 years may have confounded their results. In the present study, the mean neutral vertebral artery blood flow velocity of 36.9 cm/s (left: 45.8778.52 cm/s; right: 27.8276.90 cm/s) recorded was similar to the findings of several authors (Schoning and Walter, 1992; Rossitti and Volkmann, 1995; Li et al., 1999). The findings of the present study also support other reports of significantly decreased blood flow in both the extracranial (Refshauge, 1994; Licht et al., 1998; Rivett et al., 1999) and the intracranial (Rossitti and Volkmann, 1995; Li et al., 1999; Mitchell, 2003) vertebral artery. Although much of the existing research does not refute the possibility that cervical rotation may significantly reduce vertebral artery blood flow, those conflicting findings do indicate the need for further investigation. Moreover, it could be argued that, considering the laws of haemodynamics, the measurements of extracranial vertebral artery blood flow have limited clinical value. That is, according to Bernoulli’s law, a reduction in blood flow proximal to a point of restriction of a vessel may be compensated for by an increase in blood flow velocity distal to this point. However, if the restriction reaches a critical level, blood flow velocity is reduced distal to the point of restriction

(Ganong, 1997). It is this part of the vertebral artery and its branches that supply the hindbrain and into which branches of the collateral circulation feed to ensure adequate perfusion of brain tissue. Therefore, the assessment of the effect of cervical spine rotation on the blood flow to the hindbrain may be more clinically valid if the measurements are made distal to the believed point of restriction at the level of the atlanto-axial joints. This would imply that the use of transcranial Doppler (TCD) sonography, as used in this study, may be an appropriate method of investigation as it allows measurement of blood flow velocity in the intracranial part of the vertebral artery (Theil, 1991; Aaslid, 1986). It is acknowledged that the use of a convenience sample of 30 healthy, young females in the present study may reduce the external validity of the findings. However, female subjects were chosen to further investigate the claims made in a previous report by one of the authors (Mitchell, 2003). In this earlier study, it was found that ipsilateral rotation resulted in a significant decrease in vertebral artery blood flow in the samples of both sexes (n ¼ 60) and of male subjects only (n ¼ 30), but that this movement had no significant affect on blood flow in the right vertebral artery in the sample of females (n ¼ 30). It was suggested that the results for the female subjects were masked by those of the males in the bigger sample. In the present study of female subjects only, selected from an entirely different population group, the same lack of significant blood flow changes following ipsilateral rotation was found, thus supporting the author’s previous results. However, the reason for this lack of significant difference in blood flow in the right vertebral artery only on ipsilateral rotation of the cervical spine remains obscure. It has been suggested that it is more difficult to record blood flow changes in the smaller right vertebral artery found in females (Mitchell and MacKay, 1995; Mitchell, 2003). In the present study, the greater blood flow in the left vertebral artery indicates a larger left vessel. It was also noted during the course of the measurement procedure that the right vessel was technically more difficult to insonate, in many of the subjects, during rotation of the cervical spine. In these cases, the audio-visual spectral signal was often of poor quality, perhaps due to the size of the foramen magnum and the relative location of the vessel in particular subjects, limiting the scope for adjusting the angle of the probe, and requiring extra care to obtain optimal recordings during insonation. However, the comparative diameters and precise anatomical locations of the arteries were not visualised in this study. Nevertheless, although the same result has been obtained in two separate studies (Mitchell, 2003, and the present study), further measurements and analyses of data from larger samples of various populations would rule out the possibility of these findings being a result of a type II error.


There may be clinical implications for a population with asymmetry of the vertebral arteries. It is assumed that healthy subjects are not at risk of suffering from any signs and symptoms of VBI during both premanipulative screening and rotation mobilisation and manipulation of the cervical spine. This is because the healthy individual has the capacity to compensate for minor and transient reductions in blood flow through primary collateral circulatory channels (Terenzi and di Fabio, 1996; Mann and Refshauge, 2001). However, it is feasible that where one artery is significantly smaller, such as the right vertebral artery in young healthy females (Mitchell and MacKay, 1995), if the blood flow in the larger (left) vertebral artery is suddenly compromised, such as by end-of-range cervical rotation, the existing collateral circulation may be inadequate. As a result, this population may be more at risk of developing VBI following cervical spine rotation, which if prolonged, could cause permanent neurological dysfunction (Mann and Refshauge, 2001). The finding in the present study of a significant difference between the two sets of neutral measurements of vertebral artery blood flow, taken before and after cervical spine rotation, supports the results of Zaina et al. (2003). These data also have important clinical implications regarding both the use of cervical spine rotation as a screening test and as a movement for manual therapy techniques. That is, this significantly lower final neutral blood flow measurement, relative to the initial neutral blood flow velocity, suggests that mobilisation/manipulation should not be carried out immediately after using this rotational movement as a pre-manipulative screening test, to ensure there is sufficient time to evaluate the latent effect of this test on vertebral artery blood flow. The possible cause of reduced blood flow, after rotation of the cervical spine, is unclear. It is suggested that cervical spine rotation may cause vasospasm of the vertebral artery (Smith and Esteridge, 1962; Kanshepolsky et al., 1972; Easton and Sherman, 1977; Fast et al., 1987; di Fabio, 1999; Mann and Refshauge, 2001; Mitchell, 2003) that persists for a period after the mechanical stress to the artery ceases. Added rotational movements of the cervical spine may cause an increase in this vasospasm, leading to signs and symptoms of VBI. However, further investigation is required before such claims can be justified. The overall findings of this study, in the context of previous research, offer cumulative support for the use of cervical spine rotation to assess the competency of hindbrain blood supply. They also lend support as to the theoretical rationale for using cervical spine rotation to stress the vertebral artery and reduce blood flow. The most plausible explanation for a reduction in vertebral artery blood flow in normal healthy subjects appears to be extrinsic mechanical compression/stretching of the artery, either against the rim of the transverse foramen

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or the articular mass of the atlas vertebra, reducing the cross-sectional area of the artery which proportionally reduces its blood flow (Rossitti and Volkman, 1995; Grant, 2002; Mitchell, 2003). The natural tortuosity of the vertebral artery between the atlas and axis vertebrae would preclude over-stretching of the vessel at the atlanto-axial level during cervical spine rotation (Thiel, 1991; Johnson et al., 1995). As reductions in blood flow were found in young subjects in the present study, it may be inferred that these results have greater clinical significance in older people where vascular pathology is more prevalent (Li et al., 1999). In the older population, if cervical spine rotation compromises blood flow sufficiently, to reduce hindbrain perfusion to a critical extent thus exceeding compensatory mechanisms, signs and symptoms of VBI are likely to occur. Therefore, it could be argued that the VBI test, although it does not replicate the forces involved in manipulation (Mann and Refshauge, 2001), is of use for potentially identifying the patients at risk of complications from cervical spine manipulation. Refshauge et al. (2002) propose that even though such tests may not establish everyone that is at risk from these consequences of manipulation, it could be seen as neglect if the tests are not performed as they may reduce the potential for harm. However, it may be equally valid to emphasise that microtrauma to the artery wall as a result of external distortion or vasospasm thought to be associated with sustained end-of-range cervical spine rotation, particularly to diseased vessels, may give rise to the formation of atherosclerotic thrombi and emboli (di Fabio, 1996; Ross, 1999; Libby, 2000; Mann and Refshauge, 2001), exacerbating the risk of rotational movements and manipulation in these individuals. Under these circumstances, it is appreciated that the VBI test itself is not without risk (Dunne, 2001; Mann and Refshauge, 2001). Therefore, the use of transcranial Doppler sonography to assess vertebral artery blood flow in these patients may be an alternative pre-manipulative screening tool worth considering (Li et al., 1999).

