Inter-examiner reliability in assessing passive intervertebral motion of the cervical spine

The diagnostic validity of the cervical side bend-rotation test for C 1/2 dysfunction

INTRODUCTION

Neck pain and headaches are common, with a reported lifetime prevalence of up to 66%. Upper cervical segmental dysfunction has been implicated as meaningful in neck pain and multiple headache types. Several tests have been described to assess upper cervical joint dysfunction, including the flexion-rotation test (FRT), the side bend-rotation test (SBRT), and joint play assessment (PA). The purpose of this study was to determine the diagnostic validity of the SBRT to detect C1-2 dysfunction in a sample of people with medically diagnosed sinus headaches and controls.

METHODS

Design: prospective diagnostic accuracy study, occurring during an observational case-control study in a sample of individuals with medically diagnosed sinus headaches. All participants were assessed using the SBRT, FRT, and C1-2 joint play assessments. The diagnostic accuracy of the SBRT was assessed using a reference standard of concurrent positive FRT (a loss of at least 10° from expected ROM (≤34°)) and restriction of C1-2 joint play. Cut-off scores for the SBRT were determined using ROC curve analysis, and tests of diagnostic accuracy were calculated using 2 × 2contingency tables.

RESULTS

A total of 80 individuals (40 headache, 64 female, mean age 32.9 ± 13.8 yrs.) were included in the study. Mean ROM for the tests was: SBRT 31.4 ± 9.4°, FRT 44.9 ± 9.5°, and C1-2 mobility 22 hypomobile/58 normal. An SBRT cutoff score of <25° was confirmed using ROC curves. Using this cutoff score, the SBRT demonstrated 100% sensitivity and 62% specificity to detect C1-2 hypomobility.

DISCUSSION/CONCLUSION

The SBRT, using a cutoff score of ≤25°, appears to be a sensitive test to detect C1-2 dysfunction. Based on the strong sensitivity and negative predictive values, scores greater than 25° may effectively rule-out C1-2 dysfunction. The SBRT should be considered as part of a sequential clinical decision-making process when screening for C1-2 dysfunction, although further research is required to improve generalizability of these findings.

Intra and inter observer agreement in the mobility assessment of the upper thoracic costovertebral joints

BACKGROUND

Determining the mobility of the costovertebral joints might be important in patients with neck-upper thoracic pain. Little research has been performed on observer agreement when assessing the mobility of these joints.

PURPOSE

The purpose of this study was to determine intra- and inter-observer agreements when assessing costovertebral joint mobility of the upper three ribs in those with and without neck pain and to compare the difference between the Kappa and AC statistic.

METHODS

Forty-four participants, with and without current neck/upper-thoracic pain, were assessed by two raters. Raters applied a posterior to anterior pressure to the anatomical neck of the first three ribs bilaterally. Mobility was graded: normal, increased, or decreased. An AC1, for nominal data, AC2 for ordinal data, and the Kappa statistics were used to analyze the results. The AC statistics determines chance agreement different than Kappa.

RESULTS

AC1 showed "moderate to very good" (0.74-1.0) intra-rater reliability, while inter-rater reliability showed "fair to good" agreement (0.51-0.79). Using the AC2 Intra-rater reliability was "very good" and "almost perfect" (AC2: 0.93-1.0), while using the AC2 was "good to very good" and "good to almost perfect" (0.76-0.94). Kappa values for intra-rater reliability ranged from "fair to moderate" (0.38-0.54), while inter-rater reliability ranged from "poor to fair" (-0.10-0.26).

CONCLUSION

Posterior/anterior pressure is a reliable method to assess the mobility of the upper costovertebral joints. Assessing costovertebral mobility is important when establishing a movement diagnosis in patients with neck/upper thoracic pain.

Immediate effects of thoracic manipulation on cervical joint position sense in individuals with mechanical neck pain: A randomized controlled trial

BACKGROUND

Performing thoracic manipulations for neck pain can result in immediate improvements in neck function.

OBJECTIVE

The aim of this study was to investigate the immediate effects of thoracic manipulation on cervical joint position sense and cervical range of motion in individuals with chronic mechanical neck pain.

METHODS

Eighty male volunteers between 18-25 years and having chronic or recurrent neck or shoulder pain of at least 3 months duration with or without arm pain were randomized into two groups: Thoracic Manipulation Group (TMG:50) and Control Group (CG:30), with a pretest-posttest experimental design. The TMG was treated with thoracic extension manipulation while the CG received no intervention. Cervical joint position error and cervical range of motion of the individuals were assessed at baseline and 5 minutes later.

RESULTS

There was no difference in demographic variables such as age (p= 0.764), Body Mass Index (p= 0.917) and Neck Pain Disability Scale (NPDS) scores (p= 0.436) at baseline outcomes between TMG and CGs. Joint position error outcomes between the two groups following intervention were similar in all directions at 30 and 50 degrees. Differences in range of motion following intervention in neck flexion (p< 0.001) and right rotation (p= 0.004) were higher in TMG compared to CG.

CONCLUSIONS

A single session of thoracic manipulation seems to be inefficient on joint position sense in individuals with mild mechanical neck pain. However, thoracic manipulation might be an effective option to increase flexion and rotation of the cervical region as an adjunctive to treatment.

First rib dysfunction in patients with neck and shoulder pain: a Delphi investigation

BACKGROUND

First rib dysfunction is a possible cause of symptoms in patients with neck and/or shoulder pain.

OBJECTIVES

To explore therapists' perceptions of useful diagnostic criteria to identify first rib dysfunction.

METHODS

A Delphi survey over four rounds involving international manual therapy experts who were asked to agree on which items were most useful in identifying first rib dysfunction.

RESULTS

Consensus (>70% agreement) was reached on key aspects of first rib dysfunction being first rib mobility restriction, upper limb symptom distribution, and a subclassification into two subgroups was suggested. The main clinical findings suggested were: painful and restricted neck movements and shoulder girdle loading activities; positive Upper Limb Neural Test 1; direct palpation of first rib, neural structures, and scalene muscles; pain and hypomobility of first rib accessory movements with improvement after mobilization. The cervical rotation lateral-flexion test was considered a useful, although not widely used test among the experts. Its diagnostic accuracy and interpretation in isolation was questioned.

