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

VOLUME 12 NUMBER 2 PAGES 85– 198 MAY 2007 Editors International Advisory Board Ann Moore PhD, GradDipPhys, FCSP, Cert...

Author: Editors: Ann Moore and Gwen Jull

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VOLUME 12 NUMBER 2 PAGES 85– 198 MAY 2007

Editors

International Advisory Board

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

K. Bennell (Victoria, Australia) K. Burton (Hudders¢eld, UK) B. Carstensen (Frederiksberg, Denmark) E. Cruz (Setubal Portugal) L. Danneels (Mar|¤ akerke, Belgium) S. Durrell (London, UK) S. Edmondston (Perth, Australia) J. Endresen (Flaktvei, Norway) L. Exelby (Biggleswade, UK) J. Greening (London, UK) C. J. Groen (Utrecht,The Netherlands) A. Gross (Hamilton, Canada) T. Hall (West Leederville, Australia) W. Hing (Auckland, New Zealand) M. Jones (Adelaide, Australia) S. King (Glamorgan, UK) B.W. Koes (Amsterdam,The Netherlands) J. Langendoen (Kempten, Germany) D. Lawrence (Davenport, IA, USA) D. Lee (Delta, Canada) R. Lee (Brighton, UK) C. Liebenson (Los Angeles, CA, USA) L. Ma¡ey-Ward (Calgary, Canada) E. Maheu (Quebec, Canada) C. McCarthy (Coventry, UK) J. McConnell (Northbridge, Australia) S. Mercer (Queensland, Australia) D. Newham (London, UK) J. Ng (Hung Hom, Hong Kong) L. Ombregt (Kanegem-Tielt, Belgium) N. Osbourne (Bournemouth, UK) M. Paatelma (Jyvaskyla, Finland) N. Petty (Eastbourne, UK) A. Pool-Goudzwaard (The Netherlands) M. Pope (Aberdeen, UK) G. Rankin (London, UK) D. Reid (Auckland, New Zealand) C. Shacklady (Manchester, UK) M. Shacklock (Adelaide, Australia) D. Shirley (Lidcombe, Australia) V. Smedmark (Stenhamra, Sweden) W. Smeets (Tongeren, Belgium) C. Snijders (Rotterdam,The Netherlands) R. Soames (Dundee, UK) P. Spencer (Barnstaple, UK) M. Sterling (St Lucia, Australia) P. Tehan (Victoria, Australia) M. Testa (Alassio, Italy) M. Uys (Tygerberg, South Africa) P. van Roy (Brussels, Belgium) B.Vicenzino (St Lucia, Australia) H.J.M.Von Piekartz (Wierden,The Netherlands) M.Wallin (Spanga, Sweden) M.Wessely(Paris, France) A.Wright (Perth, Australia) M. Zusman (Mount Lawley, Australia)

Gwendolen Jull PhD, MPhty, Grad Dip ManTher, FACP Department of Physiotherapy University of Queensland Brisbane QLD 4072, Australia Associate Editor’s Darren A. Rivett PhD, MAppSc, (ManipPhty) GradDipManTher, BAppSc (Phty) Discipline of Physiotherapy Faculty of Health The University of Newcastle Callaghan, NSW 2308, Australia Tim McClune D.O. Spinal Research Unit. University of Hudders¢eld 30 Queen Street Hudders¢eld HD12SP, UK Editorial Committee Masterclass Editor Karen Beeton PhD, MPhty, BSc(Hons), MCSP MACP ex o⁄cio member Associate Head of School (Professional Development) School of Health and Emergency Professions University of Hertfordshire College Lane Hat¢eld AL10 9AB, UK Case reports & Professional Issues Editor Je¡rey D. Boyling MSc, BPhty, GradDipAdvManTher, MCSP, MErgS Je¡rey Boyling Associates Broadway Chambers Hammersmith Broadway LondonW6 7AF, UK Book Review Editor Raymond Swinkels MSc, PT, MT Ulenpas 80 5655 JD Eindoven The Netherlands

Visit the journal website at http://www.intl.elsevierhealth.com/journals/math doi:10.1016/S1356-689X(07)00051-3

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Editorial

New year electronic resolutions! The Editorial Board of Manual Therapy Journal extends its best wishes to all our readers for 2007 and we are pleased you have joined us again for another year of Manual Therapy Journal publications. We are pleased to announce that as from January 2007 the journal’s manuscript submission and peer review process will all occur on-line. This should speed up our processes signiﬁcantly and we hope authors will be pleased with the new technology. Please visit the URL at www. ees.elsevier.com/ymath to submit an article. Readers will notice that our print issues have increased in page extent this year. This is to cater for the increasing number of manuscripts received over the last few years. The submissions last year were increased by 25%. All papers which are accepted for publication are published on-line on ScienceDirect www.sciencedirect. com as soon as editorial and publication processes are complete, in advance of compilation into a print issue, and are all given a digital object identiﬁer (doi) reference to aid citation. By citing the corresponding author name, article title, journal title, year of online publication (prior to print publication) and the doi, e.g. ‘‘Tempest, D., How to cite an online article. Journal of Learned Publishing, 2007, doi:10.1087/0953151052801460’’, the online article citation can be treated the same as a print publication citation. You will see for Manual Therapy that articles recently published online as Articles in Press have a footnote advising how to cite the online article, to

1356-689X/$ - see front matter r 2007 Published by Elsevier Ltd. doi:10.1016/j.math.2007.01.007

encourage citation of these articles even though they are not yet compiled in a print issue of the journal. The increase in journal page extent is to ensure that manuscripts are compiled into a print issue in as expedient a manner as possible to serve both our contributors and readers. In 2006, we celebrated an increase in our Journal Impact Factor which rose to 1.767 and also a change in our ranking in the Thomson Scientiﬁc rehabilitation journal collection. We are now third in the rehabilitation rankings. We owe our improved position to the quality of our authors’ contributions, the quality of our reviewers and their comments and the hard work of our industrious editorial and production teams and the support and engagement of all our readership. We would like to thank all who have contributed to the journal’s academic standing and the sustained success and hope you will all enjoy the improvements in Manual Therapy with its change to the electronic submission process.

(Co-Editors) Ann Moore, Gwen Jull Clinical Centre for Health Professions, University of Brighton, 49, Darley Road, Eastbourne BN20 7UR, UK E-mail address: [email protected] (A. Moore).

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Masterclass

Diagnosis and classiﬁcation of pelvic girdle pain disorders—Part 1: A mechanism based approach within a biopsychosocial framework Peter B. O’Sullivan, Darren J. Beales School of Physiotherapy, Curtin University of Technology, GPO Box U1987, Perth, WA 6845, Australia Received 20 February 2007; received in revised form 21 February 2007; accepted 21 February 2007

Abstract The diagnosis and classiﬁcation of pelvic girdle pain (PGP) disorders remains controversial despite a proliferation of research into this ﬁeld. The majority of PGP disorders have no identiﬁed pathoanatomical basis leaving a management vacuum. Diagnostic and treatment paradigms for PGP disorders exist although many of these approaches have limited validity and are uni-dimensional (i.e. biomechanical) in nature. Furthermore single approaches for the management of PGP fail to beneﬁt all. This highlights the possibility that ‘non-speciﬁc’ PGP disorders are represented by a number of sub-groups with different underlying pain mechanisms rather than a single entity. This paper examines the current knowledge and challenges some of the common beliefs regarding the sacroiliac joints and pelvic function. A hypothetical ‘mechanism based’ classiﬁcation system for PGP, based within a biopsychosocial framework is proposed. This has developed from a synthesis of the current evidence combined with the clinical observations of the authors. It recognises the presence of both speciﬁc and non-speciﬁc musculoskeletal PGP disorders. It acknowledges the complex and multifactorial nature of chronic PGP disorders and the potential of both the peripheral and central nervous system to promote and modulate pain. It is proposed that there is a large group of predominantly peripherally mediated PGP disorders which are associated with either ‘reduced’ or ‘excessive’ force closure of the pelvis, resulting in abnormal stresses on pain sensitive pelvic structures. It acknowledges that the interaction of psychosocial factors (such as passive coping strategies, faulty beliefs, anxiety and depression) in these pain disorders has the potential to promote pain and disability. It also acknowledges the complex interaction that hormonal factors may play in these pain disorders. This classiﬁcation model is ﬂexible and helps guide appropriate management of these disorders within a biopsychosocial framework. While the validity of this approach is emerging, further research is required. r 2007 Elsevier Ltd. All rights reserved. Keywords: Pelvic girdle pain; Sacroiliac joint; Classiﬁcation; Pain mechanisms; Motor control

1. Pelvic girdle pain disorders Pelvic girdle pain (PGP) disorders represent a small but signiﬁcant group of musculoskeletal pain disorders. Pain associated with the sacroiliac joints (SIJs) and/or the surrounding musculoskeletal and ligamentous structures represent a sub-group of these disorders. Specific inﬂammatory pain disorders of the SIJs, such as sacroiliitis, are the most readily identiﬁed PGP disorders Corresponding author. Tel.: 61 8 9266 3629; fax: 61 8 9266 3699.

E-mail address: [email protected] (P.B. O’Sullivan). 1356-689X/$ - see front matter r 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2007.02.001

(Maksymowych et al., 2005). However, PGP disorders more commonly present as ‘non-specific’ (no identiﬁed pathoanatomical basis), often arising during or shortly after pregnancy (Berg et al., 1988; Ostgaard et al., 1991; Bastiaanssen et al., 2005) or following traumatic injury to the pelvis (O’Sullivan et al., 2002a; Chou et al., 2004). Frequently these pain disorders are misdiagnosed and managed as lumbar spine disorders, as pain originating from the lumbar spine commonly refers to the SIJ region. However, there is growing evidence that PGP disorders manifest as a separate sub-group with a unique clinical presentation and the need for speciﬁc management.

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A number of PGP disorders do not resolve (Ostgaard et al., 1996; Larsen et al., 1999; Albert et al., 2001; Noren et al., 2002; To and Wong, 2003), becoming chronic despite the absence of pathoanatomical abnormalities on radiological examination or signs of a systemic or inﬂammatory disorder from blood screening (Hansen et al., 2005). This leads to a broad diagnosis of a ‘non-speciﬁc’ PGP disorder and leaves a diagnostic and management vacuum. These PGP disorders are commonly associated with signs and symptoms indicating that the pain originates from the SIJs and/or their surrounding connective tissue and myo-fascial structures (Berg et al., 1988; Kristiansson and Svardsudd, 1996; Mens et al., 1999; Albert et al., 2000; Damen et al., 2001; Vleeming et al., 2002; O’Sullivan et al., 2002a; Laslett et al., 2003). However, identiﬁcation of a painful structure does not provide insight into the underlying mechanism(s) that drives the pain (O’Sullivan, 2005a). A number of theoretical models have been proposed with regard to potential underlying pain mechanisms in PGP. Chiropractic, Osteopathic and Manual Therapy models commonly propose that the SIJs can become ‘ﬁxated’ or ‘displaced’ leading to positional faults. There are a series of complex clinical procedures proposed to identify these so-called ‘positional faults’ and treatment with manipulation, mobilisation and/or muscle energy techniques has been suggested to rectify them (DonTigny, 1990; Sandler, 1996; Kuchera, 1997; Oldreive, 1998; Cibulka, 2002). Although manual and manipulative techniques can result in short term pain modulation (Wright, 1995), there is little evidence for the long term beneﬁts of SIJ manipulation or other passive treatments used in isolation for the management of chronic PGP disorders (Stuge et al., 2003). The selection of these techniques is often directed by treating the signs and symptoms of the disorder rather than a valid and clear diagnostic and classiﬁcation paradigm based on the mechanisms that underlie the pain disorder. More recently emphasis has been placed on enhancing motor control deﬁcits in PGP disorders. This is based on the premise that deﬁcits in lumbo-pelvic motor control result in impaired load transference through the pelvis and thereby contribute to a peripheral nociceptive drive of symptoms (Mens et al., 1996; Vleeming et al., 1996, 1990b; O’Sullivan et al., 2002a; O’Sullivan and Beales, 2007). There is growing evidence based on outcome studies that some PGP disorders do indeed respond well to speciﬁcally targeted motor training interventions (Stuge et al., 2004a, b; O’Sullivan and Beales, 2007). However, not all PGP disorders respond to these interventions (Stuge et al., 2006). Relevant to this inconsistency in outcome, is the existence of different patterns of motor control impairments in PGP subjects. For instance increased pelvic ﬂoor activation has been documented in subjects with peripartum PGP consistent with SIJ involvement (Pool-Goudzwaard et al., 2005),

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while another group of subjects with SIJ pain (with a positive active straight leg raise test (ASLR)) demonstrate impaired control of the pelvic ﬂoor (O’Sullivan et al., 2002a; O’Sullivan and Beales, 2007). These ﬁndings highlight that; (i) there may be various underlying mechanisms that drive different PGP disorders, and (ii) the need for a classiﬁcation based approach which guides targeted interventions for sub-groups of subjects with PGP, which is based upon the underlying pain mechanism(s) that drives the disorder.

