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PubMed2004

Biomechanical assessments of lumbar spinal function. How low back pain sufferers differ from normals. Implications for outcome measures research. Part I: kinematic assessments of lumbar function.

OBJECTIVE: To review new and advanced biomechanical assessment techniques for the lumbar spine and illustrate the differences in lumbar function in patients with low back pain and asymtomatic subjects. DATA SOURCES: The biomedical literature was searched for research and reviews on spinal kinematic differences between low back pain subjects and healthy controls. A data search for articles indexed on MEDLINE until April 2002 was performed. RESULTS: Kinematic measurements of lumbar function were categorized into 3 areas where low back patients may differ from normals: (1) end range of motion during simple movements; (2) higher order kinematics (displacement, velocity, and acceleration) during complex movement tasks; and (3) spinal proprioception. The assessment of higher order kinematics during complex movement tasks is the most highly researched and the most successful in describing differences between the populations. The use of simple end range of motion appears questionable, while assessing spinal proprioception is the least researched, yet shows potential in highlighting differences between low back sufferers and asymptomatics. CONCLUSION: Current kinematic biomechanical assessment techniques are capable of identifying functional differences between low back pain populations and controls. The use and validity of the majority of these techniques as outcome measures are currently unknown, yet may be valuable in generating functional diagnoses, evaluating the mechanisms of current therapies, and prescribing specific rehabilitation programs.

Biomechanical Phenomena↗

PubMed2002

The Mulligan concept: its application in the management of spinal conditions.

The Mulligan concept encompasses a number of mobilising treatment techniques that can be applied to the spine, these include 'NAGs' (natural apophyseal glides), 'SNAGs' (sustained natural apophyseal glides), and 'SMWLMs' (spinal mobilisations with limb movements). These techniques are described and the general principles of examination and treatment are outlined. Clinical examples are used to illustrate the concept's application to the spine, how it has evolved and been integrated into constantly changing physiotherapy practice. New applications are considered which can assist in the correction of dysfunctional movement. The paper reflects on the possible role that this concept has to play within evidence-based practice. A future research direction is proposed in the light of presently available preliminary research results.

Evidence-Based Medicine↗

PubMed2003

Segmental mobility of the lumbar spine during a posterior to anterior mobilization: assessment using dynamic MRI.

OBJECTIVES: To quantify segmental mobility of the lumbar spine during a posterior to anterior spinal mobilization procedure. DESIGN: Descriptive study using dynamic magnetic resonance imaging. BACKGROUND: The posterior to anterior spinal mobilization procedure is frequently used in the assessment and management of spinal dysfunction. How this procedure influences segmental spinal motion however, is not known. METHODS: Eleven asymptomatic subjects were positioned prone within a vertically open double donut design magnetic resonance imaging system. An anteriorly directed force was applied manually at each lumbar spinous process while magnetic resonance images were obtained continuously in the sagittal plane. The intervertebral angle was used to quantify segmental motion. RESULTS: The direction of motion at the tested segment was always extension, with values ranging from 1.2 (SD 2.2) at L2 to 3.0 (SD 2.3) degrees at L5. When the force was applied at L3, L4 and L5, the non-tested (adjacent) segments also were observed to move into extension. However, when the posterior to anterior force was applied at L1 and L2 the three caudal segments moved into flexion. CONCLUSIONS: Posterior to anterior spinal mobilization consistently caused extension at the tested segment, while the motion of the collective lumbar spine was either an increase or decrease in lordosis depending on the segment at which the force was applied. RELEVANCE: Passive movement techniques are commonly used to identify the symptomatic lumbar segment(s) and can be used as a treatment aimed at increasing mobility and/or decreasing pain. Knowledge of how this procedure influences segmental motion of healthy spines is important in understanding how altered mobility is related to symptoms.

Adult↗

PubMed1999

Risk of early closed reduction in cervical spine subluxation injuries.