CONCLUSIONS

This Delphi study produced a cluster of clinical tests aimed to identify first rib dysfunction in patients with neck and/or shoulder conditions. However, these need to be tested out in further research to establish reliability and validity.

Dry Needling Adds No Benefit to the Treatment of Neck Pain: A Sham-Controlled Randomized Clinical Trial With 1-Year Follow-up

OBJECTIVE

To examine the short- and long-term effectiveness of dry needling on disability, pain, and patient-perceived improvements in patients with mechanical neck pain when added to a multimodal treatment program that includes manual therapy and exercise.

DESIGN

Randomized controlled trial.

METHODS

Seventy-seven adults (mean ± SD age, 46.68 ± 14.18 years; 79% female) who were referred to physical therapy with acute, subacute, or chronic mechanical neck pain were randomly allocated to receive 7 multimodal treatment sessions over 4 weeks of (1) dry needling, manual therapy, and exercise (needling group); or (2) sham dry needling, manual therapy, and exercise (sham needling group). The primary outcome of disability (Neck Disability Index score) and secondary outcomes of pain (current and 24-hour average) and patient-perceived improvement were assessed at baseline and follow-ups of 4 weeks, 6 months, and 1 year by blinded assessors. Between-group differences were analyzed with a 2-way, repeated-measures analysis of variance. Global rating of change was analyzed with a Mann-Whitney U test.

RESULTS

There were no group-by-time interactions for disability (Neck Disability Index: F_2.37,177.47 = 0.42, P = .69), current pain (visual analog scale: F_2.84,213.16 = 1.04, P = .37), or average pain over 24 hours (F_2.64,198.02 = 0.01, P = .10). There were no between-group differences for global rating of change at any time point (P≥.65). Both groups improved over time for all variables (Neck Disability Index: F_2.37,177.47 = 124.70, P<.001; current pain: F_2.84,213.16 = 64.28, P<.001; and average pain over 24 hours: F_2.64,198.02 = 76.69, P<.001).

CONCLUSION

There were no differences in outcomes between trigger point dry needling and sham dry needling when added to a multimodal treatment program for neck pain. Dry needling should not be part of a first-line approach to managing neck pain. J Orthop Sports Phys Ther 2021;51(1):37-45. doi:10.2519/jospt.2021.9864.

The Importance of Optimal Gaze Direction on Deep Neck Flexor Activation in Chronic Neck Pain

Chronic neck pain (CNP) patients have weak deep neck flexors (DNF) and a hyperactive sternocleidomastoid (SCM). The cranio-cervical flexion test (CCFT) promotes activation of the DNF and decreases activity of the SCM, promoting pain recovery, but research suggests SCM activation increases with increasing gaze direction. We aimed to investigate how DNF and SCM activation varies according to gaze direction in the CCFT, and to prescribe the appropriate gaze direction for CNP. Twenty-eight CNP subjects had their maximum strength pressure level determined by CCFT for strength (20-~30 mmHg) and at each of the measured pressures, DNF and SCM thickness in each of four gaze directions (0°, 20°, 40°, and 60°) was measured by ultrasound imaging. The DNF to SCM ratio varied significantly according to gaze direction (p < 0.05), with gaze directions of 20° and 0° being significantly different from 40° (p < 0.05). Although there was no significant difference in DNF activation according to gaze direction, there was in SCM activation (p < 0.05), with SCM 60° significantly different from SCM 20° and SCM 40° (p < 0.05). In order to increase DNF activation efficiency during the CCFT, SCM activation should be controlled, and a gaze direction below 20° is the most efficient. This can inform DNF training of CNP patients in a clinical environment.

Reliability and validity of clinical tests to assess posture, pain location, and cervical spine mobility in adults with neck pain and its associated disorders: Part 4. A systematic review from the cervical assessment and diagnosis research evaluation (CADRE) collaboration

PURPOSE

To determine the reliability and validity of clinical tests to assess posture, pain location, and cervical spine mobility in adults with grades I-IV neck pain and associated disorders (NAD).

METHODS

We systematically searched electronic databases to update the systematic review of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Eligible reliability and validity studies were critically appraised using modified versions of the QAREL and QUADAS-2 instruments, respectively. Evidence from low risk of bias studies were synthesized following best evidence synthesis principles.

RESULTS

We screened 14302 articles, critically appraised 46 studies, and found 32 low risk of bias articles (14 reliability and 18 validity studies). We found preliminary evidence of: 1) reliability of visual inspection, aided with devices (CROM and digital caliper) to assess head posture; 2) reliability and validity of soft tissue palpation to locate tender/trigger points in muscles; 3) reliability and validity of joint motion palpation to assess stiffness and pain provocation in combination; and 4) range of motion tests using visual estimation (in cervical extension only) or devices (digital caliper, goniometer, inclinometer) to assess cervical mobility.

CONCLUSIONS

We found little evidence to support the reliability and validity of clinical tests to assess head posture, pain location and cervical mobility in adults with NAD grades I-III. More advanced validity studies are needed to inform the clinical utility of tests used to evaluate patients with NAD.

The interrater reliability of a pain mechanisms-based classification for patients with nonspecific neck pain

OBJECTIVE

To examine the interrater reliability and agreement of a pain mechanisms-based classification for patients with nonspecific neck pain (NSNP).

METHODS

Design - Observational, cross-sectional reliability study with a simultaneous examiner design.

SETTING

University hospital-based outpatient physical therapy clinic.

PARTICIPANTS

A random sample of 48 patients, aged between 18 and 75 years old, with a primary complaint of neck pain was included.

INTERVENTIONS

Subjects underwent a standardized subjective and clinical examination, performed by 1 experienced physical therapist. Two assessors independently classified the participants' NSNP on 3 main outcome measures.

MAIN OUTCOME MEASURES

The Cohen kappa, percent agreement, and 95% confidence intervals (CIs) were calculated to determine the interrater reliability for (1) the predominant pain mechanism; (2) the predominant pain pattern; and (3) the predominant dysfunction pattern (DP).

RESULTS

There was almost perfect agreement between the 2 physical therapists' judgements on the predominant pain mechanism, kappa=.84 (95% CI, .65-1.00), p<.001. There was substantial agreement between the raters' judgements on the predominant pain pattern and predominant DP with respectively kappa=.61 (95% CI, .42-.80); and kappa=.62 (95% CI, .44-.79), p<.001.