2. Challenging the beliefs regarding the sacroiliac joints and the pelvis The SIJ perhaps more than any other joint complex in the body has been shrouded by an enormous amount of mystique within the ﬁeld of Manual Therapy—with complex, poorly validated and often confusing theories and treatment approaches associated with it. Beliefs of the clinician (that the pelvis is ‘displaced’ or ‘unstable’) commonly become the beliefs of the patients. For many patients these clinical labels can be detrimental with the potential to render the patient passively dependent on someone to ‘ﬁx them’, elevating anxiety levels, reinforcing avoidance behaviours and promoting disability. Increased passive dependence and fear/anxiety has the potential to further increase the central drive of pain, contributing to disability and the chronic pain cycle. It is therefore important to be clear on the ‘facts’ regarding the SIJs and put them into the context of current knowledge. The basic anatomy, biomechanics and stability models proposed for the SIJ are documented elsewhere and as such will not be reviewed in full here (Pool-Goudzwaard et al., 1998; Lee and Vleeming, 2000; Vleeming et al., 2006). 2.1. The facts regarding the SIJs

The SIJs are inherently stable (Vleeming et al., 1990a, b; Snijders et al., 1993a). The joints are designed for load transfer (Kapandji, 1982; Gray and Williams, 1989) and can safely transfer enormous compressive loading forces under normal conditions (Snijders et al., 1993a). The SIJ has little movement in non-weight bearing (average 2.5 degrees rotation) (Sturesson et al., 1989; Brunner et al., 1991; Jacob and Kissling, 1995; Vleeming et al., 1992a, b), and even less in weight bearing (average 0.2 degrees rotation) (Sturesson et al., 2000). Movement of the SIJ cannot be reliably assessed by manual palpation, particularly in weight bearing (Sturesson et al., 2000; van der Wurff et al., 2000a, b). Due to its anatomical makeup, intra-articular displacements within the SIJs are unlikely to occur. No

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study utilising a valid measurement instrument has identiﬁed positional faults of the SIJ—in fact the converse is true (Tullberg et al., 1998). Distortions of the pelvis observed clinically are likely to occur secondary to changes in pelvic and trunk muscle activity, resulting in directional strain and not positional changes within the SIJs themselves (Tullberg et al., 1998). No study utilising a valid measurement tool has demonstrated that pelvic manipulation alters the position of the pelvic joints (Tullberg et al., 1998)— pain relief from these procedures is likely to result from nociceptive inhibition based on neuro-inhibitory factors and/or altered patterns of motor activity (Wright, 1995; Pickar, 2002). Asymmetrical laxity of the SIJs, as measured with Doppler imaging, has been shown to correlate with moderate to severe levels of symptoms in subjects with peripartum PGP (Damen et al., 2001). Generalised SIJ laxity is not associated with peripartum pelvic pain (Damen et al., 2001). When clinical signs of reduced force closure have been identiﬁed (positive ASLR), the increased movement is identiﬁed at the symphysis pubis—not the SIJs (Mens et al., 1999). It is likely that the torsional forces occurring at the SIJs can cause strain across pain sensitised tissue. Pain from the SIJ is located primarily over the joint (inferior sulcus) and may refer distally, but not to the low back (Fortin et al., 1994a, b; Schwarzer et al., 1995; Dreyfuss et al., 1996; Maigne et al., 1996; Slipman et al., 2000; Young et al., 2003; van der Wurff et al., 2006). SIJ pain disorders can be diagnosed using clinical examination (Laslett et al., 2003; Young et al., 2003; Petersen et al., 2004; Laslett et al., 2005a, b). This includes the ﬁnding of pain primarily located to the inferior sulcus of the SIJs, positive pain provocation tests for the SIJs and an absence of painful lumbar spine impairment. The SIJ has many muscles that act to compress and control it (force closure), thereby enhancing pelvic stability (creating stiffness) allowing for effective load transfer via the pelvis during a variety of functional tasks (Vleeming et al., 1990a, b, 1995; Snijders et al., 1993a, b; ; Snijders et al., 1998; Damen et al., 2002; Richardson et al., 2002; O’Sullivan et al., 2002a; Pool-Goudzwaard et al., 2004; van Wingerden et al., 2004; Mens et al., 2006; Snijders et al., 2006). PGP disorders may be associated with ‘excessive’ as well as ‘insufﬁcient’ motor activation of the lumbopelvic and surrounding musculature (O’Sullivan et al., 2002a; Hungerford et al., 2003; Pool-Goudzwaard et al., 2005; O’Sullivan and Beales, 2007).

3. Classiﬁcation of pelvic girdle pain disorders Chronic pain disorders are complex, multifactorial and need to be considered within a biopsychosocial framework. A different cluster of potential physical, pathoanatomical, psychosocial, hormonal and neurophysiological factors is associated with each disorder (Fig. 1). Needless to say the interactions between these factors are very complex. This highlights the need for a ﬂexible classiﬁcation and management approach for each disorder. Although the SIJs and the surrounding ligamentous and myofascial structures are potentially nociceptive structures (Fortin et al., 1994a, b; Vilensky et al., 2002), from a neurophysiologic perspective it is well known that ongoing pain can be mediated both peripherally and centrally, and the forebrain can greatly modulate this process (Zusman, 2002; Woolf, 2004). It is therefore logical that PGP disorders can potentially be both peripherally or centrally induced/maintained, with a different balance or dominance of peripheral and central factors associated with each disorder (Elvey and O’Sullivan, 2005). Furthermore with PGP there is the potential contributing role of sex hormones. There are a number of possible pathways by which hormones may inﬂuence PGP (Fig. 2). There is some evidence that sex hormones are active in pain modulation (Aloisi and Bonifazi, 2006). Sex hormones are also known to inﬂuence the inﬂammatory process in inﬂammatory pain disorders (Schmidt et al., 2006). Furthermore sex hormones may alter collagen synthesis (Kristiansson et al., 1999), thereby effecting the load capacity of the pelvis. There is some evidence to support the role of hormones in PGP disorders, with higher serum levels of progesterone and relaxin in early pregnancy being found in subjects who develop peripartum PGP compared to those who do not (Kristiansson et al., 1999). Via these processes sex hormones have the potential to contribute to PGP in different clinical presentations (Fig. 2). Further research is required to clarify how the role of hormones may differ in these various presentations of PGP. The proposed classiﬁcation model for PGP disorders is based on the potential mechanisms that can drive the PGP. This classiﬁcation approach is not exhaustive but rather provides a framework to guide the clinician. Based on the mechanism(s) that underlie these disorders and operating within a biopsychosocial framework, the classiﬁcation model aims to facilitate the diagnosis, classiﬁcation (Fig. 3), and targeted management of these disorders. 3.1. The clinical examination The clinical examination is critical to the clinical reasoning process that underpins this diagnosis and

- peripheral sensitisation - hormonal factors - central sensitisation - sympathetic nervous system activity - somatic complaints - glial cell activation

Neuro-physiological factors

Pain

Girdle

Pelvic

- mechanism of injury if present - disorder history (pregnancy related) - disorder stage − acute, sub-acute, chronic - area of pain − local / generalised / referred - pain behaviour − intermittent vs constant − provocative and relieving factors - mechanical vs non-mechanical provocation - +ve active straight leg raise - SIJ provocation tests - adaptive vs mal-adaptive movement behaviours - motor control impairments ( or motor activation) - disability levels - activity levels / conditioning / strength / muscle endurance - work / home environment / lifestyle - ergonomic factors

Physical factors

- structural pathology - ligamentous laxity - identification of peripheral pain generator (sacroiliac joint / pubic symphysis, myofascial / connective tissue)

Patho-anatomical factors

Fig. 1. Factors that need consideration within a biopsychosocial framework for the diagnosis and classiﬁcation of chronic pelvic girdle pain disorders.

- personality type - beliefs & attitudes towards pain disorder - coping strategies − passive vs active - hyper-vigilance - pacing - fear avoidance behaviour - emotions- fear / anxiety / depression / anger / helplessness - illness behaviour

Psychological factors

- relationships − family, friends, work - caring for children - work issues - medical advice and treatment - support structures - compensation (emotional, financial) - cultural factors - socio-economic factors - stress

Social factors

- potentially influencing all other domains

Genetic factors

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Medications

Altered Load Tolerance of Pelvic Ligamentous Structures

Altered Collagen Synthesis

Physical Stressors

Direct Modulation of Inflammatory Mediators

Toxins

Inflammatory Pain

Pregnancy

HORMONE LEVELS

Age

Central and/or Peripheral Sensitisation

Direct Modulation of Neural Excitability

Psychological Stressors Menstrual Cycle

Developmental Organisation of Central Nervous System

Genetics

Structural Basis Behavioural Basis Psychosocial Mechanisms

Fig. 2. Possible actions of hormones in the development and maintenance of pelvic girdle pain. Factors affecting hormone levels are also presented.

CHRONIC PELVIC GIRDLE PAIN DISORDERS

Specific pelvic pain disorders

- Specific inflammatory pain disorders (sacroiliitis) - Infections - Fractures

Non-specific inflammatory pain disorder

Non-specific pelvic pain disorders

Centrally mediated pelvic girdle pain

Non-dominant psycho-social factors

Dominant psycho-social factors

Peripherally mediated pelvic girdle pain (+/- cognitive / psychosocial factors resulting in central pain amplification)

Reduced force closure

Excessive force closure

- Medical management - Management advice

- Medical management - Functional rehabilitation

-Multi-disciplinary management Psychological (cognitive behavioural therapy), medical, functional rehabilitation

- Motor learning within cognitive framework (enhance force closure) - Functional restoration

- Motor learning within cognitive framework (reduce force closure / relaxation) - Functional restoration

Fig. 3. Mechanism based classiﬁcation and management of chronic pelvic girdle pain disorders.

classiﬁcation framework. In the interview process all the following need to be considered:

the pain area (localised versus generalised pain can indicate peripheral from central pain drive),

pain pattern (intermittent versus constant, 24 hour pain pattern, sleep disturbances), pain intensity, pain behaviour (speciﬁc movements and postures that provoke and relieve pain),

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levels of disability and impairment, speciﬁc pain history (speciﬁc and surrounding events that may have contributed to the development of symptoms), family history of PGP, the patient’s pain coping strategies (active versus passive coping), the patient’s pain beliefs, presence of avoidant behaviours due to fear of movement and other psychosocial factors including present and past history of anxiety and depression, pacing patterns and concurrent presence of disorders of continence and/ or sexual dysfunction.

Review of radiology if present and screening for speciﬁc causes of PGP may be indicated from this process. This allows for a determination as to the area and nature of the pain. A thorough physical examination is then required to determine the pain source and behaviour in relationship to the patient’s movement behaviour. Physical tests should include:

Palpation of the inferior sulcus of the SIJ and surrounding pelvic ligamentous and myo-fascial structures. Provocative tests for the SIJ and surrounding ligamentous and myofascial structures (Laslett et al., 2003, 2005a, b; Young et al., 2003; Petersen et al., 2004). The ASLR test in supine and prone as a test of load transfer, with a positive test resulting in normalisation of ASLR with the addition of pelvic compression (Mens et al., 1999; O’Sullivan and Beales, 2007). Careful analysis of the pain provoking and relieving activities and postures (functional impairments) highlighted from the interview to identify the presence of impairments of movement and motor control as well as avoidance behaviours and to determine their relationship to the pain disorder. Determining whether altered motor patterns are adaptive/protective (pain is aggravated when motor control patterns are normalised) or mal-adaptive (pain is relieved when motor control deﬁcits are normalised) is essential. Tests for speciﬁc muscle function for the pelvic ﬂoor, the abdominal wall, the back muscles, iliopsoas, quadratus lumborum, the gluteal muscles and piriformis.

In addition the adjacent areas of the lumbar spine (including neural tissue) and hip joints should be thoroughly investigated to rule out involvement of these

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areas or to assess for coexisting pathology/dysfunction in these regions. Correlating the patient’s reported pain behaviour, beliefs and levels of impairment with his/her clinical presentation (observing for avoidance behaviours, catastrophising, etc.) is important to determine whether cognitive issues such as fear of movement are present and dominant. On synthesis of this material a diagnosis and classiﬁcation of the PGP disorder can be made.

4. Speciﬁc pelvic girdle pain disorders Pelvic girdle pain disorders associated with specific pathological processes include inﬂammatory arthritis, sacroiliitis, infections and fractures. These disorders are amenable to speciﬁc diagnosis with appropriate blood screening and radiological investigation. They can be associated with altered patterns of motor control behaviour that are ‘adaptive’ and/or protective of the underlying disorder. Treating the signs and symptoms of these disorders by manual therapy and/or speciﬁc exercise interventions is generally not appropriate as it does not address the underlying pain mechanism of the disorder. Physiotherapy may be limited to management of the sequelae of the underlying disease/pathological processes especially in disorders such as ankylosing spondylitis.

5. Non-speciﬁc pelvic girdle pain disorders 5.1. Non-specific inflammatory pelvic girdle pain disorders There appears to be a group of PGP disorders that present as being inﬂammatory in nature, rather than mechanical. They are characterised by constant, disabling and non-remitting pain, located in the SIJs, that is provoked with weight bearing, pelvic compression (such as a SIJ belt) and with SIJ pain provocation tests. These disorders may show areas of increased uptake on bone scan but are not linked to a speciﬁc inﬂammatory disorder diagnosis based on blood screening. They may be relieved with rest, anti-inﬂammatory medications and local steroid injections to the SIJ, but are resistant to physical interventions. Although the exact underlying mechanism for these PGP disorders is unknown it is possible that hormonal factors play a role, particularly given their common onset in the ﬁrst trimester of pregnancy or pain modulation with hormonal cycles or changes. Although the role of sex hormones is purely speculative in this group of patients, further research into their effect is warranted.

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5.2. Peripherally mediated (mechanically induced) pelvic girdle pain disorders These disorders are characterised by localised pain that has a deﬁned anatomical location (SIJ and associated connective tissue and myofascial structures+/ symphysis pubis). The pain is intermittent in nature and is provoked and relieved by speciﬁc postures and activities related to vertical or directional loading in weight bearing positions. They are not usually asso-

Mal-adaptive chronic pelvic girdle pain disorders

ciated with spinal movement related pain and/or spinal movement impairment. A speciﬁc pain source at the SIJ and its surrounding structures can usually be identiﬁed by speciﬁc provocative manual tests (Laslett et al., 2003, 2005a, b; Young et al., 2003; Petersen et al., 2004). These disorders are usually associated with consistent local motor control changes (inhibition or excitation). These disorders usually have a clear mechanism or time of onset (either repeated strain or direct trauma to the pelvis or peripartum PGP). It is proposed that these

where motor control impairments

represent dominant underlying driving mechanism for pain

Tissue injury / localised pain

Motor response

Excessive force closure classification - hyper-activity of pelvic muscles with excessive joint compression

Factors that may influence pain and motor response

pathoanatomical ligamentous laxity physical motor control neurophysiological hormonal psychosocial coping strategies beliefs fear avoidance compensation genetic

Resolution of the disorder

Non resolution mal-adaptive patterns adopted poor coping strategies prolonged neuromuscular response excessive ↔ reduced force closure abnormal tissue loading

Management - education − regarding pain mechanism - identify factors that drive motor system - cognitive behavioural approach - relaxation of motor system - relaxation strategies - graded movement restoration - functional restoration - normalise movement behaviour

Reduced force closure classification - motor control deficit of pelvic stabilising muscles with loss of force closure

Management - education − regarding pain mechanism - cognitive behavioural motor control intervention - pain control (avoid provocation) - specific motor activation - retrain faulty postures and movements - normalise movement behaviour - functional restoration

Fig. 4. Sub-classiﬁcation of pelvic girdle pain disorders with a primary peripheral nociceptive drive. Peripheral drive is perpetuated by mal-adaptive motor control dysfunctions.