OBJECT: The authors retrospectively reviewed 121 patients with traumatic cervical spine injuries to determine the risk of neurological deterioration following early closed reduction. METHODS: After excluding minor fractures and injuries without subluxation, the medical records and imaging studies (computerized tomography and magnetic resonance [MR] images) of 82 patients with bilateral and unilateral locked facet dislocations, burst fractures, extension injuries, or miscellaneous cervical fractures with subluxation were reviewed. Disc injury was defined on MR imaging as the presence of herniation or disruption: a herniation was described as deforming the thecal sac or nerve roots, and a disruption was defined as a disc with high T2-weighted signal characteristics in a widened disc space. Fifty-eight percent of patients presented with complete or incomplete spinal cord injuries. Thirteen percent of patients presented with a cervical radiculopathy, 22% were intact, and 9% had only transient neurological deficits in the field. Early, rapid closed reduction, using serial plain radiographs or fluoroscopy and Gardner-Wells craniocervical traction, was achieved in 97.6% of patients. In two patients (2.4%) closed reduction failed and they underwent emergency open surgical reduction. The average time to achieve closed reduction was 2.1+/-0.24 hours (standard error of the mean). The incidence of disc herniation and disruption in the 80 patients who underwent postreduction MR imaging was 22% and 24%, respectively. However, the presence of disc herniation or disruption did not affect the degree of neurological recovery, as measured by American Spinal Injury Association motor score and the Frankel scale following early closed reduction. Only one (1.3%) of 80 patients deteriorated, but that occurred more than 6 hours following closed reduction. CONCLUSIONS: Although disc herniation and disruption can occur following all types of traumatic cervical fracture subluxations, the incidence of neurological deterioration following closed reduction in these patients is rare. The authors recommend early closed reduction in patients presenting with significant motor deficits without prior MR imaging.

Cervical Vertebrae↗

PubMed2005

Comparison of the effectiveness of a behavioural graded activity program and manual therapy in patients with sub-acute neck pain: design of a randomized clinical trial.

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

Behavior↗

PubMedDate not supplied

[Preliminary results of treatment for spastic forms of infantile cerebral paralysis by chronic epidural neurostimulation of lumbar enlargement].

Six patients with infantile cerebral paralysis following drug-resistant spastic syndrome were operated on. Four children suffered from lower spastic paraparesis; 2 had spastic tetraparesis. All the children were observed to have leg chiasm and myogenic equinus talipes. Electrodes were implanted under X-ray guidance into the posterior epidural cavity of the spinal cord at the level of Th10-Th12 vertebrae and the MATTRIX system. In the postoperative period, all the children had a steady-state decrease in leg and arm muscle tone during 1-2 daily high-frequency electrostimulation sessions. Within the early week, there was a regression of equinus talipes and leg chiasm. A follow-up indicated a steady-state clinical effect in all the patients. Stimulation myography revealed that the H reflex was suppressed and the H/M ratio decreased to the normal level (60-80%) in all the patients. An average of one daily electrostimulation session was sufficient to maintain muscle tone at the near-normal level.

Adolescent↗

PubMed2002

Spinal reflex excitability changes after lumbar spine passive flexion mobilization.

BACKGROUND: Flexion distraction has gained increased credibility as a therapeutic modality for treatment of low back pain. Although important work in the area has elucidated the intradiskal pressure profiles during flexion distraction, the accompanying neural responses have yet to be described. OBJECTIVE: The purpose of this pilot study was to assess neural reflex responses to motion with 3 degrees of freedom applied to the lumbar spine and to evaluate H-reflex responses of the soleus. METHODS: Subjects (n = 12) were measured for H-maximum reflexes determined from stimulus response recruitment curves measured in neutral prone position. The mean of 10 evoked H-waves (at H-maximum stimulus intensity) were measured in neutral position, flexion, left and right lateral flexion, and axial rotation of the trunk on an adjusting table. H-reflexes were expressed as a percentage of maximal M-wave for the criterion measure. Spinal range of motion was quantified by digitization. RESULTS: The data showed variation in some movement ranges, notwithstanding identical table positioning for all subjects. Mean H-reflex amplitude was decreased (15.2 +/- 5.8 mV to 13.8 +/- 5.8 mV), and the H/M ratio was also decreased in flexion compared with neutral (55.0% +/- 19.1% to 50.3% +/- 19.4%; P <.05). CONCLUSIONS: Trunk flexion is accompanied by inhibition of the motor neuron pool. Slight perturbations in numerous afferent receptors are known to significantly alter the H-reflex. The absence of measurable changes in lateral flexion and trunk rotation may indicate that both slow- and fast-adapting receptors could be involved in lumbar motion. These preliminary findings suggest the need for further dynamic motion studies of the flexion distraction neurophysiologic condition.

