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PubMed2004

Pre-manipulative testing of the cervical spine review, revision and new clinical guidelines.

Members of the Manipulative Physiotherapists Association of Australia (now Musculoskeletal Physiotherapy Australia) were surveyed to determine their use of cervical manipulation, compliance with and attitudes to the Australian Physiotherapy Association's (APA) Protocol for Pre-manipulative Testing of the Cervical Spine, and the incidence of adverse effects from cervical manipulation. The questionnaire was mailed to 740 members and returned by 480 members (65%). Cervical manipulation (84.5%) and passive mobilization (99.8%) were used by a high percentage of respondents. Most were familiar with the protocol with 63% supporting its continued endorsement. Adverse effects were reported at a rate of one per 1000 years of practice (or 0.003/week). The most common effects were symptoms potentially related to VBI (94.4% responses), with no reported major complications. Only 37.1% of respondents always informed the patient about potential dangers of cervical manipulation and consent was sought on every occasion by 33% of respondents. The results suggest that the use and interpretation of the protocol are variable among members of MPA. The risk of adverse effects from manipulative (musculoskeletal) physiotherapy practice, including cervical manipulation, appears to be very low. Recommendations for revision of the protocol were made on the basis of results of the survey and treatment diary, in addition to a review of the literature related to testing for vertebro-basilar insufficiency, adverse incidents related to cervical mobilizing and manipulative technique, differentiating features of VBI related dizziness and vertigo related to benign paroxysmal positional vertigo (BPPV) and current issues surrounding informed consent. Finally, a summary of the content of the new Clinical Guidelines for Pre-Manipulative Testing of the Cervical Spine (APA, 2000) is provided.

Adult↗
PubMed2004

Is cervical spine rotation, as used in the standard vertebrobasilar insufficiency test, associated with a measureable change in intracranial vertebral artery blood flow?

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-of-range rotation. Statistically significant decreases in blood flow were demonstrated with contralateral rotation particularly, in the left (45.9+/-8.5 to 41.8+/-11.6 cm/s) and right (27.8+/-6.9 to 25.2+/-8.2 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.

Adult↗
PubMed2004

Unravelling the complexity of muscle impairment in chronic neck pain.

Exercise interventions are deemed essential for the effective management of patients with neck pain. However, there has been a lack of consensus on optimal exercise prescription, which has resulted from a paucity of studies to quantify the precise nature of muscle impairment, in people with neck pain. This masterclass will present recent research from our laboratory, which has utilized surface electromyography to investigate cervical flexor muscle impairment in patients with chronic neck pain. This research has identified deficits in the motor control of the deep and superficial cervical flexor muscles in people with chronic neck pain, characterized by a delay in onset of neck muscle contraction associated with movement of the upper limb. In addition, people with neck pain demonstrate an altered pattern of muscle activation, which is characterized by reduced deep cervical flexor muscle activity during a low load cognitive task and increased activity of the superficial cervical flexor muscles during both cognitive tasks and functional activities. The results have demonstrated the complex, multifaceted nature of cervical muscle impairment, which exists in people with a history of neck pain. In turn, this has considerable implications for the rehabilitation of muscle function in people with neck pain disorders.

Cervical Vertebrae↗
PubMed2005

The T4 syndrome.

Explore the source record for details and available documents.

Adult↗
PubMed2005

Predictors for the immediate responders to cervical manipulation in patients with neck pain.

Cervical manipulation has been considered an effective treatment for managing neck pain. However, clinical observation showed that cervical manipulation was not effective for every patient. Development of clinical prediction rules for identifying patients with neck pain who are likely to respond to cervical manipulation may improve clinical decision-making and the treatment success rate. The purpose of the study was to identify predictors for the immediate responders to cervical manipulation treatment in patients with neck pain. One hundred patients with neck pain (34 males and 66 females, mean age = 46 +/- 11 years) participated in the study. Patient's demographic data, symptom aggravating or easing factors, pain, and disability level were obtained through an initial assessment. A series of physical examinations were also administered. After receiving a single session of cervical manipulation, the patient was re-evaluated immediately to determine if a successful response to treatment was obtained. The successful response was determined by improvements seen in one of the three outcome variables that included reduction of pain intensity, significant perceived improvement, and high satisfaction level. From these judgment criteria, patients were classified into either responders or nonresponders to the cervical manipulation. Univariate analyses were used to assess if the treatment responders and nonresponders were different in their clinical presentations. The clinical factors that showed significant differences between two groups were then entered into a stepwise multiple logistic regression analysis to identify significant predictors and the prediction rule for treatment responders. Six predictors including "initial scores on Neck Disability Index < 11.50", "having bilateral involvement pattern", "not performing sedentary work > 5 h/day", "feeling better while moving the neck", "without feeling worse while extending the neck", and "the diagnosis of spondylosis without radiculopathy" were identified to significantly predict the immediate responders. The presence of four or more of these predictors increased the probability of success with manipulation to 89%. We concluded that using favourable predictors to identify treatment responders before administering cervical manipulations could significantly increase the probabilities of a successful treatment. This study finding may enhance the efficacy of clinical decision-making in using cervical manipulation intervention.

Adult↗
PubMed2006

Work-related thumb pain in physiotherapists is associated with thumb alignment during performance of PA pressures.