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disorders may be classiﬁed into two clinical subgroups (Fig. 4). 5.2.1. Reduced force closure The ﬁrst group represents disorders where the peripheral pain drive is associated with excessive strain to the sensitised SIJs and/or surrounding connective tissue and myofascial structures secondary to ligamentous laxity (Damen et al., 2001), coupled with motor control deficits of muscles that control force closure of the SIJs (O’Sullivan et al., 2002a; Hungerford et al., 2003; O’Sullivan and Beales, 2007). These motor control deﬁcits may have originally developed secondary to the pain disorder, but now their presence is mal-adaptive as the resultant ‘reduced forced closure’ leads to impaired load transfer through the pelvis, acting as a mechanism for ongoing strain and peripheral nociceptive drive for the pain disorder. Hormonal inﬂuences on collagen synthesis may be an important factor in this group. These disorders are commonly associated with postpartum PGP and present with a positive ASLR test (normalised with pelvic compression) (O’Sullivan et al., 2002a; Stuge et al., 2004a). The motor control deﬁcits that present in these disorders are variable and are linked to a loss of functional patterns of co-contraction of the local force closure muscles of the pelvis (such as the pelvic ﬂoor, the transverse abdominal wall, the lumbar multiﬁdus, iliopsoas and the gluteal muscles). This is commonly associated with attempts to stabilise the lumbopelvic region via co-activation of other trunk muscles (quadratus lumborum, thoracic erector spinae, diaphragm, external oblique, rectus abdominis and vertical ﬁbres of internal oblique). Their primary functional impairments are associated with pain in weight bearing postures such as sitting, standing and walking, or loaded activities inducing rotational pelvic strain associated with coupled spine/hip loading activities (i.e. cycling and rowing resulting in posterior rotational strain on ilium). These patients commonly assume postures that are associated with inhibition of the local pelvic muscles (pelvic ﬂoor, transverse abdominal wall, lumbar multiﬁdus and the gluteal muscles) such as ‘sway’ standing, ‘hanging off one leg’, ‘slump’ sitting or ‘thoracic upright’ sitting (O’Sullivan et al., 2002b, 2006; Dankaerts et al., 2006; Sapsford et al., 2006) and present with a loss of lumbopelvic control (inability to disassociate pelvic from thoracic movement). These disorders may be relieved with a SIJ belt (Ostgaard et al., 1994; Mens et al., 2006), training optimal alignment of their spino-pelvic posture and functional enhancement of local co-contraction strategies across the pelvis with relaxation of the thoracopelvic musculature (O’Sullivan and Beales, 2007). These disorders may gain short term relief from mobilisation, muscle energy techniques, soft tissue massage and manipulation of the SIJs (clinical observation) although

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these in isolation tend not to beneﬁt the long term outcome of the disorder. There is evidence that long lever exercise regimes may aggravate these disorders (Mens et al., 2000). These disorders can be further subgrouped based on their pattern of motor control dysfunction. Different combinations of motor control deﬁcits may be found within the local lumbopelvic muscles such as is observed in low back pain disorders that result in different directional (vertical, rotational) strain patterns within the pelvis (O’Sullivan, 2005b). Management of these disorders focuses on functionally enhancing force closure across the pelvic structures based on the speciﬁc motor control deﬁcits present. The aim of the intervention is to provide functional activation of the motor system in order to control pain and restore functional capacity (Fig. 4). There is good evidence to support the efﬁcacy of this type of approach in these disorders (Stuge et al., 2004a, b; O’Sullivan and Beales, 2007). 5.2.2. Excessive force closure The second group is deﬁned by a group of PGP disorders where the peripheral nociceptive drive is based on excessive, abnormal and sustained loading of sensitised pelvic structures (SIJs and surrounding connective tissue and/or myofascial structures) from the excessive activation of the motor system local to the pelvis (excessive force closure). This patient group presents with localised pain to the SIJs and commonly also the surrounding connective tissue and myo-fascial structures (such as the pelvic ﬂoor and piriformis muscles) as well as positive pain provocation tests. However this group of patients has a negative ASLR (no feeling of heaviness). Compression (manual or using a SIJ belt), is often provocative, as is local muscle activation (pelvic ﬂoor, transverse abdominal wall, back muscles, iliopsoas, gluteal muscles). They commonly hold habitual erect lordotic lumbopelvic postures associated with high levels of co-contraction across various muscles such as the abdominal wall, pelvic ﬂoor, local spinal muscles (lumbar multiﬁdus, psoas major) and in some cases the gluteal and piriformis muscles which may become pain sensitised. These motor control responses often become habitual secondary to excessive cognitive muscle training and/or muscle guarding of the lumbopelvic muscles, and are themselves mal-adaptive (provocative). These patients report pain relief from cardiovascular exercise, relaxation, assuming passive spinal postures (which they seldom do), as well as short-term relief with stretching, soft tissue massage, manipulation, muscle energy techniques and cessation of stabilisation exercises. These disorders are commonly associated with the patient’s belief that their pelvis is ‘unstable’ or ‘displaced’ and that more muscle contraction or ‘pelvic re-alignment’ is beneﬁcial. This is commonly reinforced by the treating therapist’s beliefs. These disorders may be induced by

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intensive ‘stabilisation exercises’, Pilates, ball exercise, and cognitive muscle exercise training of the abdominal wall, lumbar multiﬁdus and pelvic ﬂoor. Patients with these disorders are commonly anxious, under high levels of stress, highly active and seldom rest. Management of these disorders focuses on reducing force closure across the pelvic structures (Fig. 4). This is carried out with a combination of approaches such as: general as well as targeted relaxation strategies, breathing control, muscle inhibitory techniques, enhancing passive/relaxed spinal postures, pacing strategies, hydrotherapy, cessation of stabilisation exercise training, and a focus on cardiovascular exercise. Anecdotally this approach appears very effective although clinical studies are required to validate this. 5.2.3. Psychosocial influences on peripherally mediated pelvic girdle pain It is known that chronic pain and PGP disorders are commonly associated with not only physical but also psychosocial and cognitive impairments (Main and Watson, 1999; Bastiaenen et al., 2004, 2006; Linton, 2000, 2005) (Fig. 1). Even in the presence of a dominant peripheral nociceptive drive to PGP (such as described above), cognitive and psychosocial factors are invariably linked to these disorders inﬂuencing pain ampliﬁcation and disability levels to varying degrees. This highlights the need for a biopsychosocial (behavioural) approach to understanding and managing chronic PGP disorders even when they are peripherally mediated in nature. Psychosocial factors have the potential to both ‘up’ regulate or ‘down’ regulate pain. For example, a classiﬁcation of ‘reduced force closure’ may be associated with cognitive impairments such as faulty beliefs, elevated anxiety levels and passive coping strategies that ampliﬁes pain via the central nervous system and promotes high levels of disability associated with the pain disorder. In this case the intervention must address the cognitive impairments associated with the disorder within the motor learning intervention such as by promoting accurate beliefs, relaxation techniques and active coping strategies. On the other hand, if the same ‘reduced force closure’ classiﬁcation is associated with positive beliefs, active coping strategies and limited functional impairments, then the primary focus can be placed more on the physical impairments of the disorder to establish pain control. Similarly a classiﬁcation of ‘excessive force closure’ may be associated with underlying stress and anxiety. In this case dealing with these cognitive factors with relaxation, breathing strategies, pacing and cardiovascular exercise is a critical adjunct to the motor learning management of these disorders. Where the psychosocial/ cognitive components of the disorders are resistant to change, complementary psychological and/or medical intervention may be essential.

5.3. Central nervous system driven pelvic girdle pain disorders The mechanisms of central nervous system sensitisation and/or glial cell activation and their involvement in the maintenance of chronic pain states are well known (Woolf, 2004; Hansson, 2006), and may persist even once a peripheral nociceptive drive is removed or has resolved. In this way chronic PGP can be potentially mediated largely or entirely via the central nervous system. In these disorders, the pain may have initially presented as a peripherally driven disorder, but once chronic, the pain does not have a presentation consistent with a peripheral pain source. These pain disorders are commonly associated with widespread, severe, and constant pain that is non-mechanical in nature. They lack a speciﬁc detectable peripheral nociceptive drive or pathological basis and are commonly associated with widespread allodynia. These disorders are associated with high levels of physical impairment and social impact, and may be associated with widespread and inconsistent motor control disturbances and abnormal pain behaviours that are secondary to the pain state and do not clearly drive the pain disorder. These disorders are often associated with dominant psychosocial factors (somatisation, catastrophising, pathological fear and/or elevated anxiety, depression, as well as signiﬁcant social factors such as past history of sexual abuse etc). Although these disorders appear to represent a small sub-group of chronic PGP disorders, they are highly disabling and resistant to physical interventions. Management of these disorders must be multidisciplinary involving medical and psychological management as a primary approach. Functional rehabilitation should aim to enhance normal general body function and address abnormal pain behaviours without a focus on pain. Passive treatments and rehabilitation that focuses on speciﬁc muscle control strategies may simply act to reinforce abnormal pain behaviours and hyper-vigilance in these patients. 5.4. Genetics and pelvic girdle pain The role that genetics play with non-speciﬁc PGP disorders is largely unknown although its potential must be recognised. Subjects with PGP are more likely to have a mother or sister who also has PGP (Mogren and Pohjanen, 2005; Larsen et al., 1999) which may implicate a genetic link although social inﬂuences may also mediate this effect. A genetic predisposition in PGP patients related to changes in action of relaxin is proposed as one mechanism of genetic inﬂuence on PGP (MacLennan and MacLennan, 1997). Clearly further research into genetic inﬂuences is required.

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6. Summary This paper provides a broad clinical classiﬁcation model for the management of chronic PGP disorders. It is a ﬂexible, mechanism-based approach within a multifactorial biopsychosocial framework. The classiﬁcation model directs appropriate management based on the underlying mechanism/s that drives the pain. Although there is growing support for the validity of this approach, further research is required into this area.

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Review

Mulligan’s mobilization-with-movement, positional faults and pain relief: Current concepts from a critical review of literature Bill Vicenzino, Aatit Paungmali, Pamela Teys Division of Physiotherapy, The University of Queensland, St Lucia QLD 4072, Australia Received 30 September 2003; received in revised form 29 May 2006; accepted 3 July 2006

Abstract There are an increasing number of reports espousing the clinically beneﬁcial effects of Mulligan’s mobilization-with-movement (MWM) treatment techniques. The most frequent reported effect is that of an immediate and substantial pain reduction accompanied by improved function. Prompted by these dramatic effects are questions regarding the mechanism(s) of action that underpins MWM. It appears timely that a review of the current literature is performed to synthesize and evaluate claims of the effectiveness of MWM and speculation about the proposed mechanisms of action. This article provides an overview of the literature concerning the clinical efﬁcacy, effects and putative mechanisms of action of the MWM approach in the treatment of musculoskeletal conditions. The literature regarding the mechanisms of action in both the biomechanical and pain science paradigms is covered herein by reviewing all available scientiﬁc evidence from laboratory-based studies. Limitations of reported studies and directions for further research are also considered. r 2006 Elsevier Ltd. All rights reserved. Keywords: Mechanism(s); Mobilization-with-movement; Pain; Positional faults

1. Introduction Mulligan’s mobilization-with-movement (MWM) treatment techniques are gaining a reputation for use in musculoskeletal conditions, many of which have a reputation of being difﬁcult to treat and for which manual therapy is not traditionally used (e.g. lateral epicondylalgia, complicated De Quervain’s). MWM is a manual therapy treatment technique in which a manual force, usually in the form of a joint glide, is applied to a motion segment and sustained while a previously impaired action (e.g. painful reduced movement, painful muscle contraction) is performed. The technique is indicated if, during its application the Corresponding author. Musculoskeletal Pain and Injury Research Unit, Division of Physiotherapy, The University of Queensland, St Lucia QLD 4072, Australia. Tel.: +61 7 33652781; fax: +61 7 33652775. E-mail address: [email protected] (B. Vicenzino).

1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.07.012

technique enables the impaired joint to move freely without pain or impediment (Mulligan, 1993). The direction of the applied force (translation or rotation) is typically perpendicular to the plane of movement or impaired action and in some instances it is parallel to the treatment plane (Mulligan, 1992, 1993, 1996). Reports of clinical cases and case series have described the success of MWM in the management of various musculoskeletal conditions (Stephens, 1995; Vicenzino and Wright, 1995; Hetherington, 1996; O’Brien and Vicenzino, 1998; Miller, 2000; Exelby, 2001; Folk, 2001; Backstrom, 2002; Horton, 2002; Kochar and Dogra, 2002; Scaringe et al., 2002). This paper reviews the clinically based studies in order to develop an understanding of the current level of knowledge of the MWM approach and to provide a basis for future work in this area. Clinically based studies are deﬁned for the purpose of this paper as studies that follow a treatment program through to completion as opposed to studying the effects of a treatment technique at only one treatment session.

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The mechanism(s) by which the MWM exerts its ameliorative effects in clinical practice remains somewhat of an enigma. It has been proposed that the MWM treatment technique produces its effects by correcting positional faults of joints that occur following injuries or strains (Mulligan, 1993). This putative mechanism of action is in need of further evaluation, especially when considering the controversy generated by similar proposals for spinal manipulation, such as in chiropractic subluxation (LeBoeuf-Yde, 1998; Haldeman, 2000). The aim of this review was to critically evaluate the relevant current literature under two broad paradigms: the biomechanical and neurophysiological paradigms. Current concepts of the efﬁcacy and mechanism of action of MWM will be presented and directions for future research provided.