Adult↗

PubMed2001

[New approaches to diagnosis and treatment of fibromyalgia in spinal osteochondrosis].

AIM: To compare effectiveness of manual and bioresonance therapies for fibromyalgia (FM) in spinal osteochondrosis (SO). MATERIAL AND METHODS: The trial enrolled 60 FM patients with x-ray diagnosis of SO. In addition to routine clinical examination all the patients have undergone kinesthetic study with estimation of the muscular syndrome index, brain echoscopy, neurological examination, electropuncture diagnosis. Group 1 patients received manual therapy (MT) and point massage (PM); group 2 patients received MT, PM and bioresonance therapy (BRT). The treatment took 5-6 weeks. The examinations were made before the treatment and 1-1.5 months after it. RESULTS: The response was observed in both the groups, but in group 2 it occurred more frequently and earlier, was higher and longer. BRT produces no side effects, has no contraindications, acts on the body systemically. It is rather effective against symptoms of neurocirculatory dystonia frequently diagnosed in FM patients.

Adult↗

PubMed2003

Manual therapy and exercise therapy in patients with chronic low back pain: a randomized, controlled trial with 1-year follow-up.

STUDY DESIGN: A multicenter, randomized, controlled trial with 1-year follow-up. OBJECTIVES: To compare the effect of manual therapy to exercise therapy in sick-listed patients with chronic low back pain (>8 wks). SUMMARY AND BACKGROUND DATA: The effect of exercise therapy and manual therapy on chronic low back pain with respect to pain, function, and sick leave have been investigated in a number of studies. The results are, however, conflicting. METHODS: Patients with chronic low back pain or radicular pain sick-listed for more than 8 weeks and less than 6 months were included. A total of 49 patients were randomized to either manual therapy (n = 27) or to exercise therapy (n = 22). Sixteen treatments were given over the course of 2 months. Pain intensity, functional disability (Oswestry disability index), general health (Dartmouth COOP function charts), and return to work were recorded before, immediately after, at 4 weeks, 6 months, and 12 months after the treatment period. Spinal range of motion (Schober test) was measured before and immediately after the treatment period only. RESULTS: Although significant improvements were observed in both groups, the manual therapy group showed significantly larger improvements than the exercise therapy group on all outcome variables throughout the entire experimental period. Immediately after the 2-month treatment period, 67% in the manual therapy and 27% in the exercise therapy group had returned to work (P < 0.01), a relative difference that was maintained throughout the follow-up period. CONCLUSIONS: Improvements were found in both intervention groups, but manual therapy showed significantly greater improvement than exercise therapy in patients with chronic low back pain. The effects were reflected on all outcome measures, both on short and long-term follow-up.

Adult↗

PubMedDate not supplied

Contribution of ribcage movement to thoracolumbar posteroanterior stiffness.

OBJECTIVE: To investigate (1) whether thoracolumbar posteroanterior (PA) stiffness differs between 2 conditions of ribcage movement: unconstrained and constrained, and (2) whether the effect of ribcage constraint on PA stiffness varies according to where the PA force is applied. DESIGN: Two-factor within-subjects design. SETTING: Spinal Mechanics Laboratory, University of Sydney. INTERVENTION: A convenience sample of 41 subjects, asymptomatic for back pain, participated. PA stiffness at T12-L4 was measured in the unconstrained and constrained ribcage conditions with a mechanical device. For the constrained condition, we used a clamping device to apply a force to the subject's lower thorax to reduce movement. MAIN OUTCOME MEASURES: PA stiffness at T12-L4 under both ribcage conditions. RESULTS: PA stiffness at T12-L4 significantly increased when the ribcage was constrained (P<.05). However, the effect of ribcage movement did not depend on the location of the PA force. CONCLUSIONS: These findings suggest that the properties of the ribcage influence measures of PA stiffness in the thoracolumbar (T12-L4) spine uniformly. Variations in PA stiffness in segments T12-L4 may reflect the properties of the intervertebral joints.