CONCLUSION(S)

The proposed classification exhibits substantial to almost perfect interrater reliability. Further validity testing in larger neck pain populations is required before the information is used in clinical settings.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03147508 (https://clinicaltrials.gov/ct2/show/NCT03147508).

Spinal PA movements behave 'as if' there are limitations of local segmental mobility and are large enough to be perceivable by manual palpation: A synthesis of the literature

BACKGROUND

Posterio-anterior (PA) movements are one type of passive intervertebral movement used to assess and treat perceived deficits in localized segmental mobility.

OBJECTIVES

To describe: 1) The specific effects that reductions in segmental mobility would be expected to have on PA movements; 2) How differences in PA movements in clinical situations compare to what would be expected with reduced segmental mobility; and 3) Whether such differences in PA movements are likely to be perceivable by manual palpation.

METHODS

Multiple modelling studies and in vivo measurements of PA movements are described.

RESULTS

The findings indicate the differences in PA movements present in clinical conditions corresponds with the differences that would be expected with decreased segmental mobility. The differences both predicted from the modelling and found in clinical conditions were greatest at low levels of force. Additionally, the differences are large enough that individuals with training are likely to be capable of 1) consistently producing controlled movements with sufficiently small magnitudes of force to assess the movements, and 2) detecting the differences in stiffness expected from modelling and found in clinical situations.

CONCLUSIONS

Implications for clinical practice and teaching include the need to attend to the stiffness of PA movements at lower levels of force than those typically described. The authors recommend a three tiered approach to assessment of PA movements which may assist in both clinical practice and teaching manual therapy skills.

Dry Needling for Patients With Neck Pain: Protocol of a Randomized Clinical Trial

BACKGROUND

Neck pain is a costly and common problem. Current treatments are not adequately effective for a large proportion of patients who continue to experience recurrent pain. Therefore, new treatment strategies should be investigated in an attempt to reduce the disability and high costs associated with neck pain. Dry needling is a technique in which a fine needle is used to penetrate the skin, subcutaneous tissues, and muscle with the intent to mechanically disrupt tissue without the use of an anesthetic. Dry needling is emerging as a treatment modality that is widely used clinically to address a variety of musculoskeletal conditions. Recent studies of dry needling in mechanical neck pain suggest potential benefits, but do not utilize methods typical to clinical practice and lack long-term follow-up. Therefore, a clinical trial with realistic treatment time frames and methods consistent with clinical practice is needed to examine the effectiveness of dry needling on reducing pain and enhancing function in patients presenting to physical therapy with mechanical neck pain.

OBJECTIVE

The aim of this trial will be to examine the short- and long-term effectiveness of dry needling delivered by a physical therapist on pain, disability, and patient-perceived improvements in patients with mechanical neck pain.

METHODS

We will conduct a randomized, double-blind, placebo-controlled trial in accordance with the CONSORT guidelines. A total of 76 patients over the age of 18 with acute or chronic mechanical neck pain resulting from postural dysfunction, trauma, or insidious onset who are referred to physical therapy will be enrolled after meeting the eligibility criteria. Subjects will be excluded if they have previous history of surgery, whiplash in the last 6 weeks, nerve root compression, red flags, or contraindications to dry needling or manual therapy. Participants will be randomized to receive (1) dry needling, manual therapy, and exercise or (2) sham dry needling, manual therapy, and exercise. Participants will receive seven physical therapy treatments lasting 45 minutes each over a maximum of 4 weeks. The primary outcome will be disability as measured by the Neck Disability Index. Secondary outcomes include the following: pain, patient-perceived improvement, patient expectations, and successful blinding to the needling intervention. Outcome measures will be assessed at 4 weeks, 6 months, and 12 months by an assessor who is blind to the group allocation of the participants to determine the short- and long-term treatment effects. We will examine the primary aim with a two-way, repeated-measures analysis of variance with treatment group as the between-subjects variable and time as the within-subjects variable. The hypothesis of interest will be the two-way group by time interaction. An a priori alpha level of .05 will be used for all analyses.

RESULTS

Recruitment is currently underway and is expected to be completed by the end of 2017. Data collection for long-term outcomes will occur throughout 2017 and 2018. Data analysis, preparation, and publication submission is expected to occur throughout the final three quarters of 2018.

CONCLUSIONS

The successful completion of this trial will provide evidence to demonstrate whether dry needling is effective for the management of mechanical neck pain when used in a combined treatment approach, as is the common clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02731014; https://clinicaltrials.gov/ct2/show/NCT02731014 (Archived by WebCite at http://www.webcitation.org/6ujZgbhsq).

Intra- and inter-rater reliability of movement and palpation tests in patients with neck pain: A systematic review

Neck pain is common and often becomes chronic. Various clinical tests of the cervical spine are used to direct and evaluate treatment. This systematic review aimed to identify studies examining the intra- and/or interrater reliability of tests used in clinical examination of patients with neck pain. A database search up to April 2016 was conducted in PubMed, CINAHL, and AMED. The Quality Appraisal of Reliability Studies Checklist (QAREL) was used to assess risk of bias. Eleven studies were included, comprising tests of active and passive movement and pain evaluating participants with ongoing neck pain. One study was assessed with a low risk of bias, three with medium risk, while the rest were assessed with high risk of bias. The results showed differing reliabilities for the included tests ranging from poor to almost perfect. In conclusion, active movement and pain for pain or mobility overall presented acceptable to very good reliability (Kappa >0.40); while passive intervertebral tests had lower Kappa values, suggesting poor reliability. It may be a coincidence that the studies indicating very good reliability tended to be of higher quality (low to moderate risk of bias), while studies finding poor reliability tended to be of lower quality (high risk of bias). Regardless, the current recommendation from this review would suggest the clinical use of tests with acceptable reliability and avoiding the use of tests that have been shown to not be reliable. Finally, it is critical that all future reliability studies are of higher quality with low risk of bias.

Effects of 12 Weeks of Chiropractic Care on Central Integration of Dual Somatosensory Input in Chronic Pain Patients: A Preliminary Study

OBJECTIVE

The purpose of this preliminary study was to assess whether the dual somatosensory evoked potential (SEP) technique is sensitive enough to measure changes in cortical intrinsic inhibitory interactions in patients with chronic neck or upper extremity pain and, if so, whether changes are associated with changes in pain scores.