2. Methods The literature was accessed through computerized bibliographic medical and allied health databases (AMED, CINAHL, Cochrane library, EMBASE, MEDLINE and SPORT Discus). All available literature written in the English language was searched without restriction of the publication date (from databases’ inception to current issue, 02/2006). Relevant articles were identiﬁed by using the keywords ‘‘mobilization* or mobilization*’’ and ‘‘movement’’; ‘‘MWM’’; ‘‘SNAG’’ and ‘‘Mulligan’’. This search was complemented by an on-line library search (i.e. ScienceDirect), article citation tracking, and through correspondence with researchers in the ﬁeld. Due to the limited numbers of studies in this ﬁeld, articles in refereed journals were selected for inclusion if their reported data was based on a study of symptomatic subject(s) (e.g. case studies, case series, controlled clinical trial, randomized-controlled trial, randomized-controlled design with blinding procedures). Reports in dissertations, personal or anecdotal experience were excluded as it is considered to be the lowest hierarchy of evidence (NHMRC, 2000; Harbour and Miller, 2001). The results of search strategies revealed that publications in this topic area of MWM have appeared since 1992. A total of 45 non-overlapping journal articles were found. Of these, only 19 met the prespeciﬁed criteria and were included in this qualitative review. Two main categories of the MWM studies were explored; clinical-based studies (9) and laboratorybased studies (10). Two investigators reviewed these articles. We used a qualitative approach as we could only ﬁnd one randomized clinical trial. The majority of the studies to date are largely descriptive in nature. No systematic quantitative review was possible (NHMRC, 2000).

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3. Clinically based studies The clinical efﬁcacy of MWM techniques in the treatment of musculoskeletal conditions has attracted much interest recently. Kochar and Dogra (2002) conducted a quasi-randomized-clinical trial of MWM with ultrasound (US), US alone and a no treatment control on 66 subjects with lateral epicondylalgia (Table 1). Forty-six of the 66 cases were randomized into the two treatment groups (23 each group). The remaining 20 cases, who were unable to visit the hospital for therapy sessions, were included in the study as a non-randomized control group. Ten therapy sessions of the assigned treatment condition (i.e. MWM+US or US) were delivered within the ﬁrst 3 weeks and then followed up by a progressive exercise regime for a further 9 weeks. Four outcome measures (10 cm pain visual analogue scale (PVAS), grip strength, a weight lifting test, and patient self-assessment) were evaluated at baseline and then after weeks 1, 2, 3 and 12. The results showed that the MWM+US group was superior to the US group and that both interventions (MWM+US, US) were superior to control, which remained unchanged. At the ﬁnal outcome measurement session the MWM+US group demonstrated a 5.9 cm (97%) improvement in PVAS and an approximate 4.4 kg increase in weight lifted. The US group also showed improvements of 1.7 cm (29%) on PVAS and approximately 1.6 kg on weight lifted. The patient self-assessment scale improved signiﬁcantly with the MWM+US group but not the US and control groups, whereas changes in maximum grip strength were not signiﬁcantly different from the US group. Several methodological issues compromise the internal and external validity of the study of Kochar and Dogra (2002). The subjects were not randomly allocated to the control group, the demographics (e.g. attitude, socio-economic, health care) of the control group was therefore likely to be different from that of the treatment groups. Also, there were scant details about the baseline comparisons of the duration of the condition between the three groups prior to the commencement of the study. Apart from Kochar and Dogra (2002) all other studies of clinical efﬁcacy that we identiﬁed were case reports and case series (Table 1). Interestingly, the majority of these papers deal with upper limb injuries that are widely recognized as soft tissue disorders (e.g. De Quervain’s, ‘‘trigger thumb’’, lateral epicondylalgia). There were also two case studies describing the effects of sustained natural apophyseal glides (SNAG); a form of MWM applied to the spine (Mulligan, 1999). Folk (2001) described the use of MWM in a 39-yearold female who had injured her thumb during a fall on to her outstretched hand while rollerblading. The patient reported pain around the thumb with radiation across the hand dorsally to the medial side of the wrist

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Table 1 Clinical-based studies on efﬁcacy of mobilization-with-movement treatment techniques First author (year)

Design (N)

Condition Treatment(s)

Outcome Measures

Backstrom (2002)

Case study

De Quervain’s

Pain level

MWM (radial glide) at radio-carpal joint

Exelby (2001)

Folk (2001)

Hetherington (1996)

Case studies

Locked lumbar zygapophyseal joint

Horton (2002)

Kochar and Dochar (2002)

Minor discomfort

Case study

Post-traumatic (recalcitrant) thumb

Pain level

Internal rotation MWM at ﬁrst MCP joint

ROM

Ankle sprains

Pain level

Case study

Quasi-RCT N ¼ 66

O’Brien and Vicenzino (1998)

Pain level Lumbar PAIVM ROM Number of treatments

Case studies

N¼2

Pain level

T8/9 SNAG

Thoracic spine ROM

MWMLE (lateral glide) plus US or US alone for 3 weeks followed by 9 weeks of exercise were compared to control (no treatment) Lateral ankle sprains

Posterior glide distal ﬁbular MWM

Pain VAS

Other physiotherapy was also used; making it difﬁcult to delineate speciﬁc MWM effects.

Long-term follow up was

remained, PAIVM OO, and increase Lumbar ROM initially after treatment. ROM OO or minor discomfort EOR and 3 or fewer treatments required by discharge.

ROM OO initially after

not described in detail.

Juxtaposed the clear-cut

treatment and symptom free at 1, 8 and 52 weeks later.

Inversion OO and

guidelines of MWM (i.e. treatment only proceeds if there is a substantial reduction in pain and impairment) against a prior 10-month history of treatment by an MD, orthopaedic surgeon and OT with 3 different diagnoses.

Number of cases in the

observed balance improved initially after treatment.

Ankle inversion Observed balance

Locked thoracic zygapophyseal joint

Lateral epicondylalgia

Comments

level initially after treatment. Wrist/thumb ROM OO and ve Finklestein test on discharge and full function 12 months later.

L4/5 SNAG (posteroanterior with cephalad inclination)

Posterior glide distal ﬁbular MWM

25% improvement in pain

ROM Self-rated function level

N¼5

Case study

Results

95% improvement with

residual intermittent mild ache initially after treatment. ROM OO except for pain at EOR left Lateral Flexion a day later.

MWMLE plus US was better than US and control on all outcomes, except grip strength, which was only better than control.

Grip strength Weight lift Self-assessment score

Pain and function VAS Ankle ROM

1–4.5 cm reduction on

Kaikkonen functional

pain VAS and 2– 51inversion gain during application. Over the course of 5 weeks the Kaikkonen

study and long term follow up were not reported. Taping was added postMWM

Clinically reasoned that

SNAG was no longer required after 1 session as patient was better. No long-term follow-up. Taping was used after MWM

Control group was not randomised.

An immediate effect after treatment was not evaluated.

Included a short control period in one patient at the outset in order to cater for the anticipated rapid resolution of acute pain and impairment

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Table 1 (continued ) First author (year)

Design (N)

Condition Treatment(s)

Outcome Measures

Results

Scaringe et al. (2002)

Case study

Chronic shoulder, arm and neck pain Shoulder MWM: postero-lateral glide on humerus with scapular stabilization Spinal MWM with shoulder abduction (pressure on T4 spinous process) Cx spine manipulations

Vicenzino and Wright (1995)

Case study

Lateral epicondylalgia MWMLE (lateral glide) Self-treatments (selfMWM, stretching and strengthening exercises, elbow taping)

performance test Pain level

score signiﬁcantly improved (5.3–7.4 units/ day), which was greater than the natural rate of progression (i.e. 1.5 units/ day) Pain-free and full function Progression rates were greater than natural recovery

Initially after treatment:

Shoulder and Cx ROM Limited function

MWM increased abduction from 1051 to 1451 and spinal MWM further increased abduction to full ROM. After 2-weeks: abduction was OO, function 95%, and there was mild pain (3/10) after golﬁng. At 29 weeks postdischarge: Cx spine ROM was OO, function 100%, and there was minor discomfort (1–2/10) with golf

Pain and function VAS Pain-free function questionnaire PFG

Pain was reduced by

PPT

Full resolution 10 weeks

36%, and PFG increased by 200% initially after treatment. No improvement in baseline after ﬁrst 2 treatment sessions

Comments

following ankle sprain.

Comparison with the

actively treated patient, showed the MWM to exert superior effects to that of natural resolution. Tape was applied posttreatment.

Multiple techniques were

applied making it difﬁcult to delineate the speciﬁc effects of a certain treatment. Gliding directions for Spinal MWM were not described

Used A-B-C study design

(modiﬁed A-B-A design) with within-subject baseline comparisons. Tape, self MWM and exercises were used following MWMLE as a home programme of physical treatment

after discharge (i.e. full function, restored grip strength and 230% improvement in PPT) Abbreviation: OO (double ticks), pain-free full range of motion; Cx, cervical; EOR, end of range; L, lumbar; MCP, metacarpophalangeal; MWM, mobilization-with-movement; MWMLE, mobilization-with-movement for lateral epicondylalgia; N, number of subjects; PAIVM, passive accessory intervertebral movements; PFG, pain-free grip force; PPT, pressure pain threshold; ROM, range of motion; SNAG, sustained natural apophyseal glide; US, ultrasound; VAS, visual analogue scale.

and forearm. No bony injury was seen on X-ray. Prior to presentation to physical therapy, the patient underwent numerous interventions, including rest, splinting, corticosteriod injections, and at approximately 6 months post-injury, surgery. The physical therapist was consulted 6 weeks after surgery. Physical examination of the thumb found that overpressure into extension of the

ﬁrst metacarpophalangeal (MCP) joint produced pain. A sustained internal rotation of the ﬁrst proximal phalanx about its longitudinal axis with manual ﬁxation of the ﬁrst metacarpal bone abolished the pain and allowed the patient to move into full pain-free extension. This manoeuvre was then applied as a MWM for 2 sets of 10 after which post-treatment assessment revealed full

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pain-free range of extension at the MCP, which was maintained at the 1 year follow-up. Folk (2001) speculated that the MCP joint dysfunction following the injury might have manifested as a positional fault that lead to the patient’s symptoms and that the MWM reduced the positional fault. Backstrom (2002) reported a case study of a 61-yearold woman with a 2-month history of trauma-induced stiffness, pain and limited function of the thumb and hand during activities such as grooming, brushing, and washing. Radiographs at 6 weeks revealed no fractures. All motions of the right wrist, carpals and ﬁrst carpometacarpal joints were limited and pain was elicited on contraction of the right extensor pollicis brevis and abductor pollicis longus. There was a positive Finklestein test. A MWM, which consisted of a sustained radial glide of the proximal row of carpal bones allowed full thumb and wrist motion to occur painlessly. Following the ﬁrst treatment session, which included 3 sets of 10 repetitions, there was a 25% improvement in PVAS. A total of 12 treatment sessions over a 2-month period resulted in complete resolution of the condition, which was maintained throughout the following year. Although the author ascribed much of the success in outcomes to the MWM, the inclusion of many other treatments (e.g. elastic support, carpal mobilization, massage, iontophoresis and exercises) may have compromised this assertion. Vicenzino and Wright (1995) reported a single case study of MWM treatment for lateral epicondylalgia (MWMLE) in a 39-year-old female with a 3-month history of lateral epicondylalgia. The patient had previously attended 6 sessions of therapy consisting of massage, ice, LASER, electrical stimulation, stretching and gripping exercise over a 5-week period, without any progress. The MWMLE was applied for 6 repetitions per treatment session during 4 sessions over a 2-week period. The patient’s elbow was taped following treatment, and she performed self-MWMLE and exercises involving stretching and gripping within pain limits as a home programme. Sustained and signiﬁcant changes in pain-free-grip force (PFG), PVAS and function occurred during the treatment phase of the trial when compared to baseline data (2 weeks of data collected pre-treatment). The improvement was maintained during the 6-week post-treatment phase. No symptoms of elbow discomfort were demonstrated following the treatment phase as evaluated by the pain-free function questionnaire. The reduction in pain during the course of the study occurred more rapidly than the increase in function prompting the authors to speculate that the mechanism of action of this MWM technique and associated home programme of taping, exercises and self-MWM may be primarily related to its direct effect on pain (Vicenzino and Wright, 1995).

O’Brien and Vicenzino (1998) investigated the effect of a MWM for lateral ankle pain in 2 male patients following acute ankle sprain (2–3 days post-injury) using a single subject design. Subject I underwent an ABAC protocol while subject II underwent a BABC protocol, where ‘‘A’’ ¼ no intervention period, ‘‘B’’ ¼ intervention period, and ‘‘C’’ ¼ post-treatment return to sport period. The MWM treatment technique involved a sustained posterior glide with cephalad inclination to the distal ﬁbula, while the patient actively inverted the ankle to the end of pain-free range with overpressure. Following treatment a strapping tape was applied to replicate the effects of the posterior glide of the ﬁbula. The MWM produced immediate improvements in pain, range of motion and function within each treatment session, which accumulated over several (4) treatment sessions and was far greater than the natural resolution over time as observed in the ‘‘A’’ phase of subject 1. The authors speculated that the results may reﬂect the reduction of a positional fault at the inferior tibioﬁbular joint. SNAG techniques are also used in the treatment of spinal musculoskeletal conditions with as many as 41% of British therapists’ who treat low back pain reporting their use (Konstantinou et al., 2002). Exelby (2001) reported success following a MWM treatment of a clinically diagnosed locked lumbar facet joint syndrome. A 46-year-old female presented to physiotherapy 3 days after experiencing a sharp pain in the lower lumbar region whilst returning from a ﬂexed position after performing arm curls with a barbell in a ﬂexed lumbar spine position. Physical examination revealed a ﬂexed lower lumbar spine and lordotic (extended) upper lumbar spine with all active movements limited to a quarter range by pain. Treatment included a SNAG consisting of a central sustained glide of the L4 spinous process while the patient ﬁrst performed repeated ﬂexion followed by repeated extension in lying. A further four case studies were also reported. Long-term effects of the treatment were not reported. Horton (2002) also reported success in treating an acute locked thoracic joint with a modiﬁed SNAG. The case involved a 20-year-old male university student who presented with acute left-sided thoracic pain adjacent to the T8/9 inter-vertebral joint following an incident the previous night when his friend had picked him up and shaken him in a bear hug manoeuvre. Initial examination revealed that he had a constant dull ache over the left thoracic spine and was locked in a position of forward and right side ﬂexion such that he needed to support himself on his right hand. Any attempt to extend, ﬂex to the left or rotate produced acute severe pain. Pain and resistance to displacement was elicited on palpation of the left T8/9 zygapophyseal joint. The initial treatment involved a central SNAG applied in a cephalad direction on the spinous process of T8 while