Adult↗

PubMedDate not supplied

Changes in vertebral artery blood flow following normal rotation of the cervical spine.

BACKGROUND: Extreme rotation of the cervical spine may cause compromised vertebral artery (VA) blood flow. This is of particular interest to manual therapists because of the potential risks associated with these movements. The question is whether the decreased blood flow is significant and therefore likely to cause vertebrobasilar insufficiency/ischemia (VBI) and whether contralateral and ipsilateral rotations are equally affected. Several studies measuring VA blood flow have been reported. However, different parts of the VA were studied, in small samples of normal subjects and patients over a wide range of ages. Hence, the results are controversial. OBJECTIVE: To investigate intracranial VA blood flow in normal male subjects and female subjects, aged 20 to 30 years, in neutral and maximally rotated cervical spinal positions. METHODS: Transcranial Doppler sonography was used to measure intracranial VA blood flow, with the cervical spine in neutral and then rotated maximally to the left and later to the right. The sample consisted of 60 male subjects and 60 female subjects (240 VAs). Comparisons between the neutral and rotated head positions were made within and between the groups. RESULTS: There was a significant decrease (P =.001) in intracranial VA blood flow following cervical spine rotation, irrespective of side but greater on the contralateral side, in the total sample and in male subjects. Female subjects had a significantly higher blood flow than male subjects, and although they showed a significant decrease with contralateral rotation, there was no significant difference in blood flow on the ipsilateral side. CONCLUSION: Maximal rotation of the cervical spine may significantly affect vertebral artery blood flow, particularly when used in the treatment of patients with underlying vascular pathology.

Adult↗

PubMed1976

Reflection on the 1976 Toronto Olympiad for the physically disabled.

A report is given on the various aspects of the 1976 Olympiad of the Physically Disabled. The aspects discussed are the historical background, planning and preparation of the Games, accommodation for amputees, blind and paraplegics, transport, games site, organisation of sports events, medical supervision, publicity of the Games, standards of performance and records and last, but by no means least, politics and sport.

Canada↗

PubMed2004

Failure characteristics of the thoracic spine with a posteroanterior load: investigating the safety of spinal mobilization.

STUDY DESIGN: In vitro biomechanical study of human cadaveric thoracic spine segments and one intact cadaver and applied load measurements in human volunteers. OBJECTIVES: To quantify failure load and pattern of midthoracic vertebrae under a posteroanterior load and to compare failure load in vitro with applied load in vivo. SUMMARY OF BACKGROUND DATA: Osteoporosis and back pain are common alone and in combination among older adults. Spinal mobilization techniques have been shown to relieve back pain and improve function in various clinical settings. However, whether controlled spinal mobilization can cause vertebral fracture in individuals with osteoporosis is not known. METHODS: Twelve T5-T8 cadaveric specimens (mean age, 77 years) were scanned using bone densitometry, radiographed, and measured for bone size. The authors measured failure load, failure site, and intervertebral motion (using a precision optoelectronic camera system) when a posteroanterior load was applied at the spinous process of T6 using a servohydraulic material testing machine. Post-test radiography and CT scan were used to verify failure site. These tests were repeated in an intact cadaver using a Tekscan I-Scan sensor to measure applied loads. The authors also quantified in vivo applied loads during posteroanterior mobilization during seven trials by two experienced physiotherapists. RESULTS: Mean (SD) in vitro failure load of 479 N (162 N) was significantly higher than the mean (SD) in vivo applied load of 145 N (38 N) (P = 0.0004). Macroscopic observation revealed a fracture at the T6 spinous process in 11 specimens and one at the T7 spinous process. These fractures were detected by plain radiography in three of 12 cases and by CT scan in six of 12 cases. CONCLUSIONS: The results suggest a reasonable margin between failure load in vitro and applied mobilization load in vivo.