METHODS

The dual peripheral nerve stimulation SEP ratio technique was used for 6 subjects with a history of chronic neck or upper limb pain. SEPs were recorded after left or right median and ulnar nerve stimulation at the wrist. SEP ratios were calculated for the N9, N13, P14-18, N20-P25, and P22-N30 peak complexes from SEP amplitudes obtained from simultaneous median and ulnar stimulation divided by the arithmetic sum of SEPs obtained from individual stimulation of the median and ulnar nerves. Outcome measures of SEP ratios and subjects' visual analog scale rating of pains were recorded at baseline, after a 2-week usual care control period, and after 12 weeks of multimodal chiropractic care (chiropractic spinal manipulation and 1 or more of the following: exercises, peripheral joint adjustments/manipulation, soft tissue therapy, and pain education).

RESULTS

A significant decrease in the median and ulnar to median plus ulnar ratio and the median and ulnar amplitude for the cortical P22-N30 SEP component was observed after 12 weeks of chiropractic care, with no changes after the control period. There was a significant decrease in visual analog scale scores (both for current pain and for pain last week).

CONCLUSION

The dual SEP ratio technique appears to be sensitive enough to measure changes in cortical intrinsic inhibitory interactions in patients with chronic neck pain. The observations in 6 subjects revealed that 12 weeks of chiropractic care improved suppression of SEPs evoked by dual upper limb nerve stimulation at the level of the motor cortex, premotor areas, and/or subcortical areas such as basal ganglia and/or thalamus. It is possible that these findings explain one of the mechanisms by which chiropractic care improves function and reduces pain for chronic pain patients.

Intra- and inter-rater reliability of 3D passive intervertebral motion in subjects with non-specific neck pain assessed by physical therapy students: A pilot study

BACKGROUND

Passive Intervertebral Movements (PIVMs) are commonly used to assess and treat patients with non-specific neck pain. Only very few studies have investigated 3D movements until now.

OBJECTIVE

This study assessed intra- and inter-rater reliability of three-dimensional (3D) cervical PIVMs performed by physical therapy students in patients with non-specific neck pain.

METHODS

Thirty-one patients, mean age 47.2 ± 7.2 years, were independently evaluated by 2 physical therapy students. The raters (A and B) assessed mobility, end-feel and pain provocation performing bilaterally the 3D cervical segmental side-bending test (3D CSSB) from levels C2-C3 to C6-C7. Percentage agreement (raw, positive and negative), Cohen's kappa (95% CI), prevalence index and bias index were calculated to estimate intra- and inter-reliability.

RESULTS

Intra-rater reliability showed kappa values ranging between fair and substantial (k 0.29-0.80) for pain provocation, mobility and end-feel, with percentage agreements between 61%-90%. Inter-rater reliability presented kappa values ranging between fair and substantial (k 0.22-0.62) for pain provocation, mobility and end-feel, with percentage agreements between 61% and 80%.

CONCLUSIONS

Intra-rater reliability of 3D PIVMs was superior to inter-rater reliability in patients with non-specific neck pain. The most repeatable evaluation parameter was pain. However overall poor reliability suggests avoiding the use of these techniques alone to examine patients and measure their outcome. Further studies are needed to investigate PIVMs reliability in combination with other assessment procedure in symptomatic patients.

Range of motion and cervical myofascial pain

Several studies investigating myofascial pain syndrome include assessments of range of motion (ROM) as a diagnostic criterion. However, the value of ROM in this context has not yet been evaluated in controlled clinical studies. We aimed to examine whether patients with myofascial pain syndrome display alterations of ROM when compared to healthy subjects. Twenty-two individuals (13 females, 9 males; aged 33.4 ± 13.9 yrs) afflicted with active myofascial trigger points in the upper trapezius muscle as well as 22 age and sex matched healthy controls were included. All subjects underwent an examination of maximal active cervical ROM in flexion/extension assessed by means of a 3D ultrasonic movement analysis system (30 Hz; Zebris CMS 70). In the patients group, pressure pain threshold (PPT) of the trigger points was determined using a pressure algometer. Maximum range of motion in the sagittal plane did not differ between individuals with MTrP (125.9 ± 23.2°, 95% CI: 116.2-135.6°) and asymptomatic subjects (128.2 ± 20.4°, 95% CI: 119.7-136.7°; p > .05). In patients, PPT (1.7 ± .6, 95% CI: 1.5-1.9) was not correlated with cervical mobility (r = -.13; p > .05). Based on these pilot data, range of motion in flexion/extension is not a valid criterion for the detection of myofascial trigger points. Additional research incorporating movement amplitudes in other anatomical planes and additional afflicted muscles should be conducted in order to further delineate the relative impact of MTrP on range of motion.

Powerful exact unconditional tests for agreement between two raters with binary endpoints

Asymptotic and exact conditional approaches have often been used for testing agreement between two raters with binary outcomes. The exact conditional approach is guaranteed to respect the test size as compared to the traditionally used asymptotic approach based on the standardized Cohen's kappa coefficient. An alternative to the conditional approach is an unconditional strategy which relaxes the restriction of fixed marginal totals as in the conditional approach. Three exact unconditional hypothesis testing procedures are considered in this article: an approach based on maximization, an approach based on the conditional p-value and maximization, and an approach based on estimation and maximization. We compared these testing procedures based on the commonly used Cohen's kappa with regards to test size and power. We recommend the following two exact approaches for use in practice due to power advantages: the approach based on conditional p-value and maximization and the approach based on estimation and maximization.

Review of methods used by chiropractors to determine the site for applying manipulation

Background

With the development of increasing evidence for the use of manipulation in the management of musculoskeletal conditions, there is growing interest in identifying the appropriate indications for care. Recently, attempts have been made to develop clinical prediction rules, however the validity of these clinical prediction rules remains unclear and their impact on care delivery has yet to be established. The current study was designed to evaluate the literature on the validity and reliability of the more common methods used by doctors of chiropractic to inform the choice of the site at which to apply spinal manipulation.

Methods

Structured searches were conducted in Medline, PubMed, CINAHL and ICL, supported by hand searches of archives, to identify studies of the diagnostic reliability and validity of common methods used to identify the site of treatment application. To be included, studies were to present original data from studies of human subjects and be designed to address the region or location of care delivery. Only English language manuscripts from peer-reviewed journals were included. The quality of evidence was ranked using QUADAS for validity and QAREL for reliability, as appropriate. Data were extracted and synthesized, and were evaluated in terms of strength of evidence and the degree to which the evidence was favourable for clinical use of the method under investigation.