5. Conclusions The results of this study provide further evidence that sustained end-of-range cervical spine rotation significantly reduces blood flow in the intracranial vertebral arteries. This study also reports that there may be a latent reduction in blood flow after cervical spine rotation. The presented evidence is of value to manipulative therapists in patient risk-assessment, and the implications of these findings provide ethical grounds for further research as alterations in blood flow to the brain need to be fully investigated to ensure safe clinical



practice and to support or refute the evidence base of our profession.

Acknowledgements This research was carried out under the auspices of the School of Allied Health Professions, Faculty of Health and Social Care, University of the West of England, Bristol. The authors owe their thanks to the physiotherapy students of the University who took part in this study. The support of Dr R. Jones, Co-ordinator of the Research and Development Support Unit, United Bristol Healthcare Trust, and the use of the facilitities in the Multiple Sclerosis Research Laboratory at the Bristol General Hospital are gratefully acknowledged.

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ARTICLE IN PRESS



Case Report

The patient-centredness of evidence-based practice. A case example to discuss the clinical application of the bio-psychosocial model John Langendoen Seeblickstr 7, 87466 Faistenoy, Germany Received 29 October 2002; accepted 4 May 2004

1. Introduction The evidence for physiotherapeutic procedures is growing fast. Databases are required which keep up which all new research developments and which house emerging evidence for the clinician as well as for the researcher. As, many procedures have not been investigated yet and remain a matter of experience and clinical reasoning, a case report is a primary way to focus on the efficacy of a technique, test or procedure. An uncommonly applied soft-tissue technique has been taken to demonstrate a false positive magnetic resonance imaging diagnosis in a muscle injury as well as its clinical efficacy. Moreover, the management of this simple, monostructural impairment will serve as an example to discuss the characteristics of patient-centredness. Patient-centredness is considered to be the practical application of the multidimensional biopsychosocial illness model. The shift in paradigm in medicine has led to the development of, and discussion on, domains of patient-centredness (Stewart et al., 1995). In an analogy to patient-centredness in medicine, such domains have recently been proposed (Langendoen, 2002). Analysis of these characteristics seems relevant as patient-centredness builds one of the three cornerstones of evidence-based practice: (1. evidence, 2. experience, clinical reasoning, 3. practical, patientcentred application).

2. A patient-centred approach The practical application of the bio-psychosocial illness model has been called a patient-centred approach (PCA) (Stewart et al., 1995). To avoid misunderstandE-mail address: [email protected] (J. Langendoen). 1356-689X/$ - see front matter r 2004 Published by Elsevier Ltd. doi:10.1016/j.math.2004.05.004

ings and misconceptions about PCA, its characteristics have to be defined (Stewart et al., 1995; Skelton, 2001; Stewart, 2001). In medicine, it is generally understood not to be technology-, doctor-, hospital- or diseasecentred. ‘‘Patient-centred’’, also called client-centred, seeks to make the implicit in commonsensical patient care explicit (Skelton, 2001), but previous definitions failed to capture the indivisible whole of a healing relationship (Stewart et al., 1995; Stewart, 2001). Six domains of PCA (Table 1) have been recognized to date (Stewart et al., 1995; Brown et al., 1995; Little et al., 1995; Stewart, 2001). As science has only recently begun to investigate PCA, limited evidence indicating a preference of patients for a PCA exists. The patients’ perception of the patientcentredness of the interaction was the stronger predictor, indeed, not only of health outcomes (Stewart et al., 2000), but also of efficiency of health care, such as fewer diagnostic tests and fewer referrals, and so was considered to be the ultimate patient-centred finding (Stewart et al., 1995). An intuitive flexible style of care, an implicit PCA, has been shown to positively influence treatment outcome in contrast to non-empathic confrontational attitudes or model-centred care (Heaney, 2001). Moreover, the first three, probably four, domains (Table 1) have been recognized to be important in primary care (Little et al., 2001). Confounding factors such as age, level of education, psychological state of the patient, type of problem and care (primary, secondary, palliative), or consultation style, have been estimated or recognized (Savage and Armstrong, 1990; Cherkin et al., 1995; Arnold, 2001; Kraemer, 2001; Little et al., 2001; Morris et al., 2001; Robinson, 2001). Categorization in domains could erroneously be interpreted that patient-centred care can be neatly separated into divisible parts and that patients may not want all components of PCA (Howie, 2001; Little

ARTICLE IN PRESS J. Langendoen / Manual Therapy 9 (2004) 228–233

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Table 1 Presently acknowledged domains of patient-centredness in medicine (Stewart et al., 1995; Brown et al., 1995; Little et al., 1995; Stewart, 2001) 1. 2. 3. 4. 5. 6.

Exploration the patients’ main reason for the visit, concerns and need for information Seeking an integrated understanding of the patients’ world—that is, their whole person, emotional needs and life issues Finding a common ground on what the problem is and mutually agree on management, however acknowledging the reality of patients accepting or rejecting advice or treatment Enhancement of prevention and health promotion Enhancement of the continuum relationship between the patient and the care provider (=teacher, facilitator) A realistic use of time and resources

Table 2 The 4 categories of failure, with examples 1.

Problem

The magnitude of the structural impairment or inappropriate diagnosis may limit treatment outcome

2.

Patient

Physical, psychological or intellectual shortcomings prevent an optimal result

3.

Provider

Referral to a non-appropriate discipline, to an appropriate discipline but incompetent provider, to an appropriate, competent provider, who however lacks motivation or time. Iatrogenic worsening due to: a not-indicated treatment, inappropriate handling of an indicated measure, non-, under- or over-treatment, inadequate presentation of information or insufficient explanations

4.