Aged↗

PubMed2001

Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity.

Recent findings that spinal manual therapy (SMT) produces concurrent hypoalgesic and sympathoexcitatory effects have led to the proposal that SMT may exert its initial effects by activating descending inhibitory pathways from the dorsal periaqueductal gray area of the midbrain (dPAG). In addition to hypoalgesic and sympathoexcitatory effects, stimulation of the dPAG in animals has been shown to have a facilitatory effect on motor activity. This study sought to further investigate the proposal regarding SMT and the PAG by including a test of motor function in addition to the variables previously investigated. Using a condition randomised, placebo-controlled, double blind, repeated measures design, 30 subjects with mid to lower cervical spine pain of insidious onset participated in the study. The results indicated that the cervical mobilisation technique produced a hypoalgesic effect as revealed by increased pressure pain thresholds on the side of treatment (P=0.0001) and decreased resting visual analogue scale scores (P=0.049). The treatment technique also produced a sympathoexcitatory effect with an increase in skin conductance (P<0.002) and a decrease in skin temperature (P=<0.02). There was a decrease in superficial neck flexor muscle activity (P<0.0002) at the lower levels of a staged cranio-cervical flexion test. This could imply facilitation of the deep neck flexor muscles with a decreased need for co-activation of the superficial neck flexors. The combination of all findings would support the proposal that SMT may, at least initially, exert part of its influence via activation of the PAG.

Adult↗

PubMed2000

Training primary care physicians to give limited manual therapy for low back pain: patient outcomes.

STUDY DESIGN: Randomized controlled study of standard manual therapy given by 31 generalist physicians to 295 patients, in primary care practice. OBJECTIVES: To determine whether training primary care physicians in techniques of limited manual therapy would result in improved outcomes for their patients with acute low back pain. SUMMARY OF BACKGROUND DATA: Controversy continues regarding the benefit of spinal manual therapy and the role of highly trained manual therapists in the care of low back pain. Continuing medical education in manual therapy is frequently offered to generalist physicians, but nothing is known of the value and effectiveness of this training. METHODS: Thirty-one primary care physicians were trained to provide optimal low back care (enhanced care) and a sequence of eight standard manual therapy techniques. Two hundred ninety-five patients were randomized into two treatment groups: enhanced care alone and enhanced care with manual therapy. Main outcome measures included the Roland-Morris functional disability scale measured over time and patient-reported time to functional recovery, time to complete recovery, and satisfaction with care. RESULTS: No differences were found in Roland-Morris scores over time, mean functional days to recovery, days absent from work, or patient satisfaction. More patients receiving manual therapy (21; 14%) had completely recovered after the first visit compared with the control group (8; 6%; P = 0.01). Patients who received more intense manual therapy (four or more maneuvers) had a more rapid return to functional recovery (7.8 days) compared with those who received less intense manual therapy (11.1 days; P = 0.02). CONCLUSION: Limited training in manual therapy techniques offers very modest benefit compared with high-quality (enhanced) care for acute low back pain. Outcomes may have been modified by failure of some participant physicians to undertake the required sequence of maneuvers. Intensity of manual therapy may be a factor in improving patient outcomes and needs further study.

Disability Evaluation↗

PubMed2006

Regional trabecular morphology assessed by micro-CT is correlated with failure of aged thoracic vertebrae under a posteroanterior load and may determine the site of fracture.