Pain is common in the thumbs of physiotherapists. The purpose of this observational study was to investigate whether there is an association between the alignment of the thumb during performance of postero-anterior (PA) pressures and the presence of thumb pain. One hundred and twenty-nine physiotherapists who attended the Musculoskeletal Physiotherapy Association Conference (2003) participated. After providing a history of any work-related thumb pain, participants applied a PA pressure mimicking the technique they would use on a cervical spine, while the position of their metacarpophalangeal (MP) and interphalangeal (IP) joints was photographed. There was an association (p<0.05) between work-related thumb pain and alignment of the thumb during performance of PA pressures: participants who were able to maintain their MP and IP joints in extension were less likely to report pain. These findings serve as a guide to the safe performance of mobilization techniques, both for beginning practitioners and for experienced therapists complaining of thumb pain.

Adult↗
PubMed2006

Construct validity of lumbar extension measures in McKenzie's derangement syndrome.

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

Female↗
PubMed2006

Cervical arterial dysfunction assessment and manual therapy.

In this paper, we present a clinical overview of cervical arterial dysfunction (CAD) for manual therapists who treat patients presenting with cervical pain and headache syndromes. An overview of vertebrobasilar arterial insufficiency (VBI) is given, with reference to assessment procedures recommended by commonly used guidelines. We suggest that the evidence supporting contemporary practice is limited and present a more holistic, evidence-based approach to considering CAD. This approach considers typical pain patterns and clinical progressions of both vertebrobasilar, and internal carotid arterial pathologies. Attention to the risk factors and pathomechanics of arterial dysfunction is also given. We suggest that consideration of the information provided in this Masterclass will enhance the manual therapist's clinical reasoning with regard to differential diagnosis of cervical pain syndromes, and prediction of serious adverse reactions to treatment.

Carotid Artery, Internal↗
PubMed2005

The kinematics and intra- and inter-therapist consistencies of lower cervical rotational manipulation.

The aim of this study was to determine the in vivo kinematics of cervical rotational manipulation in normal subjects and examine the consistency of this technique within and between therapists. A four camera motion analysis system operating at 120 Hz was used to measure the head on trunk angular displacements during manipulation performed by three therapists on eight subjects. One of the therapists performed the manipulation twice for each subject over separate sessions. A consistent pattern of de-rotation prior to thrust was found with little motion other than axial rotation during de-rotation and thrust. The pooled mean de-rotation displacement was 4.8 degrees and the pooled mean thrust angle was 11.3 degrees , but these varied widely, and none of the kinematic parameters recorded proved to be consistent within or between therapists. Most of the kinematic parameters were correlated with the exception of thrust duration. Qualitative analysis shows a consistent technique in cervical rotational manipulation. Pre-manipulation positioning of the head relative to the trunk was fairly consistent for a single therapist over separate sessions, but other than this, the kinematic parameters in cervical rotational manipulation are generally inconsistent within and between therapists.

Adult↗
PubMed2006

The validity of manual examination in assessing patients with neck pain.

BACKGROUND CONTEXT: Although manual therapists believe that they can diagnose symptomatic joints in the neck by manual examination, that conviction is based on only one study. That study claimed that manual examination of the neck had 100% sensitivity and 100% specificity for diagnosing painful zygapophyseal joints. However, the study indicated that its results should be reproduced before they could be generalized. PURPOSE: The present study was undertaken to answer the call for replication studies. The objective was to determine the sensitivity, specificity, and likelihood ratio of manual examination for the diagnosis of cervical zygapophyseal joint pain. STUDY DESIGN: The study was conducted in a private practice located in a rural town. The practice specialized in musculoskeletal pain problems. PATIENT SAMPLE: The study sample was 173 patients with neck pain in whom cervical zygapophyseal joint pain was suspected on clinical examination, and who were willing to undergo controlled diagnostic blocks of the suspected joint or joints. OUTCOME MEASURES: The validity of manual diagnosis was determined by calculating its sensitivity, specificity, and positive likelihood ratio. METHODS: Patients who exhibited the putatively diagnostic physical signs of cervical zygapophyseal joint pain were referred to a radiologist who performed controlled, diagnostic blocks of the suspected joint, and other joints if indicated. The results of the blocks constituted the criterion standard, against which the clinical diagnosis was compared, by creating contingency tables. RESULTS: Manual examination had a high sensitivity for cervical zygapophyseal joint pain, at the segmental levels commonly symptomatic, but its specificity was poor. Likelihood ratios barely greater than 1.0 indicated that manual examination lacked validity. Although the results obtained were less favorable than those of the previous study, paradoxically they were statistically not different. CONCLUSIONS: The present study found manual examination of the cervical spine to lack validity for the diagnosis of cervical zygapophyseal joint pain. It refutes the conclusion of the one previous study. The paradoxical lack of statistical difference between the two studies is accounted for by the small sample size of the previous study.

Adult↗
PubMed2001

Horner's syndrome and dissection of the internal carotid artery after chiropractic manipulation of the neck.

PURPOSE: To report a case of Horner's syndrome and dissection of the internal carotid artery after chiropractic manipulation of the neck. METHODS: Case report. A 44-year-old woman with no prior ocular or vascular history presented with severe right-sided head and neck pain, ptosis, and miosis following chiropractic treatment for a strained right shoulder muscle. RESULTS: Magnetic resonance angiography of the neck and brain revealed a dissection of the right internal carotid artery as well as a suggestion of subtle dissection in the right vertebral artery. No significant brain abnormalities were noted on magnetic resonance imaging. Pharmacological testing was consistent with preganglionic oculosympathetic damage. CONCLUSION: Acute, painful Horner's syndrome as a manifestation of vascular dissection may be associated with chiropractic manipulation of the neck.

Adult↗