Environment

Restrictions of the health system, financial difficulties of the patient, role of family/spouses, transportation difficulties, refusal of employer (in relation to ergonomic measures, recovery time or vocational change not allowed)

et al., 2001). However, patients uniformly valued all aspects of patient-centredness and the components of this holistic concept interact and unite in a unique way in each patient–provider encounter (Stewart, 2001). Categorization may carry the danger of simplifying complicated bio-psychosocial matters. For example, it was concluded that (subgroups of) patients may not prefer a PCA and hence its universal adoption would be unwise (Little et al., 2001). Although the wording PCA may give the impression, it does not necessarily mean sharing all information and all decisions (Seigel, 2001). However, PCA is supposed to be taking into account the patient’s desire for information and for sharing decision making and responding appropriately (Stewart, 2001). In other words, the kind of locus of health control the patient lives or chooses is his/her right, for which however the patient has to take over responsibility. This implies that one of the tasks of the care provider might be to educate for adjustment of the locus of health control. Patients’ rights are nothing but a modification of general human rights as formulated by the United Nations, applicable to people with an illness condition (Van der Zeijden, 2000). Patient’s rights movements are growing, which will continuously influence socio-political decision-making (Van der Zeijden, 2000). The

interacting entities PCA and socio-political developments will undoubtedly lead to a further recognition, application and development of the bio-psychosocial illness model. Poor treatment outcome was taken as a sign of the patient’s denial or unwillingness to change, but now is considered to represent therapist failure (MacQueen, 2001) or health system shortcoming (Heaney, 2001; Miller, 2001). The many reasons for failure can be categorized (Table 2), which offers an option for analysis and correction, enabling to reach other, more realistic goals, without the denial of self-responsibility of the patient. As enablement is significantly associated with longer consultations and greater personal continuity of care (Heaney, 2001), its consequence is that the carer must enter the patient’s world (Table 1, domain 2) and set their mind (pacing) to achieve better outcomes (MacQueen, 2001). In this sense, learner-centred training programmes in PCA for primary care physicians were shown too effective (Kinnersley et al., 2000; Moral et al., 2001) and physicians can identify and mobilize personal health resources (Malterud and Hollnagel, 1997). It is advocated that patient-centred care needs proper foundations (Heaney, 2001; Miller, 2001; Morris et al.,


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2001; Skelton, 2001; Stewart, 2001), which require profound changes throughout society including the educational and healthcare systems (Miller, 2001).

3. Patient-centredness in physiotherapy Physiotherapists are specialists in management of movement disorders or for dysfunction of the neuromusculo-articular system. The main primary task of the therapist is to analyse and classify the functional disorder in daily life (disability), and subsequently to identify physical impairments possibly related with the problem. Additionally, the therapist needs to assess causes, physical and non-physical contributing factors and mechanisms (psychosocial and socio-economic factors or ‘‘yellow flags’’, Kendall et al., 1997) that seem to play a role in the overall clinical presentation. Such an application of the bio-psychosocial paradigm is in concordance with the international classification of functions, disabilities and health (ICF, formerly ICIDH) of the world health organisation, being developed since 1980 (WHO, 2001). Characteristics of a PCA are not defined in physical therapy as yet. However, in analogy with its present understanding in medicine it is supposed to be not technique-, method-, therapist-, science-, explanationor diagnosis-centred. Therefore, while considering the special characteristics of physiotherapy within the varied law-frames and health systems in different countries, all aspects proposed below (Table 3) seem to be in consonance with the domains of patient-centredness in medical practice.

kicked in his left calf during a training session (Langendoen, 2003). The next morning he could not use his extremely swollen lower leg due to pain. A magnetic resonance imaging (MRI) examination was performed almost 24 h after the onset. This showed a clear longitudinal contrast (10 2 cm) at the medial head of the gastrocnemius muscle (see Fig. 1). The following diagnosis ‘‘muscle tear’’ implied that the tournament would be over for L before it was started. As he was an important starting player for the team, the disappointed head coach did not intend to accept this fate (Hiddink, 2002). Some discussion between the therapists and the doctor of the medical staff nourished doubt about the diagnosis. From the history (exogenous cause) and the behaviour of the symptoms immediately after the onset (could walk with some weight-bearing), the diagnosis could be questioned. Examination of the lower leg showed an overall tense swelling and palpation of the

4. Case example 4.1. History, medical diagnosis and examination Two days prior to their first World Cup 2002 match a player (L) of the Korean National Football Team was

Fig. 1. MRI of patient’s gastrocnemius.

Table 3 Aspects or domains of patient-centredness in physiotherapy 1. 2. 3. 4. 5. 6. 7. 8.

A comprehensive, empathic, semi-structured subjective examination, exploring the patients’ main problem and need for information, and seeking an integrated understanding of the whole person Planning of the physical examination, while summarising and explaining the working hypotheses of the therapist, and Comprehensive, systematic, appropriate, valid and tailored functional assessments to analyse the disabilities and to detect, possibly relevant, impairments, resulting in a mutual agreement on the comprehensive (multidimensional) characteristics of the problem(s). Planning the management with formulating and agreeing on treatment goals. These are binding for both therapist and patient, recognising that agreement may develop gradually over time and/or may require further / continuous discussions Patient education towards an adequate level of self-responsibility and independence (which should not be not contradictory to a confiding relationship between patient and therapist) Adaptation of goals and treatment direction due to changed or changing circumstances Individualised adequate application of passive techniques, active exercises, ergonomics, further measures and advice, as appropriate, all with reassessment for efficacy control Adequate use of time and resources


medial muscle belly revealed a localized circular hyperalgesic spot within the MRI-diagnosed and painful area. Clinical differential diagnosis by adding proximal sensitizing movements for neural tissue provocation did not reveal any change in symptoms. Apparently there was no neural tissue involvement. An alternative diagnosis was proposed: severe muscle contusion with spreading of the haematoma throughout a muscle fascicle, being responsible for the contrast visible at the MRI. 4.2. Initial treatment and prognosis Repeated soft-tissue posterior–anterior oscillations (Grieve, 1981) into resistance with some (decreasing) pain in rhythm of the movement at the lesion site in the medial head of the gastrocnemius muscle (Fig. 2) decreased the pain in minutes and this was confirmed as the patient could take some weight at his injured leg to the point of onset of the pain (P1). For reasons of objectivity, this action of weightbearing should have been performed with a pair of scales without the patient being able to watch. However, there were no scales available at that time and there was no doubt about the spontaneous reaction of a heavily disappointed player who suddenly saw a ray of hope. The vertical oscillatory technique was preferred to deep transverse frictions (Cyriax and Russell, 1977), solely on the basis of personal long-time experience. There is no evidence available that the chosen technique is effective, or superior to the friction technique, being another reason to report this case. The treatment was repeated with another reassessment showing a further decrease in pain. After a second repetition there was no further improvement and the first treatment with passive mobilization was stopped. It was agreed to repeat this treatment until reassessment revealed no further improvement every 2–3 h and to use the intermediate

Fig. 2. Soft-tissue posterior-anterior oscillations into resistance with (decreasing) pain in rhythm of the movement at the lesion site in the medial head of the gastrocnemius muscle.