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supporting the patient’s trunk and assisting him to move into an upright posture. This procedure, performed pain-free, was repeated another three times until the patient was able to sit upright independently with only a mild ache. Tape was applied to provide further support. On the second visit the patient reported a 95% improvement and had maintained an upright posture. Examination of range of movement revealed only a slight restriction in lateral ﬂexion to the left and slight tenderness over the left T8/9 area. The biomechanical explanation for the clinical presentation was that of a locked T8/9 zygapophyseal joint in which there was compromise of a meniscoid structure (Bogduk and Jull, 1984; Singer et al., 1990). Horton (2002) postulated that the SNAG could be likened to a longitudinal distraction, which may have been sufﬁcient to release the trapped meniscoid, allowing it to re-enter the joint space. Scaringe et al. (2002) reported a case in which manual therapy was employed in a 50-year-old male golfer who presented with a 3 year history of intermittent pain (4/ 10–8/10) over the left shoulder, upper trapezius, medial border of scapula, postero-lateral aspect of the arm and forearm. The pain increased in severity with arm movements. Shoulder range of motion (abduction) and function was restricted by 20–30%. Two MWM treatment techniques were used: one a postero-lateral glide of the humeral head while the scapula was stabilized, and two a spinal mobilization with arm movement for the T4 spinal segment. Additionally, chiropractic manipulation to the cervical spine was also used. There were a total of 3 treatment sessions over a 6week period (Table 1). The authors reported that a signiﬁcant improvement was observed immediately after the ﬁrst treatment and that telephone and fax follow-up at 29 weeks revealed full function with only occasional minor shoulder pain (1/10–2/10). Although only a manual therapy approach was used in treating this patient, the combination of various forms of different manual treatment applications make it difﬁcult to differentiate the speciﬁc therapeutic effect of any one individual treatment. In summary, the level of evidence for the clinical efﬁcacy of MWM treatments is presently low, consisting in the main of case reports. Further studies, such as randomized clinical trials, are required to substantiate or refute the positive claims from these preliminary reports. Many authors speculate about the underlying mechanism of action of MWM techniques with a tendency to conceptualize this as one of reducing positional faults at joints (subluxations). While randomized clinical trials will provide evidence of clinical efﬁcaciousness, they will not address the issue of the underlying mechanism of action of MWM techniques. Questions regarding mechanism(s) of action are best answered in laboratory studies (Vicenzino and Wright, 2002).

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4. Laboratory-based studies: biomechanics It has been hypothesized that MWM reduces minor positional faults at joints (Mulligan, 1993; Exelby, 1995; Exelby, 1996; Hetherington, 1996; O’Brien and Vicenzino, 1998; Kavanagh, 1999; Mulligan, 1999; Exelby, 2001; Folk, 2001; Backstrom, 2002). This hypothesized mechanism of action is based on a premise that a minor positional fault results following joint injury (Hubbard et al., 2006) and that these faults are largely responsible for the pain and observed limitation of movement (Mulligan, 1999; Folk, 2001; Backstrom, 2002). Although many authors, putatively ascribe their observations of beneﬁcial clinical effects to the correction of bony positional faults (O’Brien and Vicenzino, 1998; Exelby, 2001; Folk, 2001; Backstrom, 2002; Collins et al., 2004), few studies have directly evaluated this proposal (Kavanagh, 1999; Hsieh et al., 2002) (Table 2). The positional fault hypothesis for MWM has been described by reference to plantarﬂexion-inversion sprain injury of the ankle (Hetherington, 1996; Mulligan, 1999). Mulligan (1999) hypothesized that the distal ﬁbula subluxes anteriorly and caudally during plantarﬂexion-inversion injury of the ankle and Hetherington (1996) has proposed that the subsequent effusion and adhesions maintain this positional fault at the inferior tibio-ﬁbular joint. There is preliminary evidence of radiographic positional faults in chronic ankle sprains that supports this hypothesis (Hubbard et al., 2006). Protagonists of this positional fault hypothesis argue that it is validated by the dramatic improvement in painfree range of inversion that is brought about by the antero-posterior glide MWM technique on the distal ﬁbula (Hetherington, 1996; O’Brien and Vicenzino, 1998). However, this evidence is based on measures of pain, range of motion and function, not of bone position. There is one exception to this trend. It is a study by Kavanagh (1999) who attempted to measure change in bone position with application of the anteroposterior glide MWM of the inferior tibio-ﬁbular joint in 25 subjects (17 normals, 2 chronic ankle sprains, and 6 acute ankle sprains). In brief, the set up was such that the foot to be tested was placed in standardized position with the posterior heel supported on a wooden block and the posterior surface of each of the malleoli resting on potentiometers. The posterior displacement that occurred at the distal ﬁbula during the MWM was recorded and plotted against the applied force, thus describing the force–displacement relationship for this technique. The author claimed that the data supported the proposal of anterior-caudal positional fault of the inferior tibio-ﬁbular joint in ankle sprain patients, despite a P-level of 0.15 when comparing the treatment effect in the acute ankle sprain group to the normal and chronic sprained ankle groups. The author argued that the data from 2 of the 6 acute ankle sprains that

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Table 2 Laboratory-based studies of MWM in which the biomechanical and pain effects were measured immediately after the treatment was applied, unless otherwise stated in the results and comments Authors (year)

Biomechanics Collins et al. (2004)

Hsieh et al. (2002)

Design and N

Condition and treatment

Outcome measures

Double blind, cross-over, RCT with placebo

Subacute, grade II lateral ankle ligament sprain.

Ankle dorsiﬂexion

N ¼ 14

Weight-bearing MWM of talocrural joint (tibial PA glide)

Case study

Post-traumatic thumb injury. MWM (external rotation) at MCP joint of the thumb.

PPT TPT

MRI

Results

MWM signiﬁcantly

Pain Science Abbott (2001)

Abbott et al. (2001)

McLean et al. (2002)

quasiexperimental design

Acute (N ¼ 6) and chronic (N ¼ 12) ankle sprain

N ¼ 25

Normal (N ¼ 17) MWM (posterior glide) at distal ﬁbular

Case series

Lateral epicondylalgia

N ¼ 23

MWMLE (lateral glide)

Case series

Lateral epicondylalgia

N ¼ 23

Although a correction of

improved ankle dorsiﬂexion greater than placebo and control. No signiﬁcant changes in PPT and TPT following the MWM, but a small change in PPT with placebo.

positional fault was hypothesized as being responsible for the observed change in dorsiﬂexion; bony position was not measured.

MRI revealed 41 pronated

Identiﬁed a positional

Pain VAS Thumb ROM Grip strength

Kavanagh (1999)

Comments

positional fault of MCP joint before treatment, which was not present with MWM in situ. Full pain-free ROM initially with MWM in place, after 4 weeks treatment and ondischarge. Repeat MRI after discharge revealed no change from pretreatment.

fault on MRI, which was reversed during the application of the MWM, but not after discharge; despite full resolution of the thumb pain and impairment.

Force– displacement relationship of distal ﬁbular

2 out of 6 of the acutely

Shoulder ROM (IR and ER)

Deﬁcit in Shoulder ROM

Elbow treatment resulted

pre-treatment was reduced after treatment of the elbow.

in a change in shoulder ROM; suggesting that MWMLE evokes more than local mechanisms at the elbow.

PFG

PFG and maximum grip

MWMLE (lateral glide)

Maximum grip strength

Randomized, cross-over design

Lateral epicondylalgia

Level of force applied by a MWMLE

N¼6

MWMLE (lateral glide)

sprained ankles showed a greater amount of movement per unit force than normal.

strength increased signiﬁcantly (17% and 5%, respectively).

Force level of 2.5 N/cm

PFG

(66% of therapist rated maximum force) increased PFG signiﬁcantly when compared to lower force levels. Higher levels of applied force did not improve the PFG any further.

Conclusion relied on the data of 2 cases.

MWM-effect on pain and ROM was not reported.

Only cases that responded

to the MWMLE were included in the study. Showed that the hypoalgesic effect was related to the inclination of the MWMLE in the transverse plane.

Preliminary evidence that the hypo-algesic effect of MWMLE depends on the amount of applied manual force.

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Table 2 (continued ) Authors (year)

Design and N

Condition and treatment

Outcome measures

Paungmali et al. (2003a)

Double blind, cross-over, RCT with placebo

Lateral epicondylalgia

PFG

N ¼ 24

MWMLE (lateral glide)

Paungmali et al. (2004)

Paungmali et al. (2003b)

Vicenzino et al. (2001)

Results

Increase PFG (48%) and

PPT TPT HR and BP Sudomotor and vasomotor function PFG

PPT (15%), which were greater than placebo and control. Sympatho-excitation also occurred concurrently.

Pain relieving effects

Double blind, cross-over, RCT with placebo

Lateral epicondylalgia

N ¼ 18

Naloxone, Saline and Control delivered prior to the MWMLE (lateral glide)

PPT TPT ULTT2b

Repeated measure design

Lateral epicondylalgia

PFG

Magnitude of

N ¼ 24

MWMLE (lateral glide)

PPT

improvement in PFG and PPT was not reduced with repeated applications of MWMLE over 6 successive sessions.

Double blind, cross-over, RCT with placebo N ¼ 24

Lateral epicondylalgia

PFG

Increase PFG (46%) and

MWMLE (lateral glide)

PPT

produced by the MWMLE were not antagonized by Naloxone. Changes in outcome measures were not different from placebo and control conditions.

PPT (10%), which were greater than placebo and control conditions. No such changes occurred when the asymptomatic elbow was treated.

Comments

This study investigated a

possible physiological effect of MWMLE, which was previously proposed for spinal manipulation. Only short-term (immediate) effects were evaluated.

This is consistent with an

endogenous non-opioid analgesia. Later effects were not studied and so cannot discount a possible latent effect of endogenous opioid peptides

Interpreted as supporting an endogenous nonopioid mechanisms of MWMLE-induced hypoalgesia.

The MWMLE effect appears to be speciﬁc to the symptomatic elbow and to the sensory modality by which it is measured.

Abbreviation: PA, postero-anterior; BP, blood pressure; ER, external rotation; HR, heart rate; IR, internal rotation; MCP, metacarpo-phalangeal; MRI, magnetic resonance imaging; MWM, mobilization-with-movement; MWMLE, mobilization-with-movement for lateral epicondylalgia; N, number of subjects; PFG, pain-free grip force; PPT, pressure pain threshold; RCT, randomized clinical/control trial; ROM, range of motion; TPT, thermal pain threshold; ULTT2b, upper limb neural tissue provocation test 2b; VAS, visual analogue scale.

demonstrated greater posterior movement (displacement) per unit force was sufﬁcient to support the positional fault hypothesis. This study did not report the effects of the MWM on pain, a critical omission for a technique that is strongly focused on pain alleviation. A recent case study utilized magnetic resonance imaging (MRI) to evaluate the positional fault hypothesis in a 79-year-old female who injured her right thumb (hyperabduction of the MCP joint) during a fall with an umbrella in her right hand (Hsieh et al., 2002). One month after the injury the intensity of pain during function was 6 on a 10-point VAS. MRI examination showed the proximal phalanx of the right thumb to be 41 pronated compared to the left thumb (i.e. position fault) and that this was corrected with a supination MWM of the proximal phalanx while the patient ﬂexed the MCP

joint to full range without pain. A course of such MWM treatment (including self-MWM) was then commenced. After 3 weeks of treatment, the patient reported that her right thumb was much improved. A further MRI evaluation was then performed. It showed that there was no change to the initial positional fault even though the patient was now symptom free. This ﬁnding implies that although MWM techniques may alter positional faults during their application, the long-term pain relieving effects are independent of permanent changes in the positional fault. On the basis of this case it would appear that the longer-term effect of MWM may occur via other mechanisms. Collins et al. (2004) cited ﬁndings from their randomized placebo-controlled trial of 14 subacute ankle sprains as evidence of a predominantly mechanical

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basis that underpins the initial clinical efﬁcacy of MWM (Table 2). Ankle dorsiﬂexion but not pain threshold (pressure and thermal) was signiﬁcantly greater immediately after the application of a MWM that consisted of a postero-anterior gliding technique of the tibia (i.e. a relative antero-posterior glide of talus) performed in a functional weight bearing position (Collins et al., 2004). In summary, currently there is no substantive evidence that supports or refutes the hypothesis that a reversal of a positional fault is the predominant mechanism of action for MWM, although improvements in range of motion have been shown. Further work is urgently required in addressing this issue.