Results

A total of 2594 titles were screened from which 201 articles met all inclusion criteria. The spectrum of manuscript quality was quite broad, as was the degree to which the evidence favoured clinical application of the diagnostic methods reviewed. The most convincing favourable evidence was for methods which confirmed or provoked pain at a specific spinal segmental level or region. There was also high quality evidence supporting the use, with limitations, of static and motion palpation, and measures of leg length inequality. Evidence of mixed quality supported the use, with limitations, of postural evaluation. The evidence was unclear on the applicability of measures of stiffness and the use of spinal x-rays. The evidence was of mixed quality, but unfavourable for the use of manual muscle testing, skin conductance, surface electromyography and skin temperature measurement.

Conclusions

A considerable range of methods is in use for determining where in the spine to administer spinal manipulation. The currently published evidence falls across a spectrum ranging from strongly favourable to strongly unfavourable in regard to using these methods. In general, the stronger and more favourable evidence is for those procedures which take a direct measure of the presumptive site of care– methods involving pain provocation upon palpation or localized tissue examination. Procedures which involve some indirect assessment for identifying the manipulable lesion of the spine–such as skin conductance or thermography–tend not to be supported by the available evidence.

A simulated passive intervertebral motion task: observations of performance in a cross-sectional study

INTRODUCTION

Passive motion palpation is an integral component in examination, diagnosis or classification, and treatment of persons with mechanical disorders of the cervical spine. If the magnitude of force application during passive movement assessment is associated with greater palpatory accuracy has not been established.

METHODS

This investigation used a novel mechanical model as a basis for assessing the palpatory force of students and clinicians. The model included multiple palpable resistance and displacement levels similar to that observed in humans. The ability of the subjects to discriminate the various levels of resistance and displacement offered by the model was concurrently measured.

RESULTS

Large variability occurred in the amount of force applied by the subjects in completing the palpatory examination. The data indicated no major differences in palpatory accuracy across the student and clinician groups with different training and experience levels beyond basic competency. Those subjects applying less force in the palpatory exam demonstrated greater accuracy of palpatory assessment with one measure.

DISCUSSION

The data indicate training and experience had minimal relationship to palpatory interpretation precision beyond the basic level and individual natural discriminatory ability may be a factor in accuracy of palpatory skill. The results demonstrate remarkable inconsistency in palpatory force among examiners and suggest that palpatory accuracy may be related to less force application.

Reliability of a seated three-dimensional passive intervertebral motion test for mobility, end-feel, and pain provocation in patients with cervicalgia

OBJECTIVES

Neck pain can be evaluated with passive intervertebral motion (PIVM). No study has evaluated the reliability of three-dimensional (3D) segmental PIVM testing of the cervical spine in symptomatic subjects in a functional, seated position. The purpose of this study was to evaluate inter-rater reliability of such 3D PIVM technique for pain provocation, hypomobility, and end-feel detection.

METHODS

Subjects (n = 63), age 44±15·6 years, neck pain 3·4±1·6 cm with visual analog scale, were evaluated by two of three raters with varied manual therapy education and experience. To perform the test, the rater passively invoked side-bending motion at each cervical joint from C2-C3 to C6-C7, allowing segmental synkinetic rotation and extension to occur. Each joint was assessed for hypomobility, hard end-feel, and pain provocation. Kappa statistics were used to determine the inter-rater reliability for each variable for joints C2-C3 through C6-C7 for both the most painful and least painful sides.

RESULTS

Percent agreements for pain provocation, hypomobility, and end-feel ranged 65-83%, 62-84%, and 68-87%, respectively. Kappa values for pain provocation, hypomobility, and end-feel on the most painful side were fair to moderate (0·29-0·53, 0·21-0·48, and 0·25-0·50, respectively), and on the least painful side were fair to substantial (0·43-0·65, 0·33-0·58, and 0·28-0·60, respectively).

DISCUSSION

This is the first investigation to assess reliability of 3D cervical segmental testing in sitting and to assess reliability of end-feel. The seated 3D PIVM test has sufficient clinical reliability for use in patients with cervicalgia for the assessment of hypomobility, end-feel, and pain provocation.

Evidence-based pain management: is the concept of integrative medicine applicable?

This article is dedicated to the concept of predictive, preventive, and personalized (integrative) medicine beneficial and applicable to advance pain management, overviews recent insights, and discusses novel minimally invasive tools, performed under ultrasound guidance, enhanced by model-guided approach in the field of musculoskeletal pain and neuromuscular diseases. The complexity of pain emergence and regression demands intellectual-, image-guided techniques personally specified to the patient. For personalized approach, the combination of the modalities of ultrasound, EMG, MRI, PET, and SPECT gives new opportunities to experimental and clinical studies. Neuromuscular imaging should be crucial for emergence of studies concerning advanced neuroimaging technologies to predict movement disorders, postural imbalance with integrated application of imaging, and functional modalities for rehabilitation and pain management. Scientific results should initiate evidence-based preventive movement programs in sport medicine rehabilitation. Traditional medicine and mathematical analytical approaches and education challenges are discussed in this review. The physiological management of exactly assessed pathological condition, particularly in movement disorders, requires participative medical approach to gain harmonized and sustainable effect.

A structured review of spinal stiffness as a kinesiological outcome of manipulation: its measurement and utility in diagnosis, prognosis and treatment decision-making

PURPOSE

To review and discuss the methods used for measuring spinal stiffness and factors associated with stiffness, how stiffness is used in diagnosis, prognosis, and treatment decision-making and the effects of manipulative techniques on stiffness.

METHODS

A systematic search of MEDLINE, EMBASE, CINAHL, AMED and ICL databases was conducted. Included studies addressed one of four constructs related to stiffness: measurement, diagnosis, prognosis and/or treatment decision-making, and the effects of manipulation on stiffness. Spinal stiffness was defined as the relationship between force and displacement.