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time for additional applications like ultrasound, electrotherapy and massage. Unfortunately, no equipment was available at that initial stage. On the other hand, combined treatment would have interfered with the reassessment of the manual techniques. A second, not previously described, technique was introduced in conjunction to the first: keeping a constant posterior– anterior pressure on while passively moving the ankle joint from plantar flexion to P1 at dorsi-flexion (Fig. 3a and b). Obvious explanations for the improvement are offered by the gate-control theory (Melzack and Wall, 1965) and the stimulation of fluid dynamics—pumping mechanism to reduce the oedema and to stimulate the, interstitial, fluid flow (Schou et al., 1965; Lundvall et al., 1970; Gifford, 1995). The result of the initial treatment and the, almost, optimal circumstances supported the optimistic prognosis that full training could be resumed within 1 week. Continuous reassessment at and after treatment and, later, during progressive loading techniques and individual rehabilitative training would assure no time delay in recovery. Continuous communication between player and therapists is normal in these cases, but in this situation was complicated: the player did not speak any other language than Korean and communication with

Fig. 3. Combination of posterior-anterior pressure at the lesion site and physiological plantar-dorsiflexion.


J. Langendoen / Manual Therapy 9 (2004) 228–233

Although the described injury is usually considered a pure bio-medical issue, it is obvious that the bio-medical model was not applied adequately and that many other aspects played a major role. The visible contrast at the magnetic resonance imaging was interpreted as a muscle tear, which may seem logical, but only in isolation without adequate clinical examination. Inadequate application and interpretation of the latter seems to represent a major flaw in medical diagnosing. Moreover, the psycho-spiritual and socio-economic (further abbreviated as psycho-social) consequences of the definitive loss of an essential player would have been widespread. The player himself would be very disappointed, and missing the experience of participating at the World Cup (in his homeland), for which he had prepared himself so intensively for, could become a long-lasting traumatic experience. His motivation demonstrated the positive side of psychosocial factors, implying that the therapist sometimes has to slow down rather than to stimulate the patient. The financial loss, during and probably after his active career, demonstrates another essential element of the holistic model.

beginning or increase of pain (domain 3). It was explained to the patient why his feedback on pain was essential (domain 2). Fulfilling domain 4 was the easiest part. It is however essential not to interpret patientcentredness as doing whatever the patient wants, as his/ her aims may be unrealistic or unwise. The confidence of the player in the management of his injury and the closed setting of the training camp definitively prevented additional treatment from others (domain 5). Secret or unknown additional, therapy however, is a problem in general practice, in professional sports in particular, as well as in research. In line with domain 4, there was no need to adapt the management plan (domain 6). The course of the rehabilitation even allowed starting the rehabilitative training earlier than expected (domain 7). Even the, imaginary, costs of a 24 h therapy service must be considered adequate in this case (domain 8). The result of this case cannot be generalized. A therapist bias is evident in case studies. Moreover, it will always be present in patient-centred management, being an implicit aspect contributing to the outcome. Research does not yet seem to have produced an adequate answer as to how to assess this aspect of patient-centredness. In this case however, the therapist was a stranger to the player, not even speaking his language (domain 1). The determinant factor seems to have been the immediate improvement after the first application of the passive technique (domain 7.) Possible reasons for failure, as outlined in Table 2 can be recognized as well. A wrong, false positive MRI diagnosis, would have initiated different clinical management. The absence of equipment could have been another reason for failure (exceeding the time limit), assuming that its correct application may have helped to reduce recovery time. Apart from treatment outcome studies, other types of quantitative, correlative research with a sound methodology, can determine relevant aspects in selected subgroups of patients (Jull and Moore, 2000; Novak and Mackinnon, 2000). Further clinically relevant subgroups may be detected. Such designs could validate, or reveal further, features of (subgroups of) patients. Further discussion of isolated aspects of syndromes is beyond the scope of this case example.

6. The patient-centredness of the case example

7. Conclusion

All proposed aspects of patient-centred management, with their practical limitations or, in contrast, their optimal use, can easily be detected in this example. Despite the language problem, understanding the precise onset was crucial (domain 1). The problem was categorized as a pain problem according to the clinical groups defined by Maitland (1985) (domain 2), implying that the intensity of physical tests would not exceed the

A simple mono-structural problem has been described. It however demonstrates that imaging procedures should be interpreted in the light of the hypotheses to be developed during a thorough physical examination. As has been shown, the impact of such a simple injury may be enormous, concerning all dimensions of a holistic paradigm. The practical application of the biopsychosocial illness model is called a patient-centred

the Dutch therapists was limited to the Korean word ‘‘apo’’ for pain, complemented by a Japanese translating Korean in English. The obvious motivation of the player could have been a good reason for playing down his actual complaints. 4.3. Result Numerous treatment sessions and progressive recovery training enabled L to join the last group training session before the second World Cup match, 8 days after the injury onset. He re-entered the team as a substitute, but was not used due to the unfavourable course of the match. Four days later however, he joined the starting team and probably played the match of his life. He played all further four matches without any complaint of his left calf.

5. The bio-psychosocial illness model


approach. In conjunction to its use in medicine and to avoid misunderstandings, its characteristics for the physiotherapeutic profession have been formulated and discussed in the light of the case example.

Acknowledgements Many thanks to the members of the technical and medical staff of the Korean National Football Team for their co-operation at the FIFA World Cup 2002 in Korea and Dr. Herzog in Kempten for the MRI.

References Arnold PC. Differing patients, different expectations. British Medical Journal 2001;322:468 [electronic response]. Brown J, Stewart M, Tessier S. Assessing communication between patients and doctors: a manual for scoring patient-centred communication. London: Thames Valley Family Practice Research Unit; 1995. Cherkin DC, Deyo RA, Wheeler K, Ciol MA. Physicians views about treating low back pain: the results of a national survey. Spine 1995;20(1):1–10. Cyriax J, Russell G. Textbook of orthopaedic medicine. Vol. 2, 9th ed. London: Bailli"ere Tindall; 1977. Gifford L. Fluid dynamics in Moving in on pain. In: Shacklock M, editor. Chatswood: Butterworth-Heinemann; 1995. Grieve GP. Common vertebral joint problems. Edinburgh: Churchill Livingstone; 1981. Heaney D. Patient-centredness in primary care. British Medical Journal 2001; 322 [Electronic response to Stewart M, 16 March]. Hiddink G. My way. Seoul: Chosun Ilbo; 2002 [in Korean]. Howie JGR. Patient-centredness in primary care. British Medical Journal 2001;322:468 [Electronic response]. Jull G, Moore A. Evidence based practices: the need for new research directions. Manual Therapy 2000;5(3):131. Kendall NAS, Linton SJ, Main CJ. Guide to assessing psychosocial yellow flags in acute low back pain: risk factors for long-term disability and work loss. Wellington, New Zealand: Accident Rehabilitation & Compensation Insurance Corporation of New Zealand, and the National Health Committee, Ministry of Health; 1997. Kinnersley P, Stott N, Peters T, Harvey I. The patient-centredness of consultations and outcome in primary care. British Journal of General Practice 2000;49:711–6. Kraemer S. How do we know who want patient centred care. British Medical Journal 2001 [BMJ online Electronic response to Little]. Langendoen J. Thoracic outlet syndromes analysis of the literature and the role of physiotherapy in a patient-centred approach. Cardiff: University of Wales College of Medicine; 2002. Langendoen J. Falsch-positiv bei der FuXballweltmeisterschaft 2002 in Korea. Fallbeispiel zur Erl.auterung des patientenzentrierten Managements. Manuelle Therapie 2003;7(2):95–102.