5. Laboratory-based studies: pain science The initial pain relieving effects of the MWMLE has been demonstrated in several studies (Abbott, 2001; Abbott et al., 2001; Vicenzino et al., 2001; McLean et al., 2002; Paungmali et al., 2003; Hubbard et al., 2006) (Table 2). Abbott et al., (2001) evaluated the effect of a MWMLE in 23 patients by measuring PFG and maximum grip strength before and after a single session of 10 repetitions of the technique. PFG improved by 17% following the MWMLE compared to a 5% increase in maximum grip strength, thereby, conﬁrming ﬁndings by Stratford et al. (Stratford et al., 1993) that PFG is more sensitive in detecting clinical change. This study supports the pain ameliorative properties of MWMLE reported in other studies using similar outcome measures (Vicenzino and Wright, 1995; Vicenzino et al., 2001; Kochar and Dogra, 2002; McLean et al., 2002; Paungmali et al., 2003a). However, no control or placebo groups were included in this study, limiting its internal validity. Abbott (2001) has also measured shoulder range of motion after the application of a MWMLE. At entry into the study subjects had signiﬁcant reduction in shoulder external rotation range of motion on the affected side when compared to the unaffected side. This deﬁcit was ameliorated after completion of the MWMLE treatment session, prompting Abbott (2001) to postulate that the technique may act neurophysiologically to decrease the level of contractile activity of the shoulder rotator muscles. This interpretation of the data should be construed with caution because it did not account for factors such as shoulder positioning during treatment and testing (Boon and Smith, 2000), as well as potential effects of muscular effort overﬂow to the shoulder during maximum grip strength testing (especially on the unaffected side) (Nelson and Cornelius, 1991). The inclusion of a no treatment control condition may have accounted for these factors (Bordens and Abbott, 1996). A fundamental tenet of manual therapy (including MWM) is that the application of treatment requires

precise and speciﬁc application of manual forces to the target motion segments (Maitland, 1991). Abbott et al. (2001) demonstrated that the majority of the 23 subjects with lateral epicondylalgia responded to the lateral glide component of the MWMLE when it was inclined 51 posterior to the frontal plane or when directed purely laterally, but not when directed 51 anterior to the frontal plane. McLean et al. (2002) in a study of the manual force levels applied during the MWMLE in 6 subjects (4 female, 2 male) showed that manual force levels of approximately 75N (95% conﬁdence interval (95 CI): 62–87 N) improved PFG signiﬁcantly when compared to lower mean force levels (e.g. 37–56 N) and that a maximum force level of 113 N did not provide any better effect. The 75 N force level equated to approximately 66% of the maximum force that the therapist was prepared to apply to the unaffected side. It would appear that there is an optimal force (McLean et al., 2002) and direction of force (Abbott et al., 2001) that is necessary in bringing about the initial effect. Several studies further evaluated the initial pain relieving effect of the MWMLE technique for lateral epicondylalgia using a randomized, controlled, repeated measures study design (Vicenzino et al., 2001; Paungmali et al., 2003a). The results demonstrated an immediate and substantial increase in PFG in the order of 46–48% following treatment, which was signiﬁcantly greater than placebo and control (no treatment). Pressure pain threshold (PPT) improved approximately 10% under the treatment condition, which was signiﬁcantly greater than placebo and control. A drawback of these studies is the lack of long-term follow-up. Nonetheless, there are two interesting characteristics of the initial effect of the MWMLE that have become apparent from this research. The ﬁrst is that the MWMLE favours improvements in PFG over changes in PPT deﬁcits, indicating it is speciﬁc in its effects (Vicenzino et al., 2001; Paungmali et al., 2003a). The second characteristic is that the treatment technique when applied to asymptomatic elbows does not produce changes in PFG or PPT, implying that the presence of symptoms and dysfunction is an important precondition of MWMLE (Vicenzino et al., 2001). Recent work in our laboratory has further evaluated characteristics of the hypoalgesic effect of MWMLE (Paungmali et al., 2003; Paungmali et al., 2003a; Paungmali et al., 2004). The data indicate that the MWMLE produces a hypoalgesia and concurrent sympathoexcitation (indicated by changes in heart rate, blood pressure, and cutaneous sudomotor and vasomotor function) (Paungmali et al., 2003a). This ﬁnding of initial sympathoexcitation was similar to that reported previously with oscillatory manipulative therapy of the cervical spine (Vicenzino et al., 1998; Sterling et al., 2001). Further work by Paungmali and his colleagues evaluated the role of endogenous opioid peptides in

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MWM-induced hypoalgesia by studying the effect of naloxone blockade on MWMLE-induced hypoalgesia (Paungmali et al., 2004) and the development of tolerance with repeated application of the treatment technique (Paungmali et al., 2003). The results of both these studies demonstrated that the initial hypoalgesic effect of the MWM does not appear to involve endogenous opioid systems, as the hypoalgesia did not demonstrate tolerance to repeated applications of the MWMLE treatment technique (Paungmali et al., 2003) and also it was not antagonized by naloxone (Paungmali et al., 2004). It has been previously proposed that the combination of sympathoexcitation, non-opioid hypoalgesia and improvements in motor function are indirect signs of a possible involvement of endogenous pain inhibition systems in manual therapy treatment effects (Wright, 1995; Vicenzino et al., 1998; Sterling et al., 2001). In summary, there is much speculation about the probable role of neurophysiologic mechanisms in the pain relieving effect of MWM and some emerging evidence that indicates that the effect, although speciﬁc, appears to be intricately complex. Further research in this area is required to better understand the underlying mechanism(s) of MWM techniques.

6. Conclusion The literature concerning MWM may be categorized according to study type, such as studies of clinical efﬁcacy, biomechanics and the pain sciences. Much of the evidence contained in the literature is considered to be of low level. Despite this, there are trends in the data that support the clinical claim of the rapid ameliorative effects on pain and function during and initially after a single treatment application and also after a course of treatment. Further randomized-controlled trials are needed to evaluate the efﬁcacy of the treatment intervention. The predominant explanation provided for this rapid pain relieving effect is mechanical in nature and based on the proposed existence of bony positional faults and the ability of MWM to correct these faults. The evidence from the pain science studies that have attempted to characterize the hypoalgesic effect has indicated that it may be non-opioid in nature as well as exhibiting features that are complex and widely distributed to other systems, such as the motor and sympathetic nervous systems. At this stage the literature does not support or refute this contention. Instead, it provides valuable insights into possible future directions for better-designed studies (i.e. randomizedcontrolled designs with adequate sample size) in both the biomechanical and pain sciences paradigms. The biomechanical hypothesis that MWM reverses positional faults requires further investigation.

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Manual Therapy 12 (2007) 109–118 www.elsevier.com/locate/math

Original article

The initial effects of knee joint mobilization on osteoarthritic hyperalgesia Penny Mossa, Kathleen Slukab, Anthony Wrighta, a

School of Physiotherapy, Curtin University of Technology, GPO Box U1987, Perth, WA, Australia Physical Therapy and Rehabilitation Science Graduate Program, University of Iowa, Iowa City, IA 52242, USA

b

Received 22 September 2004; received in revised form 25 January 2006; accepted 15 February 2006

Abstract Physiotherapists often employ lower limb joint mobilization to reduce pain and increase function. However, there is little experimental data conﬁrming its efﬁcacy. The purpose of this study was to investigate the initial effects of accessory knee joint mobilization on measures of pain and function in individuals with knee osteoarthritis. The study employed a double-blind, controlled, within-subjects repeated-measures design. Thirty-eight subjects with mild to moderate knee pain participated. The effects of a 9-min, non-noxious, AP mobilization of the tibio-femoral joint were compared with manual contact and no-contact interventions. Pressure pain threshold (PPT) and 3-m ‘up and go’ time were measured immediately before and after each intervention. Results demonstrated a signiﬁcantly greater mean (95% CI) percentage increase in PPT following knee joint mobilization (27.3% (20.9–33.7)) than after manual contact (6.4% (0.4–12.4)) or no-contact (9.6% (20.7 to 1.6)) interventions. Knee joint mobilization also increased PPT at a distal, non-painful site and reduced ‘up and go’ time signiﬁcantly more (5% (9.3 to 0.8)) than manual contact (0.4% (4.2 to 3.5)) or no-contact control (+7.9% (2.6–13.2)) interventions. This study therefore provides new experimental evidence that accessory mobilization of an osteoarthritic knee joint immediately produces both local and widespread hypoalgesic effects. It may therefore be an effective means of reducing pain in this population. r 2006 Elsevier Ltd. All rights reserved. Keywords: Knee; Osteoarthritis; Mobilization; Pressure pain threshold

1. Introduction The application of passive accessory movements to painful joints has long underpinned manual therapy practice. Although spinal and peripheral joint mobilization continues to be applied extensively in clinical practice, there is little experimental data to substantiate its effectiveness in reducing pain or improving function. Evidence for the efﬁcacy of lower limb mobilization is particularly scarce, with the majority of studies of peripheral joints using an upper limb model (Vicenzino et al., 1996; Paungmali et al., 2003). To date, just two studies explore the hypoalgesic effects of lower limb Corresponding author. Tel.: +61 9266 3618.

E-mail address: [email protected] (A. Wright). URL: http://www.physiotherapy.curtin.edu.au. 1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.02.009

mobilization, both of which focus on the ankle joint (Collins et al., 2004; Yeo and Wright, 2004). There is consequently an urgent need for further lower limb studies. Although scientiﬁc literature has begun to characterize the effects of spinal manual therapy (Koes et al., 1996; Haldeman, 1999; Wright, 2002), there are only a few studies which investigate the hypoalgesic effects of peripheral joint mobilization techniques. In subjects with sub-acute ankle injury, an antero-posterior (AP) mobilization of the talo-crural joint immediately and signiﬁcantly increased pressure pain threshold (PPT) and increased dorsiﬂexion range of motion (Yeo and Wright, 2004). This mobilization-induced hypoalgesia was signiﬁcantly more effective than either an identical procedure involving static manual contact, or a control procedure with no contact. Using similar methodology

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for subjects with lateral epicondylalgia, an elbow mobilization with movement technique signiﬁcantly reduced hyperalgesia more effectively than either the manual contact or no-contact control procedures (Vicenzino et al., 2001). Similarly, in an animal study, knee joint mobilization reduced capsaicin-induced hyperalgesia when compared to either manual contact or nocontact control procedures (Sluka and Wright, 2001). These results, from humans and animals, support the hypothesis that peripheral mobilization reduces hyperalgesia both locally and at a distant site. Few studies have investigated the initial effects of mobilization on motor function. Vicenzino et al. (2001) found that elbow mobilization with movement not only reduced pain but also increased pain-free grip strength in subjects with chronic tennis elbow. A similar increase in pain-free grip strength was found following a cervical glide mobilization in a similar subject group (Vicenzino et al., 1998). In a study of subjects with chronic, nonspeciﬁc neck pain, Sterling et al. (2001a) found that cervical mobilization decreased hyperalgesia and also reduced over-activity of the superﬁcial neck ﬂexors during the cranio-cervical ﬂexion test, suggesting improved activation of deep cervical ﬂexor muscles. There have been no studies exploring the effects on motor function of lower limb joint mobilization. A number of mechanisms have been proposed to explain how the hypoalgesic effects of passive joint mobilization may be mediated. Local mechanical disturbance may modify the chemical environment and thereby alter concentrations of inﬂammatory mediators (Sambajon et al., 2003). Movement may also trigger segmental inhibitory mechanisms (Melzack and Wall, 1999). In addition, it has been hypothesized that mobilization may activate descending pain inhibitory systems, mediated supraspinally (Wright, 2002; Souvlis et al., 2004). Human studies have demonstrated that joint mobilization produces rapid hypoalgesia with concurrent sympathetic nervous system and motor system excitation, a pattern similar to that generated by direct stimulation of the periaqueductal gray matter (Vicenzino et al., 1998; Sterling et al., 2001a). Recent animal studies show that the analgesia produced by knee joint mobilization involves serotonin and noradrenaline receptors in the spinal cord, thereby supporting a role for descending pain modulatory systems (Skyba et al., 2003). There is, however, a need for further studies to analyse the respective roles of local, segmental and supraspinal mechanisms in the mediation of hypoalgesia following joint mobilization. There is little experimental data exploring the initial effects of lower limb joint mobilization. The purpose of this study therefore was to investigate the immediate effect of passive knee joint mobilization on measures of pain and function in individuals with chronic knee osteoarthritis. In addition, the study sought to explore in humans the

animal model of mobilization-induced hypoalgesia demonstrated by Sluka and Wright (2001). Consequently, methodology similar to that used in previous clinical and animal models of joint mobilization was applied, whereby the effects of 9 min of joint mobilization were compared with those of manual contact and no-contact control procedures (Vicenzino et al., 1998, 2001; Yeo and Wright, 2004; Sluka and Wright, 2001).

2. Methods The study employed a double-blind, controlled, repeated-measures design, with all within-subject factors. 2.1. Participants Volunteers reporting mild to moderate pain from knee osteoarthritis were sought. Forty subjects from the community in Perth, Western Australia, responded to advertisements placed with local newspapers, hospital outpatient departments and community physiotherapy groups. Following a brief telephone interview, volunteers were included if they fulﬁlled the American College of Rheumatology classiﬁcation for knee osteoarthritis (classiﬁcation-tree format) (Altman et al., 1986). This requires the regular experience of knee pain, plus either osteophytes on radiograph or a combination of morning stiffness, crepitus and age 40 years or above. This classiﬁcation system has demonstrated good reliability and validity (Altman et al., 1986) and is widely used as a clinical diagnostic tool (Hochberg et al., 1995). Volunteers were requested to bring their most recent knee X-rays with them to the ﬁrst session. This study also required participants to be able to walk short distances, with or without an aid. Volunteers were excluded if they had recently undergone lower limb surgery, had co-existing inﬂammatory or neurological conditions, experienced altered sensation around their knee, or exhibited cognitive difﬁculties. Ethical approval was obtained from Curtin University Human Research Ethics Committee & Royal Perth Hospital Human Ethics Committee. All participants provided written informed consent. 2.2. Outcome measures (dependent variables) Three pain-related measures were employed, together with two measures of function. 2.2.1. Pain-related measures 1. Pressure pain threshold (PPT) was measured using a digital pressure algometer (Somedic AB, Farsta, Sweden), in accordance with similar clinical studies

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(Vicenzino et al., 2001; Collins et al., 2004; Yeo and Wright, 2004). This measure has demonstrated good reliability in a number of previous investigations, demonstrating intra-class correlation coefﬁcients (ICCs) between 0.95 and 0.99 (Vicenzino et al., 2001; Collins et al., 2004). PPT has been deﬁned as the lowest stimulus intensity at which a subject perceives mechanical pain (Vanderweeen et al., 1996). Hypoalgesia, or decreased response to mechanical pain stimuli, therefore exhibits as increased PPT. The most tender point on the medial aspect of the subject’s affected knee was palpated, marked and photographed to ensure standardization between sessions. With the subject in side-lying, a 1 cm2 algometer probe was used to apply pressure at 901 to the skin, at a rate of 40 kPa/s (Fig. 1). Subjects were instructed to activate a button when the sensation of pressure had clearly become one of painful pressure and the resultant value was recorded. Subjects were given one practice followed by three recorded trials before, and three immediately after each experimental condition. Change in mean PPT was calculated for analysis. A series of PPT readings was taken in the same manner from the medial ipsilateral heel in order to provide control data from a distal, non-pathological site. 2. A horizontal 10 cm visual analogue scale (VAS), with end-points marked ‘no pain’ and ‘worst pain imagin-

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able’, was administered immediately after the timed ‘up and go’ test, before and after each experimental condition, with difference scores used for analysis. 3. The self-administered Western Ontario and McMaster Universities (WOMAC) knee osteoarthritis index pain subscale (Bellamy et al., 1988) was used to evaluate knee pain at baseline and in the 24 h before and after each test session. The pain index comprises ﬁve written questions, for which there is a choice of ﬁve categorical responses, each assigned a numerical value between 0 and 4. Possible total scores for the pain subscale therefore range between 0 and 20, with a higher score indicating greater pain. This diseasespeciﬁc index has shown excellent validity, reliability and repeatability in numerous studies (Theiler et al., 1999; Angst et al., 2001; Parent and Moffet, 2002).