RESULTS

One hundred and four studies are discussed in this review, with the majority of studies focused on the measurement of stiffness, most often in asymptomatic persons. Eight studies investigated spinal stiffness in diagnosis, providing limited evidence that practitioner-judged stiffness is associated with radiographic findings of sagittal rotational mobility. Fifteen studies investigated spinal stiffness in prognosis or treatment decision-making, providing limited evidence that spinal stiffness is unlikely to independently predict patient outcomes, though stiffness may influence a practitioner's application of non-thrust manipulative techniques. Nine studies investigating the effects of manipulative techniques on spinal stiffness provide very limited evidence that there is no change in spinal stiffness following thrust or non-thrust manipulation in asymptomatic individuals and non-thrust techniques in symptomatic persons, with only one study supporting an immediate, but not sustained, stiffness decrease following thrust manipulation in symptomatic individuals.

CONCLUSIONS

The existing limited evidence does not support an association between spinal stiffness and manipulative treatment outcomes. There is a need for additional research investigating the effects of manipulation on spinal stiffness in persons with spinal pain.

Treatment of patients with degenerative cervical radiculopathy using a multimodal conservative approach in a geriatric population: a case series

STUDY DESIGN

Retrospective clinical case series.

OBJECTIVE

To describe the management of 10 patients with advanced cervical spondyloarthrosis with radiculopathy, using manual therapy, intermittent mechanical cervical traction, and home exercises.

BACKGROUND

Predictors and short-term outcomes of cervical radiculopathy have been published. These predictors have not been developed for, or applied to, geriatric patients with spondylitic radiculopathy.

CASE DESCRIPTION

A series of 10 patients (aged 67 to 82 years) were referred to a physical therapist for medically prediagnosed cervical spondyloarthrosis and radiculopathy, as determined by magnetic resonance imaging. Neck Disability Index (NDI), numeric pain rating scale (NPRS), upper limb tension testing, Spurling's test, and the cervical distraction test were all completed on each patient at initial examination and at discharge. NDI and NPRS data were also collected at 6 months posttreatment. Intervention included manual therapy (including high-velocity low-amplitude thrust manipulation) of the upper thoracic and cervical spine, intermittent mechanical cervical traction, and a home program (including deep cervical flexor strengthening) for 6 to 12 sessions over a period of 3 to 6 weeks.

OUTCOMES

All 10 patients had substantial improvement in NPRS and NDI scores. The mean NPRS score was less than 1/10, and the mean NDI score was 6/50 at discharge, compared to the original mean NPRS and NDI scores of 5.7 and 27.4, respectively. All patients reported maintaining those gains for 6 months.

DISCUSSION

A multimodal approach for patients diagnosed with cervical spondyloarthrosis with radicular symptoms was useful in this geriatric population to reduce pain, minimize radicular symptoms, and improve functional outcomes.

LEVEL OF EVIDENCE

Therapy, level 4.

Assessment of patients with neck pain: a review of definitions, selection criteria, and measurement tools

OBJECTIVE

The purpose of this literature review was to synthesize the existing literature on various definitions, classifications, selection criteria, and outcome measures used in different studies in patients with neck pain.

METHODS

A literature search of MEDLINE and CINAHL through September 2008 was performed to gather articles on the reliability, validity, and utility of a wide variety of outcome measurements for neck pain.

RESULTS

Different types of definitions appear in the literature based on anatomical location, etiology, severity, and duration of symptoms. Classifications according to severity and duration of pain and the establishment of selection criteria seem to play a crucial role in study designs and in clinical settings to ensure homogeneous groups and effective interventions. A series of objective tests and subjective self-report measures are useful in assessing physical abilities, pain, functional ability, psychosocial well-being, general health status, and quality of life in patients with neck pain. Self-administered questionnaires are commonly used in clinical practice and research projects.

CONCLUSIONS

Because of multidimensionality of chronic neck pain, more than just one index may be needed to gain a complete health profile of the patient with neck pain. The instruments chosen should be reliable, valid, and able to evaluate the effects of treatment.

Interrater reliability of palpation of myofascial trigger points in three shoulder muscles

This observational study included both asymptomatic subjects (n=8) and patients with unilateral or bilateral shoulder pain (n=32). Patient diagnoses provided by the referring medical physicians included subacromial impingement, rotator cuff disease, tendonitis, tendinopathy, and chronic subdeltoid-subacromial bursitis. Three raters bilaterally palpated the infraspinatus, the anterior deltoid, and the biceps brachii muscles for clinical characteristics of a total of 12 myofascial trigger points (MTrPs) as described by Simons et al. The raters were blinded to whether the shoulder of the subject was painful. In this study, the most reliable features of trigger points were the referred pain sensation and the jump sign. Percentage of pair-wise agreement (PA) was >/= 70% (range 63-93%) in all but 3 instances for the referred pain sensation. For the jump sign, PA was >/= 70% (range 67-77%) in 21 instances. Finding a nodule in a taut band (PA = 45-90%) and eliciting a local twitch response (PA = 33-100%) were shown to be least reliable. The best agreement about the presence or absence of MTrPs was found for the infraspinatus muscle (PA = 69-80%). This study provides preliminary evidence that MTrP palpation is a reliable and, therefore, potentially useful diagnostic tool in the diagnosis of myofascial pain in patients with non-traumatic shoulder pain.

Subclinical neck pain and the effects of cervical manipulation on elbow joint position sense

OBJECTIVE

The objectives of this study were to investigate whether elbow joint position sense (JPS) accuracy differs between participants with a history of subclinical neck pain (SCNP) and those with no neck complaints and to determine whether adjusting dysfunctional cervical segments in the SCNP group improves their JPS accuracy.

METHOD

Twenty-five SCNP participants and 18 control participants took part in this pre-post experimental study. Elbow JPS was measured using an electrogoniometer (MLTS700, ADInstruments, New Zealand). Participants reproduced a previously presented angle of the elbow joint with their neck in 4 positions: neutral, flexion, rotation, and combined flexion/rotation. The experimental intervention was high-velocity, low-amplitude cervical adjustments, and the control intervention was a 5-minute rest period. Group JPS data were compared, and it was assessed pre and post interventions using 3 parameters: absolute, constant, and variable errors.

RESULTS

At baseline, the control group was significantly better at reproducing the elbow target angle. The SCNP group's absolute error significantly improved after the cervical adjustments when the participants' heads were in the neutral and left-rotation positions. They displayed a significant overall decrease in variable error after the cervical adjustments. The control group participants' JPS accuracy was worse after the control intervention, with a significant overall effect in absolute and variable errors. No other significant effects were detected.