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Little P, Everitt H, Williamson I, Warner G, Moore M, Gould C, Ferrier K, Payne S. Preferences of patients for patient centred approach to consultation in primary care: observational study. British Medical Journal 2001;322:468–72. Lundvall J, Mellander S, Westling H, White T. Dynamics of fluid transfer between the intra- and extravascular compartments during exercise. Acta Physiological Scandanavion 1970;80(4): 31A–2A. MacQueen R.Some have been patient centred for years. British Medical Journal 2001; 322 [Electronic response to Stewart M. 24 February]. Maitland GD. Vertebral manipulation, 5th ed. Sydney: :Butterworths; 1985. Malterud K, Hollnagel H. Women’s self-assessed personal health resources. Scandanavion Journal of Primary Health Care 1997; 15(4):163–8. Melzack R, Wall P. Pain mechanisms: a new theory. Science 1965;150:971–9. Miller L. Towards a global definition of patient centred care. British Medical Journal 2001; 322 [Electronic response to Stewart M 2 March]. Moral RR, Alamo MM, Jurado MA, de Torres LP. Effectiveness of a learner-centred training programme for primary care physicians in using a patient-centred consultation style. Family Practice 2001;18(1):60–3. Morris S, Jaob E, Dewhurst M. Further research is needed on patient centred approaches. British Medical Journal 2001 [BMJ online Electronic response to Little]. Novak CB, Mackinnon SE. Clinical research: impossible or possible. Journal of Hand Theory. 2000;13(3):241–4. Robinson G. Patient centredness and physician personality. British Medical Journal 2001 [BMJ online Electronic response to Little]. Savage R, Armstrong D. Effect of a general practitioner’s consulting style on patients’ satisfaction: a controlled study. British Medical Journal 1990;301:968–70. Schou J, Langgaard H, Szporny L, Hvidberg E. A quantitative method for studying formation, composition and dynamics of inflammatory oedema fluid. Bibliotheca Anatomice. 1965;7: 467–71. Seigel S. Patient centred care requires learner centred education. British Medical Journal 2001; 322 [Electronic response to Stewart M 3 March]. Skelton JR. What is patient centredness? British Medical Journal 2001 [BMJ online Electronic response to Little]. Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR. Patient-centred medicine transforming the clinical method. Thousand Oaks: Sage Publications; 1995. Stewart M, Brown JB, Donner A, McWhinney IR, Oates J, Weston WW, Jordan J. The impact of patient-centered care on outcomes. Journal Family Practice 2000;49(9):796–804. Stewart M. Towards a global definition of patient centred care. British Medical Journal 2001;322:444–5. Van der Zeijden A. The patient rights movement in Europe. Pharmacoeconomics. 2000;18(Suppl. 1):7–13. WHO. ICF, International Classification of Functions, Disabilities and Health. Geneva: WHO; 2001, http://ifrr.vdr.de

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Book reviews Chiropractic technique, 2nd ed. Peterson, D.H. and Bergmann, T.F.; Mosby, St. Louie, MO, 2000, price d92,22, ISBN 032302016 This textbook will admirably serve two main audiences: other practitioners of manual therapy who want to understand the manipulative techniques of chiropractors, and chiropractic undergraduate students who need a well organised and illustrated technique manual. For both of these, Peterson and Bergmann’s second edition provides a good basic coverage, along with a healthy amount of circumspection and humility. This is supplemented by the personal bibliographies of the authors. These reveal what research has most informed thinking over the past 30 years or so. (You can almost hear the discussions at the International Conferences on Spinal Manipulation as you flick through them). The book’s objective is to ‘‘give a fair representation of what the chiropractic profession has to offer’’. It does this by starting with a flavour and context of the profession and then moving to joint anatomical considerations, assessment procedures and principles of ‘adjustive

technique’. Then comes the spine, after that the extremities, and then ‘non-thrust procedures’. (Anyone who thinks that chiropractic manipulation and highvelocity thrust are synonymous will see the flaws in that perception). Yes, the book is beautifully illustrated and yes, it is well written. Its main weakness lies perhaps in its introductory overview that deals with the past, present and future context of chiropractic. This is inward looking and appeals to a sense of self-gratification by focusing on how chiropractic and manipulation have been supported by the evidence. However, there is no sense of how the profession should meet the WHO’s challenge and integrate the psychological and social elements of health with the biological. But then, the chiropractors are not alone in that!

Alan Breen Anglo-European College of Chiropractic 13-15 Parkwood Road, Bournemouth BH52DF, UK

doi:10.1016/j.math.2004.01.005

The concise encyclopaedia of fibromyalgia and myofascial pain Patarca-Montero R. Haworth Medical Press, New York, 2002, p. 212, price d24,95 ISBN 0789015285

Half of this paperback is an A–Z list of material related or possibly related to fibromyalgia and myofascial pain. The other half comprises around 1300 references and as such it makes a very valuable resource for students and practitioners. The material collected is wide ranging—for example, entries include the relationship of the weather, breast implants, breathing disorders, sleep, post-polio syndrome, neurogenic inflammation and genetics to fibromyalgia and myofas-

cial pain. Overall, the entries emphasise current views of the importance of central nervous system processing changes with perturbed neuroendocrine and immune responses as essential parts of fibromyalgia and myofascial pain. We could reflect on the role of an encyclopaedia for a collection of signs and symptoms where aetiology and pathogenesis remain uncertain and clinical overlaps exists with other syndromes such as chronic fatigue syndrome. With so many possible management strategies and contributing factors listed, patients should read it with care or in consultation with a health provider. Health providers should have a open-minded working definition of what comprises fibromyalgia and myofascial pain syndromes.