INTRODUCTION: Spinal mobilization is commonly used in the treatment of patients with back pain, including individuals with osteoporosis. Previous data indicated that traditional predictors of skeletal failure-lateral or anteroposterior bone mineral density (BMD) by dual energy X-ray absorptiometry (DXA) or geometry of the spinous process or vertebral body-do not predict failure load during posteroanterior spinal mobilization. Morphological differences and inhomogeneities in BMD may have important effects on vertebral strength but integral BMD values by DXA cannot reflect these potentially important differences. We investigated the determinants of spinal fracture using muCT. MATERIALS AND METHODS: We measured failure load and failure site in 11 T5-8 cadaveric specimens (mean age 78 years) when a posteroanterior load was applied at the spinous process of T6 using a servohydraulic material testing machine. Radiography and CT scan were used to verify failure site. We observed no damage to the adjacent T7 vertebrae following the T6 posteroanterior failure test. The T7 vertebrae were sectioned to produce regional samples of the spinous process, the lamina and a vertebral body core. Each sample was scanned with muCT to measure bone microarchitectural parameters. We segmented and analysed four trabecular regions (spinous process base and middle, central lamina and central vertebral body). We used one-way repeated measures ANOVA to compare regions and computed Pearson correlations to assess the relation between PA failure load of T6 and the morphological parameters of T7. RESULTS: The BV/TV at the base or middle of the T7 spinous process (fracture sites), Tb.N and Tb.Th at the base were significantly correlated with posteroanterior failure load of T6 (BV/TV base: r=0.74, p=0.01; BV/TV middle: r=0.73, p=0.01; Tb.N base: r=0.64, p=0.03; Tb.Th base: r=0.65, p=0.03). The Tb.Th of the lamina was significantly greater than Tb.Th of the spinous process base (p=0.002). CONCLUSIONS: Whereas previous data indicated that BMD by DXA was not a good predictor of posteroanterior failure load, regional BV/TV of the spinous process base and middle regions, the sites of fracture, are correlated with posteroanterior failure load. Trabecular thickness differed significantly between the base of the spinous process and the lamina, and may have influenced the site of fracture.

Aged↗

PubMed2000

Standardized initial head position in cervical range-of-motion assessment: reliability and error analysis.

OBJECTIVE: To assess the clinical reliability and precision of the OSI CA-6000 Spinal Motion Analyzer for measurement of range of motion in cervical spines of pain-free subjects by using a novel procedure designed to minimize variability and quantitatively evaluate sources of errors. METHODS: Twenty asymptomatic volunteer subjects were evaluated twice by each of two trained examiners in one session. Subject position was carefully standardized. Rotation, lateral bending, and flexion-extension were evaluated in repeated movements (cycles) from extreme to extreme. ANALYSIS: Descriptive statistics and reliability coefficients (interclass correlation coefficients [ICCs]) were calculated for all full- and half-cycle motions. Possible sources of systematic errors were evaluated, and random errors were estimated. RESULTS: ICCs indicate that the instrument performs very reliably for rotation and lateral bending (0.93-0.97) and acceptably for flexion-extension (0.75-0.93) measurements. Differences in instrument placement, subject posture, or both in different trials correlate neither with differences in measured values nor with variances. Within-trial errors did not correlate with ranges of motion. Standardizing head position resulted in increases in reliability of from 3% to 15% for axial rotation and lateral bending but actually decreased the ICCs for flexion-extension (up to 14%) compared with data collected under a less-stringent protocol. Errors in clinical use are estimated at 4.5 degrees. CONCLUSIONS: By using our modifications to the accessories and standardization of subject position, the CA-6000 is a highly precise and reliable instrument for measuring active cervical motion about the 3 Cartesian axes. Individuals can repeat the same patterns of motion in sequential trials on the same day with very little variation. Ease of repetitious measurement without examiner intervention contributes to the instrument's ability to obtain highly reliable data. Changes in instrument placement or subject body posture between trials do not give rise to systematic errors. Design of the instrument for flexion-extension could be improved.

Adult↗

PubMedDate not supplied

An overview of osteopathic medicine.

Despite an initial lack of acceptance by mainstream medicine, and amidst projections of a serious oversupply of physicians, the osteopathic profession continues to grow, successfully competing for shrinking health care resources and attracting the attention of insurers and those in managed care. However, a recent telephone survey of 800 health maintenance organization beneficiaries suggested that the public is not yet familiar with osteopathic medicine. The history, philosophy, and current status of the osteopathic profession are presented, along with theories of the physiologic basis of and supporting evidence for palpatory diagnosis and manipulative therapy.

History, 20th Century↗