CONCLUSION

These results suggest that asymptomatic people with a history of SCNP have reduced elbow JPS accuracy compared to those with no history of any neck complaints. Furthermore, the results suggest that adjusting dysfunctional cervical segments in people with SCNP can improve their upper limb JPS accuracy.

The effects of spinal manipulation on central integration of dual somatosensory input observed after motor training: a crossover study

OBJECTIVE

This study sought to investigate the influence of spinal dysfunction and spinal manipulation on the response of the central nervous system to a motor training task.

METHODS

The dual peripheral nerve stimulation somatosensory evoked potential (SEP) ratio technique was used in 11 subjects before and after a 20-minute typing task and again when the typing task was preceded with cervical spine manipulation. Somatosensory evoked potentials were recorded after median and ulnar nerve stimulation at the wrist (1 millisecond square wave pulse, 2.47 Hz, 1x motor threshold). The SEP ratios were calculated for the N9, N11, N13, P14-18, N20-P25, and P22-N30 peak complexes from SEP amplitudes obtained from simultaneous median and ulnar (MU) stimulation divided by the arithmetic sum of SEPs obtained from individual stimulation of the median (M) and ulnar (U) nerves.

RESULTS

There was a significant increase in the MU/M+U ratio for both cortical (ie, N20-P25 and P22-N30) SEP components after the 20-minute repetitive contraction task. This did not occur when the motor training task was preceded with spinal manipulation. Instead, there was a significant decrease in the MU/M+U ratio for the cortical P22-N30 SEP component. The ratio changes appear to be due to changes in the ability to suppress the dual input as concurrent changes in the MU amplitudes were observed.

DISCUSSION

This study suggests that cervical spine manipulation not only alters cortical integration of dual somatosensory input but also alters the way the central nervous system responds to subsequent motor training tasks.

CONCLUSION

These findings may help to clarify the mechanisms responsible for the effective relief of pain and restoration of functional ability documented after spinal manipulation and the mechanism involved in the initiation of overuse injuries.

Altered central integration of dual somatosensory input after cervical spine manipulation

OBJECTIVE

The aim of the current study was to investigate changes in the intrinsic inhibitory interactions within the somatosensory system subsequent to a session of spinal manipulation of dysfunctional cervical joints.

METHOD

Dual peripheral nerve stimulation somatosensory evoked potential (SEP) ratio technique was used in 13 subjects with a history of reoccurring neck stiffness and/or neck pain but no acute symptoms at the time of the study. Somatosensory evoked potentials were recorded after median and ulnar nerve stimulation at the wrist (1 millisecond square wave pulse, 2.47 Hz, 1 x motor threshold). The SEP ratios were calculated for the N9, N11, N13, P14-18, N20-P25, and P22-N30 peak complexes from SEP amplitudes obtained from simultaneous median and ulnar (MU) stimulation divided by the arithmetic sum of SEPs obtained from individual stimulation of the median (M) and ulnar (U) nerves.

RESULTS

There was a significant decrease in the MU/M + U ratio for the cortical P22-N30 SEP component after chiropractic manipulation of the cervical spine. The P22-N30 cortical ratio change appears to be due to an increased ability to suppress the dual input as there was also a significant decrease in the amplitude of the MU recordings for the same cortical SEP peak (P22-N30) after the manipulations. No changes were observed after a control intervention.

CONCLUSION

This study suggests that cervical spine manipulation may alter cortical integration of dual somatosensory input. These findings may help to elucidate the mechanisms responsible for the effective relief of pain and restoration of functional ability documented after spinal manipulation treatment.

Reliability of manual examination and frequency of symptomatic cervical motion segment dysfunction in cervicogenic headache

This study investigated the reliability of manual examination procedures and the frequency that each or multiple segments in the upper cervical spine above the C4 vertebra were the dominant source of pain in subjects with cervicogenic headache (CGH). Eighty subjects were evaluated, 60 with CGH (39 females, mean age 33 years) and arbitrarily a further 20 asymptomatic subjects (13 females, mean age 34 years) included to reduce examiner bias, but subsequently omitted from data analysis. Two experienced physiotherapists examined on the same day each subject with standard manual examination procedures, independently rating each segment in the upper cervical spine above the C4 vertebra for involvement. Examiners were blind to each other's findings and the subject's clinical status. Standard and adjusted Kappa coefficients were calculated for each segment in symptomatic subjects only. Chi-squared analysis for goodness of fit was used to identify the segment that was most frequently determined the predominant symptomatic segment. Manual examination above the C4 vertebra showed good reliability. The C1/2 segment was most commonly symptomatic, with a positive finding at this segment in 63% of cases. The high frequency of C1/2 involvement in CGH highlights the importance of examination and treatment procedures for this motion segment.

Physical examination and self-reported pain outcomes from a randomized trial on chronic cervicogenic headache

OBJECTIVE

Objective clinical measures for use as surrogate markers of cervicogenic headache (CGH) pain have not been established. In this analysis, we investigate relationships between objective physical examination (PE) measures with self-reported CGH outcomes.

METHODS

This is an exploratory analysis of data generated by attention control PE from an open-label randomized clinical trial. Of 80 subjects, 40 were randomized to 8 treatments (spinal manipulative therapy or light massage control) and 8 PE over 8 weeks. The remaining subjects received no PE. Physical examination included motion palpation of the cervical and upper thoracic regions, active cervical range of motion (ROM) and associated pain, and algometric pain threshold evaluated over articular pillars. Self-reported outcomes included CGH and neck pain and disability, number of CGH headaches, and related disability days. Associations between PE and self-reported outcomes were evaluated using generalized linear models, adjusting for sociodemographic differences and study group.

RESULTS

At baseline, number of CGH and disability days were strongly associated with cervical active ROM (P < .001 to .037). Neck pain and disability were strongly associated with ROM-elicited pain (P < .001 to .035) but not later in the study. After the final treatment, pain thresholds were strongly associated with week 12 neck pain and disability and CGH disability and disability days (P < or = .001 to .048).

CONCLUSIONS

Cervical ROM was most associated with the baseline headache experience. However, 4 weeks after treatment, algometric pain thresholds were most associated. No one PE measure remained associated with the self-reported headache outcomes over time.