2.2.2. Function-related measures 1. A 3 m timed ‘up and go’ walk test (Podsiadlo and Richardson, 1991) was applied before and after each experimental condition. The test measured time taken to stand from a standard arm-less chair, briskly walk to a 3 m mark, turn and return to sit. The test has demonstrated high inter and intra-rater reliability (ICC 0.99) with elderly arthritic populations (Podsiadlo and Richardson, 1991; McMeeken et al., 1999). In order to assess more speciﬁcally the high load sit-to-stand phase, a lap-timer stop-watch was used to record sit-to-stand time as well as total time (Wall et al., 2000). It was found that two practices were required before one reliable trial could be recorded. Percentage change was used for analysis. 2. The self-administered WOMAC function subscale (Bellamy et al., 1988) was completed at the ﬁrst session in order to provide baseline functional data. The index comprises 17 written questions, presented in Likert-scale format, identical to the pain subscale. Total possible scores range from 0 to 68, with a higher score demonstrating greater disability.

2.3. Experimental conditions (independent variables) Each subject experienced all three experimental conditions in random order over three sessions. All conditions were applied for a total of 10 min, comprising three sets of 3 min, alternating with 30-s rests. All verbal instructions and positioning were strictly standardized using a script. Fig. 1. Subject positioning for pressure pain testing, showing standardized patient positioning plus the use of tape to standardize knee angle. The pressure algometer (Somedic AB, Sweden) was applied to a pre-assessed and marked point on the medial aspect of the knee.

1. The treatment condition consisted of a large-amplitude, AP glide of the tibia on the femur (Maitland, 1990). The subject was positioned comfortably in supine, knees in slight ﬂexion, supported on a pillow.

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The therapist stabilized the femur with one hand whilst applying pain-free, oscillatory glides of the proximal tibia with the other. 2. The manual contact condition precisely reproduced the hand positioning of the treatment condition without applying any movement. All interactions, procedures and timings were identical. 3. The no-contact control condition reproduced all interactions, procedures and timing, without applying any manual contact.

2.4. Main procedures Subjects attended at the same time of day on three occasions, each separated by at least 48 h in order to control for carry-over effects (Vicenzino et al., 1998). Subjects were requested to continue with their normal medications for the duration of the study. At the ﬁrst session, preliminary data about knee pain, chronicity, co-morbidities, medications and functional status were collected using a specially designed questionnaire together with WOMAC pain and function subscales. Knee X-ray reports were reviewed by the primary researcher when needed to fulﬁl ARC criteria. A brief physical examination evaluated knee joint range of movement and sensation, and ensured that all subjects could differentiate between sharp and blunt. In the case of bilateral knee pain, the subject nominated the most painful side. At subsequent sessions, the subject was asked to complete just the WOMAC-pain subscale before testing. Following this, the assessing researcher administered the timed ‘up and go’ test plus VAS, followed by heel and knee PPT measurements. On completion, in order to remain blind to condition, the assessor left the room whilst an experienced manipulative physiotherapist applied one of the three experimental conditions. Condition order was pre-randomized and constrained in order to ensure application of an equal spread of conditions between days. Immediately following the procedure, the assessor returned to repeat PPT, timed ‘up and go’ and VAS measurements. Subjects were asked to complete a WOMAC-pain subscale 24 h after the session. The assessor remained blind to condition throughout the data collection phase. In order to facilitate subject blinding and reduce potential interactions, discussion between researchers and subjects was minimized at all times, relaxing music played and subjects asked to close their eyes during procedure application. No feedback was given on performance until after the ﬁnal session. The extent of subject blinding was assessed through a short, self-administered, written post-experiment questionnaire, similar to previous studies (Vicenzino et al., 1998). Subjects were asked to indicate whether they had

experienced a physiotherapy treatment in any of the sessions and, if so, in which session. 2.5. Reliability A variety of measures were employed to ensure reliability at all stages of testing, as described in methodology sections above. Since reliable PPT measurement requires skilled application (Vicenzino et al., 1998; Sterling et al., 2001a), the assessor spent considerable time reﬁning this skill. A pilot study was performed with ﬁve subjects who fulﬁlled the study inclusion/ exclusion criteria. Test–retest reliability was calculated using ICC (model 3,k) for mean PPT values measured before and after application of the control condition (no-contact). Both ICC (95% CI) and standard error of measurement (SEM) for pilot data (n ¼ 5) indicated reasonable levels of intra-subject reliability for both knee PPT (ICC 0.94 (0.55–0.99); mean 251.84 kPa; SEM 23.90 kPa) and heel PPT (ICC 0.94 (0.59–0.99); mean 294.61 kPa; SEM 17.78 kPa). As shown in Table 1, values for the main study (n ¼ 38) showed further improvement both in reliability and measurement error. Reliability analyses for timed ‘up and go’ values showed lower, although adequate, reliability (TUG total ICC 0.79 (0.67–0.88); TUG sit-to-stand ICC 0.57 (0.40–0.76)).

3. Data management and analysis Data were analysed using SPSS statistical package (version 11.0, SPSS, Chicago, Illinois). The alpha level was set at Po0:05. 3.1. Normality PPT data showed normal distribution for each condition, with low skewness values. Timed ‘up and go’ data were also normally distributed and required no transformations. Since all underlying assumptions were found to be valid, parametric analysis was applied to these dependent variables. VAS data, however, were highly skewed due to the large number of subjects who experienced no pain either before or during the functional test. Non-parametric statistics were therefore applied to these data. 3.2. Main analyses Percentage change between pre- and post-condition values was used as the primary dependent variable. Since PPT measurements can vary widely between individuals and between areas of the body, use of percentage change allowed meaningful comparison of PPT results with similar studies (Vicenzino et al., 1998,

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Table 1 Test–retest reliability values for main study (n ¼ 38), demonstrating intra-class correlation coefﬁcient (ICC) (model 3k), with 95% conﬁdence interval (95% CI), and standard error of measurement values for mean pressure pain threshold (PPT) measured before and after the no-contact control condition (n ¼ 38)

Knee PPT Heel PPT

ICC

0.98 0.98

95% CI Low

High

0.96 0.96

0.99 0.99

2001; Sterling et al., 2001a). Although there has been some questioning of percentage change analysis (CPMP, 2003), Overall and Ashby (1991) demonstrated that actual change and percentage change data are associated with equally low levels of Type 1 error in randomized experimental studies. A recent study has additionally advised that primary analyses of change from baseline should include means adjustment through use of baseline values as a covariate (CPMP, 2003). Consequently, repeated measures analysis of covariance (ANCOVA) was used to analyse differences between percentage change in knee PPT, heel PPT, WOMAC-pain and ‘up and go’ times, using pre-condition mean as the covariate. Change in VAS scores were analysed using Friedman’s Two-Way ANOVA by Ranks. In similar fashion to previous algometry studies (Vicenzino et al., 1998; Sterling et al., 2001a), and in line with studies using both WOMAC and pain-VAS (Bird and Dickson, 2001; Gallagher et al., 2001; Bellamy et al., 2005) a 15% difference was considered the minimum required to demonstrate a clinically signiﬁcant change in PPT. Power analyses were performed using the Power and Precision (1.20) package. For the main study, power of 0.93 was calculated for the primary PPT measurements, using a sample of 38 subjects. Power was smaller for the secondary measure of TUG (0.69).

4. Results Comparability between pre-condition PPT means was evaluated, with no signiﬁcant difference found between treatment, manual contact control and no-contact control conditions (F 2;74 ¼ 1:02, P ¼ 0:365). Baseline data was also analysed according to day of testing. Again, no signiﬁcant difference was found (F 2;74 ¼ :303, p ¼ 0:740), suggesting avoidance of systematic bias. In order to evaluate carry-over effects between sessions, WOMAC pain data were analysed for differences between mean values for 24 h before, 24 h after and follow-up for each experimental condition. No signiﬁcant differences were found.

Standard error of measurement (kPa)

Mean (kPa)

SD

16.69 15.65

247.51 264.25

117.99 110.66

4.1. Subjects Of the 40 initially recruited, two subjects were unable to complete the study. One subject suffered a knee injury before starting the study, while a second was unable to attend due to altered family commitments. The ﬁnal study comprised 13 male and 25 female subjects with a mean age of 65 years, 4 months (SD 11 years; range 40–87 years). Extent of disease chronicity in the current study was similar to that of comparable studies, with 47.4% of subjects reporting knee pain for at least 5 years. However, when baseline WOMAC scores were compared with several recent knee osteoarthritis studies, subjects in the current study reported signiﬁcantly lower levels of functional disability and pain. Bennell et al. (2005) reported mean scores of 8.1 (/20) for pain and 28 (/68) for function, compared with respective means (95% CIs) of 6.3 (4.9–7.6) and 21.5 (17.1–25.9) in the current study. Bellamy et al. (2005) reported even higher mean levels both of pain (11.7) and function (39.9). 4.2. Effects on pain-related measures As illustrated in Table 1 and Fig. 2, knee mobilization signiﬁcantly increased knee PPT over and above manual contact or no-contact control conditions, when adjusting for pre-condition values (F 2;74 ¼ 5:26, P ¼ 0:008). Knee PPT increased by a mean of 27.3% (73.14) following treatment, with manual contact producing a 6.4% increase (72.97) and the no-contact intervention reducing PPT by 9.5% (75.50). Treatment differed signiﬁcantly from both manual contact (F 1;37 ¼ 7:81, P ¼ 0:008) and no-contact (F 1;37 ¼ 7:55, P ¼ 0:010) control conditions. PPT measurements taken from the distal, non-painful, heel produced a similarly signiﬁcant pattern of results (Table 2 and Fig. 2), with knee mobilization resulting in the greatest heel PPT increase (mean 15.373.08%). Treatment also differed signiﬁcantly from both manual contact (F 1;37 ¼ 10:72, Po0:001) and no-contact (F 1;37 ¼ 6:02, Po0:019) control conditions. WOMAC-pain subscale values demonstrated minimal change (less than one percent) from pre- to 24 h post-

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experimental condition and there was no signiﬁcant difference between conditions (F 2;74 ¼ 0:54, P ¼ 0:590). VAS values for pain during the timed ‘up and go’ test similarly showed little change in mean difference following any of the experimental conditions (treatment

0.6371.35; manual contact 0.7471.32; no contact 1.3270.70). Non-parametric tests of variance demonstrated no difference in VAS between conditions (Table 2).

Mean % Change in PPT

4.3. Effects on function-related measures 35 30 25 20 15 10 5 0 -5 -10 -15

Treatment Manual Contact Control No Contact Control *

*

*

*

* * Knee PPT

Heel PPT

Fig. 2. Mean (7standard error) changes in pressure pain threshold (PPT) for knee and heel, expressed as a percentage of pre-intervention values. *Denotes signiﬁcant difference between conditions (Po0:05).

Knee mobilization demonstrated a signiﬁcantly greater improvement in sit-to-stand times than manual contact or no-contact conditions, as shown in Fig. 3. Treatment decreased sit-to-stand time signiﬁcantly more than no-contact intervention (F 1;37 ¼ 12:45, P40:001). Although signiﬁcant differences between both treatment and manual contact and no contact control conditions were found (F 1;37 ¼ 24:15, P40:001; F 1;37 ¼ 8:79, P ¼ 0:006), the difference between treatment and manual contact control was not statistically signiﬁcant (F 1;37 ¼ 3:75, P ¼ 0:061). Treatment also produced the greatest improvement in total ‘up and go’ time, although this difference was not statistically signiﬁcant

Table 2 Main results for primary and secondary dependent variables in the main study (n ¼ 38), showing mean change values plus analysis of variance and co-variance statistics Condition

% difference pre- to postMean

PPT Knee

Heel

TUG: STS time

TUG: total time

WOMAC—pain

(SD)

Analysis of covariance

Low

High

a

df

Sig.

Rx MCC NCC

27.29 6.36 9.54

(19.35) (18.28) (24.89)

20.93 0.35 20.68

33.65 12.37 1.60

5.26

2.74

P ¼ 0:008

a

Rx MCC NCC

15.32 6.90 0.43

(20.13) (20.28) (13.75)

9.07 1.39 4.65

21.56 12.42 3.80

3.57

2.74

P ¼ 0:037

a

Rx MCC NCC

5.06 0.35 7.92

(13.02) (11.31) (16.28)

9.33 4.23 2.64

0.79 3.53 13.19

12.45

2.74

Po0:001

Rx MCC NCC

0.51 0.11 3.87

(10.52) (9.16) (9.39)

3.51 2.20 1.74

3.41 1.98 6.00

2.64

2.74

Rx MCC NCC

0.50 0.84 0.42

(1.94) (2.27) (1.86)

0.99 1.46 0.95

3.42 0.22 0.11

0.54

2.74

Rx MCC NCC

Denotes signiﬁcant difference (Po0:05).

P ¼ 0:590

Analysis of variance

Mean

w2r

(SD)

95% CI

0.63 0.74 1.32

(8.3) (8.16) (4.30)

3.34 3.42 0.05

a

P ¼ 0:781

Actual difference pre- to post-

Low VAS (during TUG test)

F value

95% CI

df

Sig.

2.74

P ¼ 0:284

High 2.11 1.94 2.73

2.52

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* Treatment

Mean % Change in Time

8

Manual Contact Control No Contact Control

6 4 2 0 -2 -4 -6

* STS

Total

Fig. 3. Mean (7standard error) percentage change in time for timed ‘up and go’ test, including sit to stand (STS) and total times. *Denotes signiﬁcant difference between conditions (Po0:05).

(F 2;74 ¼ 2:64, P ¼ 0:78). Power for TUG values was calculated as 0.69. 4.4. Blinding The post-experiment questionnaire revealed that 71% of subjects were unable to identify the treatment condition correctly. Removal of data for those subjects who identiﬁed the treatment session made no difference to the results.