ARTICLE IN PRESS



Book reviews Chiropractic technique, 2nd ed. Peterson, D.H. and Bergmann, T.F.; Mosby, St. Louie, MO, 2000, price d92,22, ISBN 032302016 This textbook will admirably serve two main audiences: other practitioners of manual therapy who want to understand the manipulative techniques of chiropractors, and chiropractic undergraduate students who need a well organised and illustrated technique manual. For both of these, Peterson and Bergmann’s second edition provides a good basic coverage, along with a healthy amount of circumspection and humility. This is supplemented by the personal bibliographies of the authors. These reveal what research has most informed thinking over the past 30 years or so. (You can almost hear the discussions at the International Conferences on Spinal Manipulation as you flick through them). The book’s objective is to ‘‘give a fair representation of what the chiropractic profession has to offer’’. It does this by starting with a flavour and context of the profession and then moving to joint anatomical considerations, assessment procedures and principles of ‘adjustive

technique’. Then comes the spine, after that the extremities, and then ‘non-thrust procedures’. (Anyone who thinks that chiropractic manipulation and highvelocity thrust are synonymous will see the flaws in that perception). Yes, the book is beautifully illustrated and yes, it is well written. Its main weakness lies perhaps in its introductory overview that deals with the past, present and future context of chiropractic. This is inward looking and appeals to a sense of self-gratification by focusing on how chiropractic and manipulation have been supported by the evidence. However, there is no sense of how the profession should meet the WHO’s challenge and integrate the psychological and social elements of health with the biological. But then, the chiropractors are not alone in that!

Alan Breen Anglo-European College of Chiropractic 13-15 Parkwood Road, Bournemouth BH52DF, UK

doi:10.1016/j.math.2004.01.005

The concise encyclopaedia of fibromyalgia and myofascial pain Patarca-Montero R. Haworth Medical Press, New York, 2002, p. 212, price d24,95 ISBN 0789015285

Half of this paperback is an A–Z list of material related or possibly related to fibromyalgia and myofascial pain. The other half comprises around 1300 references and as such it makes a very valuable resource for students and practitioners. The material collected is wide ranging—for example, entries include the relationship of the weather, breast implants, breathing disorders, sleep, post-polio syndrome, neurogenic inflammation and genetics to fibromyalgia and myofas-

cial pain. Overall, the entries emphasise current views of the importance of central nervous system processing changes with perturbed neuroendocrine and immune responses as essential parts of fibromyalgia and myofascial pain. We could reflect on the role of an encyclopaedia for a collection of signs and symptoms where aetiology and pathogenesis remain uncertain and clinical overlaps exists with other syndromes such as chronic fatigue syndrome. With so many possible management strategies and contributing factors listed, patients should read it with care or in consultation with a health provider. Health providers should have a open-minded working definition of what comprises fibromyalgia and myofascial pain syndromes.

ARTICLE IN PRESS Book reviews / Manual Therapy 9 (2004) 234–235

You may need to dig a little to get the best out the book, but that is a feature of any encyclopaedia. For treatment aspects relevant to manual therapists, you will need to check exercise, physical therapy, fitness, rehabilitation, treatment, alternative and complementary medicine. Overall, this little inexpensive book provides us with wide and useful views on the pathobiological processes and social influences which doi:10.1016/j.math.2004.01.004

235

contribute to chronic pain states such as fibromyalgia and myofascial pain.

David Butler Neuro Orthopaedic Institute, 31 Angus street Adelaide 5034, Australia

ARTICLE IN PRESS

Manual Therapy 9 (2004) 236 www.elsevier.com/locate/math

Honorary Membership of International Federation of Orthopaedic Manipulative Physiotherapists Citation for Professor Gwendolen Jull ‘‘In the UK and The Common Wealth there exists a system of honours for individuals who have made a particular contribution to society. These awards have in the past year received a great deal of publicity as it is sometimes claimed that they are, in some instances, made more as a thank you for financial contributions to political parties than an acknowledgement of a contribution to the greater good of society. IFOMT has as one of its pleasurable remits the possibility to honour those who have made an outstanding contribution to the field of International Manual Therapy. As IFOMT is a completely apolitical organisation, there is no ulterior motive to these awards. This year it was the great pleasure of the executive committee to recommend to the voting delegates, someone who has contributed in a multifaceted way to the International Manual Therapy community over the last two decades. This person has lectured, run courses and influenced the thinking of the management of a broad spectrum of clinical areas. In addition she has been the chairperson for the IFOMT Standards Committee since 1990. Her unstinting generosity of time and energy over the years has been enormously valued by IFOMT throughout this period. The updating of the Standards Document, which was voted in at the Perth conference in 2000, was to a large extent her work. This enabled IFOMT to reflect more accurately the international developments of Manual Therapy and

1356-689X/$ - see front matter doi:10.1016/j.math.2004.07.005

therefore be The International Organisation responsible for the standards of post-graduate Manual Therapy educational programs. Let me add that when it came to the voting, there was unanimous agreement. I am of course referring to Professor Gwen Jull. Gwen, it is with great pleasure that I, on behalf of IFOMT, award you the Honorary Membership of IFOMT. In the constitution of IFOMT it says about this awards, and I quote: ‘‘Honorary Membership may be granted to individuals who have enhanced the Federation or have rendered valuable service to Orthopaedic Physical Therapy through unique or long term service or have merited special recognition for their work in a parallel field.’’ There can be few people more deserving of this award at this time. Your inspiration and support has been a guiding light for IFOMT and personally I have much appreciated your assistance over the last 4 years. Congratulations.’’ This Citation was read and the award was presented by Ms Agneta Lando President of IFOMT at 8th IFOMT conference held in Cape Town, South Africa, March 2004. The Editorial Board of Manual Therapy Journal would like to extend their congratulations to Professor Jull on this significant achievement.

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Announcement

The MACP presents: CLINICAL EFFECTIVENESS COURSE Accredited by the MACP CEA

Do you want to improve your clinical effectiveness? Do you need the answers to these questions? • • • • •

What is EBP? Are there user-friendly time saving ways to access the evidence? How do I interpret different types of evidence? When is the evidence good enough for me to change my clinical practice? How do I incorporate the evidence into my clinical practice? Then this is the course for you!