Reproducibility of global three-dimensional motion during manual atlanto-axial rotation mobilization: an in vitro study

The reproducibility of the three-dimensional (3D) kinematic aspects of motion coupling patterns during manual mobilizing techniques is still a debatable matter. The present in vitro study analysed segmental 3D motion of the atlanto-axial joint during manual axial rotation mobilization. Twenty fresh frozen human cervical specimens were studied in a test-retest situation with two examiners. The specimens were manually mobilized using three different techniques: (1) a regional mobilization technique of the cervical spine; (2) a segmental mobilization technique of the atlas with manual fixation of the axis; and (3) a segmental mobilization of the atlas on the axis applying a locking technique. Segmental atlanto-axial kinematics was registered with a Zebris CMS-20 ultrasound-based tracking system. The Euclidian norm was used as a representation of overall 3D motion. The results indicated good reproducibility (mean intraclass correlation coefficient, ICC: 0.87). Intraobserver reproducibility was slightly higher (mean ICC: 0.91; range: 0.76-0.99) than interobserver reproducibility (mean ICC: 0.85; range: 0.56-0.98) (P < 0.05). The total range of motion expressed as the Euclidean norm of 3D motion components was a parameter with good reproducibility in the study of segmental kinematics of manual atlanto-axial mobilization. Although previous studies have demonstrated poor inter-rater reliability of manual examination and mobilization of segmental motion components, the results of the present study shed a new and more positive light on the reproducibility of techniques for manual mobilization of the upper cervical spine.

Is it reasonable to use an individual patient's progress after treatment as a guide to ongoing clinical reasoning?

Systematic assessment of a patient's progress after an intervention is frequently used to inform decision making in ongoing conservative management of patients with musculoskeletal symptoms. Although reassessment of impairments immediately after treatment is commonplace in clinical practice, relatively little research has considered whether this method is reasonable. The history of, rationale behind, and evidence for the use of patient responses to inform clinical reasoning are explored in this commentary. Although the evidence is not conclusive, an argument is presented suggesting it is more reasonable to use a patient's response to treatment to inform ongoing clinical reasoning than to follow predetermined protocols. A methodical approach that considers change in parameters such as patient impairments is likely to be a useful guide for decision making during ongoing patient management but only when the change being reassessed can be directly linked to functional goals. Changes in active range of movement or centralization of pain appear to be better indicators of treatment effectiveness than changes in either pain intensity or assessment of joint position. There is limited evidence to support the use of changes in segmental stiffness to guide ongoing management. Although reassessment of some impairments has been found to be useful, the author suggests that care is required in the selection of reassessments used to guide ongoing management. The usefulness of any reassessment is considered to rely on how well a change in the selected impairment predicts that individual patient's ability to achieve their goals.

Interexaminer reliability of a leg length analysis procedure among novice and experienced practitioners

OBJECTIVE

The purpose of this study was to evaluate the interexaminer reliability of a leg length analysis protocol between an experienced chiropractor and an inexperienced chiropractic student who has undergone an intensive training program.

METHODS

Fifty participants, aged from 18 to 55 years, were recruited from the New Zealand College of Chiropractic teaching clinic. An experienced chiropractor and a final-year chiropractic student were the examiners. Participants were examined for leg length inequality in the prone straight leg and flexed knee positions by each of the examiners. The examiners were asked to record which leg appeared shorter in each position. Examiners were blinded to each other's findings. kappa statistics and percent agreement between examiners were used to assess interexaminer reliability.

RESULTS

kappa analysis revealed substantial interexaminer reliability in both leg positions and also substantial agreement when straight and flexed knee results were combined for each participant. kappa scores ranged from 0.61, with 72% agreement, for the combined positions to 0.70, with 87% agreement, for the extended knee position. All of the kappa statistics analyzed surpassed the minimal acceptable standard of 0.40 for a reliability trial such as this.

CONCLUSION

This study revealed good interexaminer reliability of all aspects of the leg length analysis protocol used in this study.

Cervicogenic dizziness – musculoskeletal findings before and after treatment and long-term outcome

PURPOSE

To explore musculoskeletal findings in patients with cervicogenic dizziness and how these findings relate to pain and dizziness. To study treatment effects and long-term symptom progress.

METHOD

Twenty-two patients (20 women, 2 men; mean age 37 years) with suspected cervicogenic dizziness underwent a structured physical examination before and after physiotherapy guided by the musculoskeletal findings. Questionnaires were sent to the patients six months and two years after treatment.

RESULTS

Dorsal neck muscle tenderness and tightness was found in a majority of the patients. Zygapophyseal joint tenderness was found at all cervical levels. Cervical range of motion was equal to or larger than expected age and gender matched values. The cervico-thoracic region was often hypomobile. Most patients had postural imbalance. Dynamic stabilization capacity was reduced. Suboccipital muscles tightness correlated with posture imbalance and poor neck stability. The treatment resulted in reduced tenderness in levator scapula, high and middle paraspinal and temporalis muscles and zygapophyseal joints at C4-C7 and increased cervico-thoracic mobility. Reduction of middle paraspinal muscle tenderness correlated with neck pain relief. Postural alignment improved, as did dynamic stabilization in trunk, neck and shoulders. After 6 months, 13 of the 17 patients had still no or less neck pain and 14 had no or less dizziness. After 2 years, 7 patients had no or less neck pain and 11 no or less dizziness.

CONCLUSION

Patients with suspected cervicogenic dizziness have some musculoskeletal findings in common. Treatment based on these findings reduces neck pain as well as dizziness long-term but some patients might need a maintenance strategy.

Characterization of acute and chronic whiplash-associated disorders

SYNOPSIS

The development of chronic pain and disability following whiplash injury is common and contributes substantially to personal and economic costs related with this condition. Emerging evidence demonstrates the clinical presence of alterations in the sensory and motor systems, including psychological distress in all individuals with a whiplash injury, regardless of recovery. However, individuals who transition to the chronic state present with a more complex clinical picture characterized by the presence of widespread sensory hypersensitivity, as well as significant posttraumatic stress reactions. Based on the diversity of the signs and symptoms experienced by individuals with a whiplash condition, clinicians must take into account the more readily observable/measurable differences in motor, sensory, and psychological dysfunction. The implications for the assessment and management of this condition are discussed. Further review into the pathomechanical, pathoanatomical, and pathophysiological features of the condition also will be discussed.

LEVEL OF EVIDENCE

Level 5.J