This half-day course will help you develop an understanding of EBP and how you can use it to your advantage within your clinical practice. We know that finding and critiquing relevant literature within busy working lives can often be a problem and we will share strategies to make this process easier. The emphasis of this course is to give you the skills to improve your clinical effectiveness via the use of EBP. The MACP is happy to adapt the programme to suit your needs. Course number: We have put a cap on a maximum of 30 participants as this allows interactive lectures and also group work, which still caters for individuals' needs. This is flexible and please contact us if you need to discuss this further. Pre-course reading: None required but post-course activity will be encouraged as part of ongoing CPD If you wish to run this course or for further information contact: Dr Mindy Cairns: [email protected]

1356-689X/$ - see front matter doi:10.1016/j.math.2004.08.001

ARTICLE IN PRESS Announcement / Manual Therapy 9 (2004) 237–238

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MANIPULATION ASSOCIATION OF CHARTERED PHYSIOTHERAPISTS

1. Effective management of Lumbar Spine Dysfunction 2. Effective management of Cervical Spine Dysfunction About the courses These 4 day (L Sp) & 3 day courses (C Sp) are practically based and designed for those physiotherapists wishing to advance their treatment approaches in the management of low back and cervical spine pain. The initial 2 days focus on assessment and have a strong emphasis on clinical reasoning and evaluating evidence within the biopsychosocial framework. The following days are spread apart so that the participant has time to reflect on his/ her own needs within their clinical practice. These day/s aim to foster new or developing ideas in manual techniques, therapeutic exercises and to consolidate previous knowledge in the management of lumbar spine conditions. Who is the course aimed at? Those physiotherapists wishing to develop more effective and efficient management of neuromusculoskeletal dysfunction of patients with spinal pain. What is required of the participant? There are small problem solving exercises, which require the participant to draw on examples form their own clinical practice that are completed between sections of the course. Course tutors: MACP members and experienced lecturers Details of venues or information about these courses see website

MACP Administrator: [email protected]

For further information regarding running this course in your area course please contact: John Hammond (L Sp) - [email protected] Linda Exelby (C Sp) – [email protected]

Manual Therapy (2004) 9(4), 239–240

Diary of events

EXECUTIVE SECRETARIAT Connect Organizaçaõ e Promoçaõ de Eventos Rua Joaõ Cachoeira, 488-Cj. 806-04535-001 – Saõ Paulo - SP – Brazil Phone/Fax: 55 11 3168-1149/55 11 3168-3538 http://www.connecteventos.com.br mailto:[email protected]

10–13 November, 2004, Melbourne, Australia 5th Interdisciplinary World Congress on Low Back & Pelvic Pain Effective Diagnosis and Treatment of Lumbopelvic Pain. Information and Call for Papers: www.worldcongresslbp.com http://www.worldcongresslbp.com Deadline submitting papers: December 15, 2003 For all further information: info@ world congresslbp.com mailto: info@worldcongresslbp. com

VENUE Grand Hotel Meli Av. das Naço˜es Unidas, 12559 - Saõ Paulo - SP http://www.solmelia.com

11–12 March 2005, Veldhoven, The Netherlands 24th congress of the Dutch Association for Manual Therapy (NVMT) Congress theme: Evidence Based Practice on the shop floor Venue: The Conference centre of ‘‘Koningshof ’’ in Veldhoven, The Netherlands. Speakers include: Prof. Ann Moore, Ian Edwards, Deborah Falla, Anita Gross, Lorimer Mosely. Information: e-mail to: [email protected] or visit the website: www.nvmt.nl

21–26 August 2005, Sydney, Australia 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

April 8,9–2005 Biological and Applied Aspects of Somato-Autonomic Interactions Kyoyo University, Japan Aim: To critically consider and debate the current scientific research data concerning somato-autonomic interactions from the perspectives of basic physiology and clinical application. Participants: Biomedical and Clinical Scientists in the disciplines of Neuroscience and Health Care. Publication: Monograph Title: Biological and Applied Aspects of Somato-Autonomic Interactions to be published by Elsevier B.V. as a volume in the International Congress Series

23–25 September 2005 2nd International Conference on Movement Dysfunction Pain & Performance: Evidence & Effect Location: Edinburgh, UK

Dr. Brain Budgell, chair School of Health Sciences, Faculty of Medicine Kyoto University, Kyoto, Japan [email protected]

Website: www.kcmacp-conference2005.com Organizers: Hosted by Kinetic Control and the Manipulation Association of Chartered Physiotherapists Administered and Sponsored by Elsevier/Manual Therapy

Details can be found at http://www.nuancekk.com/Kyoto2005 Abstracts Deadline: Nov 15th 2004

Call for Papers Abstract Deadlines 15 January 2005

April, 10th–15th, 2005 Third World Congress of the International Society of Physical and Rehabilitation Medicine Gran Meli WTC – Saõ Paulo – Brazil REGISTRATION ON LINE http://www.isprm.org/brazil

Secretariat: Nina Woods Kinetic control and MACP Conference Secretariat Elsevier, The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, UK Tel: +44 (0) 1865 843297 Fax: +44(0) 1865 843958 E-mail: [email protected]

CONGRESS HIGHLIGHTS Hands-On Workshops Current Mechanism-Based Treatments Multiprofessional Approach Technological Advances in PM&R Meet the Expert Sessions Updates in Evidence-Based Medicine

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; 239

240 Manual Therapy

website: www.painpoints.com/seminars.htm; E-mail: [email protected] 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.

DOI: S1356-689X(04)00096-7

Volume Contents for Vol. 9, 2004 Vol. 9, No. 1

Editorial The International Federation of Orthopaedic Manipulative Therapists A. Lando

1

Masterclass Rehabilitation of pelvic floor muscles utilizing trunk stabilization R. Sapsford

3

Original articles Doppler studies evaluating the effect of a physical therapy screening protocol on vertebral artery blood flow C. Arnold, R. Bourassa, T. Langer, G. Stoneham

13

Inter- and intraexaminer reliability in palpation of the primary respiratory mechanism within the cranial concept P. Sommerfeld, A. Kaider, P. Klein

22

Long-term follow-up of patients with low back pain attending for manipulative care: outcomes and predictors A. K. Burton, T. D. McClune, R. D. Clarke, C. J. Main

30

Professional issue Referencing and quotation accuracy in four manual therapy journals C. M. Gosling, M. Cameron, P. F. Gibbons

36

Technical and measurement report Measurement of abdominal muscle thickness using M-mode ultrasound imaging during functional activities S. M. Bunce, A. D. Hough, A. P. Moore

41

Letters to the editor

45

Book reviews

49

Diary of events

51

Subject index for Volume 8

52

List of Reviewers 2003

56

Vol. 9, No. 2

Editorial Clinical anatomy serving manual therapy S. R. Mercer, D. A. Rivett Masterclass A proposed new classification system for whiplash associated disorders—implications for assessment and management M. Sterling Review Article The sensory and sympathetic nerve supply within the cervical spine: review of recent observations G. M. Johnson

241

59

60

71

242

Original articles The initial effects of a Mulligan’s mobilization with movement technique on dorsiflexion and pain in subacute ankle sprains N. Collins, P. Teys, B. Vicenzino

77

Reliability of ultrasonography for the cervical multifidus muscle in asymptomatic and symptomatic subjects E. Kristjansson

83

Impairment in the cervical flexors: a comparison of whiplash and insidious onset neck pain patients G. Jull, E. Kristjansson, P. DallAlba

89

Professional issue Pre-manipulative testing of the cervical spine review, revision and new clinical guidelines M. E. Magarey, T. Rebbeck, B. Coughlan, K. Grimmer, D. A. Rivett, K. Refshauge

95

Case report The presence and utilization of psoas musculature despite congenital absence of the right hip J. M. Elliott, E. D. Zylstra, C. J. Centeno

109

Obituary Brian Clifford Edwards Born Perth Western Australia—January 1941 Died Perth Western Australia—November 2003 L. Twomey (Vice-Chancellor)

114

Letters to the editor

116

Book reviews

119

Diary of events

121

Vol. 9, No. 3

Editorial A. Gross

123

Masterclass Unravelling the complexity of muscle impairment in chronic neck pain D. Falla

125

Systematic review The centralization phenomenon of spinal symptoms—a systematic review A. Aina, S. May, H. Clare

134

Original articles Clinicians perceptions of minor cervical instability K.R. Niere, S.K. Torney

144

How common are side effects of spinal manipulation and can these side effects be predicted? B. Cagnie, E. Vinck, A. Beernaert, D. Cambier

151

Impaired trunk muscle function in sub-acute neck pain: etiologic in the subsequent development of low back pain? G.L. Moseley

157

A survey on the importance of lumbar coupling biomechanics in physiotherapy practice C. Cook, C. Showalter

164

Case report A case of selective paresis of the deep stabilization system due to boreliosis K. Lewit, O. Horacek

173

Abstracts Manipulation Association of Chartered Physiotherapists (MACP) UK Research Awards

176

243

Book reviews

178

Diary of events

181

Vol. 9, No. 4

Editorial How to evaluate manual therapy: value and pitfalls of randomized clinical trials B.W. Koes

183

Masterclass Foot orthotics in the treatment of lower limb conditions: a musculoskeletal physiotherapy perspective B. Vicenzino

185

Original articles The flexionrotation test and active cervical mobility—A comparative measurement study in cervicogenic headache T. Hall, K. Robinson

197

Anatomical relationships between selected segmental muscles of the lumbar spine in the context of multi-planar segmental motion: a preliminary investigation R.S. Jemmett, D.A. MacDonald, A.M.R. Agur

203

Spinal kinematics and trunk muscle activity in cyclists: a comparison between healthy controls and non-specific chronic low back pain subjects—a pilot investigation A.F. Burnett, M.W. Cornelius, W. Dankaerts, P.B. OSullivan

211

Is cervical spine rotation, as used in the standard vertebrobasilar insufficiency test, associated with a measureable change in intracranial vertebral artery blood flow? J. Mitchell, D. Keene, C. Dyson, L. Harvey, C. Pruvey, R. Phillips

220

Case report The patient-centredness of evidence-based practice. A case example to discuss the clinical application of the bio-psychosocial model J. Langendoen

228

Book reviews

234

Honours and Awards

236

The MACP presents

237

Dairy of events

239

Volume Contents and Author Index for Volume 9 (2004)

241

Keyword Index

245

The list of referees for Volume 9 (2004) will appear in Vol. 10, No. 1

Author index A Agur, A.M.R., 203 Aina, A., 134 Arnold, C., 13 B Beernaert, A., 151 Bourassa, R., 13 Breen, A., 234 Bunce, S. M., 41 Burnett, A.F., 211 Burton, A. K., 30 Butler, D., 235 C Cagnie, B., 151 Cambier, D., 151 Cameron, M., 36 Centeno, C.J., 109 Clare, H., 134 Clarke, R. D., 30 Collins, N., 77 Cook, C., 164 Cornelius, M.W., 211 Coughlan, B., 95 D Dall’A lba, P., 89 Dankaerts, W., 211 Diener, I., 120 Dijkstra, P.U., 118 Dyson, C., 220 E Elliott, J.M., 109 F Falla, D., 125 G Gibbons, P. F., 36 Gokeler, A., 118

O

Gosling, C., 36 Grimmer, K., 95

Ombregt, L., 178 Oostendorp, R. A. B., 47 O’Sullivan, P.B., 211

H Hall, T., 197 Harvey, L., 220 Holey, L., 49 Horacek, O., 173 Hough, A. D., 41

P Phillips, R., 220 Pruvey, C., 220 R

J Jemmett, R.S., 203 Johnson, G.M., 71 Jull, G., 89

Rebbeck, T., 95 Refshauge, K., 95 Rivett, D.A., 59, 95 Robinson, K., 197 Roelofs, J., 47 Roy, P.V., 179

K Kaider, A., 22 Keene, D., 220 Klein, P., 22 Kristjansson, E., 83, 89 L Langendoen, J., 228 Langer, T., 13 Lewit, K., 173 Lynn, D. B., 50

S Sapsford, R., 3 Saunders, S., 49 Schomacher, J., 116 Showalter, C., 164 Sommerfeld, P., 22 Sterling, M., 60 Stoneham, G., 13 Swinkels, R. A. H. M., 47 Swinkels-Meewisse, E. J. C. M., 47 T

M MacDonald, D.A., 203 Magarey, M.E., 95 Main, C. J., 30 May, S., 134 McClune, T. D., 30 Mercer, S.R., 59 Mitchell, J., 220 Moore, A. P., 41 Moseley, G.L., 157

Testa, M., 178 Teys, P., 77 Torney, S.K., 144 Truyen, S., 45 Twomey (Vice-Chancellor), L., 114 V Verbeek, A. L. M., 47 Vicenzino, B., 77, 185 Vinck, E., 151 Vlaeyen, J. W. S., 47

N Z

Niere, K.R., 144 Nijs, J., 45, 119

Zylstra, E.D., 109

244

Keyword index A Accuracy 36 Ankle 77 Assessment 83 Atrophy 83

O Osteopathy 22 Outcomes 30

P C Care Seeking 30 Cervical 83 Cervical mobility 197 Cervical movement 13 Cervical spine 71, 144, 197 Cervical spine rotation 220 Cervicogenic headache 197 Citation 36 Cranial concept 22 D Diagnosis 144 Doppler 13 F

Pain 77 Palpation 22 Physical therapy 13 Predictors 30 Primary respiratory mechanism 22 Prospective 30 Psychological 30

Q Quotation 36

R Recurrence 30 Reference 36

Flexion-rotation test 197 I Instability 144 Interexaminer reliability 22 Intraexaminer reliability 22 L Low back pain 30

S Screening 13 Sensory nerves 71 Sympathetic nerves 71

U Ultrasonography 83

M Manipulation 30, 77 Manual examination 197 Movement 77 Multifidus 83

V VBI test 220 Vertebral artery blood flow 220 Vertebral artery 13

N Neck flexors 89 Neck pain 89

W Whiplash 83, 89

245

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 11, Issue 3, Pages 167-240 (August 2006)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 11, Issue 3, Pages 167-240 (August 2006)

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

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