5. Discussion 5.1. Effects on pain-related measures This study established that 9 min of accessory mobilization of the tibio-femoral joint immediately increased knee PPT signiﬁcantly more effectively than either manual contact or no-contact control procedures, in subjects with mild to moderate knee osteoarthritis. Mobilization increased knee PPT by 27.3%, compared with 6.4% resulting from manual contact, indicating appreciably reduced sensitivity to mechanical pain. This corresponds with evidence from spinal mobilization studies (Vicenzino et al., 1998; Sterling et al., 2001a) which demonstrated improvements in PPT of approximately 25% and 30% following treatment. It also supports a similar pattern found following peripheral joint mobilization. Yeo and Wright (2004) showed that mobilising sub-acute ankle injuries increased PPT 23% more than the manual contact procedure. Paungmali et al. (2003) found that an elbow mobilization with movement technique produced an improvement in PPT of 15.4%. Thus, both peripheral and spinal mobilizations immediately reduce mechanical hyperalgesia more

115

than control procedures. In accordance with investigations of other measures (Bird and Dickson, 2001; Gallagher et al., 2001; Bellamy et al., 2005), an improvement of more than 15% may be considered to reﬂect a clinically signiﬁcant effect. It may be that a particular type of stimulus is required to produce an optimal response. In a similarly designed study, which produced apparently contradictory results, Collins et al. (2004) reported that a sustained glide procedure (mobilization with movement) had no effect on mechanical pain thresholds in subjects with a subacute ankle injury, whereas the manual contact control procedure produced signiﬁcant increases in PPT. On closer examination, this ankle study, in direct contrast to comparable studies (Vicenzino et al., 2001; Yeo and Wright, 2004; the current study), in fact used gentle repetitive movements of the joint as the manual contact control for the sustained treatment procedure. All of this evidence suggests that it is the repetitive movement, rather than sustained pressure to the limb, which provides the hypoalgesic stimulus. Further studies are needed to conﬁrm this. The enhanced hypoalgesic effect of repetitive mobilization may reﬂect changes in the local cellular environment. A recent in vitro study of healthy animal ﬁbroblasts by Sambajon et al. (2003) suggested that movement may alter concentrations of inﬂammatory mediators, known to sensitize peripheral nociceptors. Levels of the prostaglandin PGE2, an inﬂammatory mediator strongly implicated in arthritic hyperalgesia, were assessed before and after ﬁbroblast cells were subjected to cycles of mechanical deformation, designed to mimic mobilization effects. After 24 h, these ‘mobilized’ cells were found to contain nearly 70% less PGE2 than undisturbed control cells. Future studies in vivo, comparing levels of inﬂammatory mediators in human osteoarthritic joints before and after joint mobilization would be instructive. Pain relief, however, is multifactorial and complex. Although mobilization may initiate local physiological mechanisms, additional central mechanisms may also be involved. These central mechanisms could include activation of local segmental inhibitory pathways in the spinal cord, or descending inhibitory pathways from the brainstem. It can be hypothesized that joint mobilization might activate segmental pain inhibitory mechanisms. However, we previously demonstrated in rats that pharmacological blockade of GABA or opioid receptors in the spinal cord, which are involved in segmental inhibition, has no effect on the analgesia produced by knee joint mobilization (Skyba et al., 2003). It does not appear therefore that segmental inhibitory mechanisms make a signiﬁcant contribution to manual therapy hypoalgesia, but further studies using other animal models would be valuable.

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We previously hypothesized that supraspinal pain inhibitory mechanisms are activated by manual therapy (Wright, 1995; Vicenzino et al., 1996; Wright, 2002; Souvlis et al., 2004). Activation of supraspinal inhibitory pathways would be expected to produce a widespread analgesic response that would include areas outside the site of injury. Our studies of spinal mobilization techniques (Vicenzino et al., 1996, 1998) have shown that cervical spine mobilization reduces hyperalgesia in the upper limb. The current study demonstrates for the ﬁrst time in humans that the hypoalgesic response provoked by a peripheral mobilization is widespread and not just limited to the treated joint. A 9-min mobilization of the knee joint resulted in signiﬁcant hypoalgesia distally in the foot, similar to the pattern of response seen in the animal model, where mobilising a rat knee joint for 9 min signiﬁcantly reversed experimentally induced hyperalgesia at the ankle (Sluka and Wright, 2001). In the current study, the hypoalgesic response produced at the ipsilateral foot was in proportions similar to that at the treated knee (Fig. 2). This suggests that similar mechanisms may be responsible. A number of recent human spinal studies by other groups also suggest that manipulation or mobilization of the spine may produce a more generalized hypoalgesic response. Haas et al. (2003) found that subjects with neck pain experienced as much relief with a randomly selected cervical manipulation as with a speciﬁc segmentally targeted technique. Similarly, Chiradejnant et al. (2003) found that a randomly selected lumbar mobilization technique was equally effective in reducing nonspeciﬁc low back pain as one speciﬁcally selected to treat an involved segment. Further human studies are needed to clarify the hypoalgesic response elicited by joint mobilization, through either pharmacological studies, or studies which further develop our understanding of the spatial scope and duration of the hypoalgesic response. In addition, using behavioural pharmacology Skyba et al. (2003) show that serotonergic (5-HT1A) and noradrenergic (alpha-2) receptors in the spinal cord mediate the analgesia produced by knee joint mobilization. Since serotonin and noradrenaline releasing neurons in the spinal cord originate in supraspinal sites in the brainstem, these data support a role for descending inhibitory pathways in the hypoalgesia produced by joint mobilization. 5.2. Effects on function-related measures This study also considered the immediate effect of knee joint mobilization on motor activity and found that there was a clear trend towards the greatest improvement in sit-to-stand and total ‘up and go’ time following the treatment condition (Fig. 3). This improvement may reﬂect reversal of reﬂex pain inhibition

(Hurley and Newham, 1993). Additionally, changes in motor activity may be a further indication of a centrally mediated response. It has been demonstrated that mobilization can enhance motor activity alongside hypoalgesic and sympatho-excitatory responses. Sterling et al. (2001a) found that cervical mobilization improved deep neck ﬂexor function in subjects with neck pain. Vicenzino et al. (1998) similarly found that cervical mobilization increased pain-free grip in subjects with lateral epicondylalgia, a result which was replicated with a local elbow mobilization with movement intervention (Vicenzino et al., 2001). Although the difference in STS times between treatment and manual contact control conditions were not signiﬁcant, there was a trend towards signiﬁcance (P ¼ 0:061). This may reﬂect the lower power of the secondary measures in the study, but may also signify the larger measurement error and lower reliability (ICC 0.57) associated with using a manual stopwatch to measure fractions of seconds. The signiﬁcant increase in STS time following the no-contact control condition is an interesting result. Whilst this may be a reﬂection of methodological limitations, increased stiffness and resulting movement limitations following prolonged immobility is also a clinical feature of lower limb osteoarthritis. The 10 min of complete immobility necessitated by the no-contact control procedure may have been sufﬁcient to increase TUG time. Further investigation, however, is needed in order to clarify whether mobilization of a painful arthritic knee can improve motor function. Future studies will need to employ more precise tools to measure motor improvement, perhaps using electronic timing gates, EMG, or motion analysis. 5.3. Further study limitations Both the VAS data for pain during the functional test and WOMAC pain subscale data were inconclusive, demonstrating minimal change following any of the experimental conditions. However, baseline values for both of these tools were low, thereby reducing the likelihood of signiﬁcant change following any of the experimental conditions. This reverse ceiling effect may reﬂect the relatively mild OA effects demonstrated by subjects. It has been noted above that subjects in this study reported signiﬁcantly less pain and fewer functional limitations than those in equivalent studies (Bellamy et al., 2005; Bennell et al., 2005). This, in turn, may reﬂect differing recruitment methods, since subjects in the current study were recruited directly from the general population rather than from established disease management programmes (Bellamy et al., 2005; Bennell et al., 2005). Although outside the aims of the current investigation, it would be useful to investigate further the possible relationship between clinical pain measures,

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such as the VAS and WOMAC, and experimental measures such as algometry, amongst subjects with varying degrees of disease severity. 5.4. Clinical relevance This study provides strong evidence that non-noxious accessory mobilization of an osteoarthritic peripheral joint can immediately reduce hyperalgesia. We have shown that subjects with mild to moderate knee pain experience immediate improvement in PPT of an average 27.3% after a 9-min treatment. Although estimates of clinically signiﬁcant change in PPT are difﬁcult, since pressure algometry is not used clinically, a number of studies have concluded that a 15–20% change in pain reﬂects signiﬁcant change (Bird and Dickson, 2001; Gallagher et al., 2001; Bellamy et al., 2005). This study only sought to explore the immediate effects of a single mobilization treatment. However, joint mobilization tends to be used clinically for its assumed longer-term cumulative effect, over the course of several treatment sessions. Further work is therefore needed to explore hypoalgesic effects over a longer time period in order to clarify the optimal treatment dose. Reduction in pain sensitivity may also immediately improve motor patterning (Sterling et al., 2001b). Although there were limitations in this study with regard to measurement of functional change, results suggest that mobilization of a painful osteoarthritic joint may immediately facilitate motor function. If this is so, it may be that joint mobilization could be used for its immediate effects, as a precursor to motor activation strategies, although, again, this hypothesis needs further investigation.

6. Conclusion The purpose of this study was to investigate the initial effects on pain and function of lower limb joint mobilization. The study has provided new experimental evidence that accessory mobilization of a human osteoarthritic knee joint has both an immediate local and a more widespread hypoalgesic effect. This supports the response seen in animal studies (Sluka and Wright, 2001). Clinically therefore, joint mobilization may be an effective means of reducing osteoarthritic pain and may potentially improve motor function.

Acknowledgements The assistance of the following colleagues is gratefully acknowledged: Associate Professor Kathy Briffa, Mr. Timothy Karajas, Perth Community Physiotherapy and Adjunct Associate Professor John Buchanan.

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Manual Therapy 12 (2007) 119–125 www.elsevier.com/locate/math

Original article

Associated sagittal spinal movements in performance of head pro- and retraction in healthy women: A kinematic analysis P Rune Perssona,{, Helga Hirschfeldb, Lena Nilsson-Wikmarb, a

Ho¨gsby sjukgymnastik, Ho¨gsby, Sweden Department of Neurobiology, Caring Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Stockholm, 23100, SE-141 83 Huddinge, Sweden

b

Received 24 November 2004; received in revised form 22 January 2006; accepted 15 February 2006

Abstract Sagittal head excursions are frequently used as diagnostic and treatment tools by physiotherapists. Retractions are performed to promote good head-on-body orientation. This study examined the regional contribution of spinal movements to head pro- and retraction in addition to the effect of a more or less restrained sitting position in healthy women. Fourteen healthy women performed seven sagittal head excursions in a more or less restrained sitting position, during which time their kinematic response was measured with an optoelectronic system. Total anterior/posterior head excursion was smaller (P ¼ 0:005) in the more restrained sitting position. In both sitting positions, approximately 60% of the total anterior/posterior head excursion originated from the cervical spine, almost 30% from the cervicothoracic spine C7-T4, and approximately 10% from thoracic regions down to T12. Middle thoracic vertical displacement was smaller (p ¼ 0:005) in the more restrained sitting position. A high correlation was found between total head excursion and the cervicothoracic unit displacements in both sitting positions (r ¼ 0:79, r ¼ 0:85, respectively). In each sitting position, the craniovertebral angle, and the tragus-C7-horizontal line decreased in protraction. Movements in the thoracic region contributed to the total head excursion. Therefore, clinicians should recognize the thoracic contribution to sagittal head excursion when using pro- and retraction as a diagnostic and treatment tool. r 2006 Elsevier Ltd. All rights reserved. Keywords: Biomechanics; Head posture; Movement analysis; Cervical

1. Introduction Total head excursion, is ‘‘the complete retraction to protraction range of motion in the sagittal plane’’ (Hanten et al., 2000). According to Ordway et al. (1999), pro- and retraction are deﬁned as the maximal forward/rearward gliding or anterior/posterior translation of the head while zero sagittal rotation is maintained. At Occ-C1 and C1-C2, only protraction achieves full extension and only retraction full ﬂexion (Ordway et al., 1999). It is of considerable interest to Corresponding author. Tel.: +46 8 524 888 48.

E-mail address: [email protected] (L. Nilsson-Wikmar). Deceased

{

1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.02.013

study protracted positions in everyday life, since they occur commonly, e.g. while driving a car, reading, watching television, or working at the computer (McKenzie, 1998). A Swedish evaluation of conditions while working at the computer categorized the head as protruded in 20% of subjects (Hansson Risberg et al., 2001). Extreme or almost extreme positions occur in the atlanto-occipital joint in a sitting posture with the whole spine ﬂexed (Harms-Ringdahl, 1986). Retractions are often used in the clinic to promote good head-on-body orientation (Enwemeka et al., 1986; Grimmer, 1993), e.g. in treating headache (Watson and Trott, 1993; Grant and Niere, 2000), neck pain (Enwemeka et al., 1986) or temporomandibular disorders (Wright et al., 2000) due to forward head position. Retraction might

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address neuromeningeal dysfunction by applying stretches to the suboccipital muscles. This idea is supported by the discovery of anatomical connections between rectus capitis, posterior minor and the dura mater (Hack et al., 1995). Retractions may also promote cervical root decompression and reduce radicular pain in patients with C7 radiculopathy (Abdulwahab and Sabbahi, 2000). Brault et al. (2000) also concluded that the clinician should recognize the role of cervical retraction in the mechanism of whiplash injury and avoid aggressive motion in that plane during diagnosis and treatment. Total head excursion has been measured in healthy subjects using a metric ruler (Hanten et al., 1991, 2000), and an electromagnetic device (Ordway et al., 1997), a CROM device (Ordway et al., 1997) and has been reported as a sagittal translational motion in cm. Total head excursion has also been reported as a change in craniovertebral angle, i.e. the angle between the tragus of the ear, the spinous process of vertebrae C7 and the horizontal plane (Braun and Amundson, 1989; Dalton and Coutts, 1998). The methods employed in these studies mostly describe the active range of motion (AROM) of the head, i.e. implicitly global functions of the neck (Bogduk and Mercer, 2000). In addition, these included associated movements below C7 without specifying these movements. The possibility that movements in the thoracic spine inﬂuence cervical measurements cannot be ruled out (Ordway et al., 1997) and might be considered a reliability problem (Rheault et al., 1992). However, the upper thoracic spine plays a functional role in the motions of the cervical spine (White and Panjabi, 1990). Repeated protraction and retraction are frequently used as diagnostic and treatment tools (Donelson et al., 1997) by physiotherapists. Pro- and retractions are usually performed with thoracic and lumbar support in order to minimize thoracic movements (Ordway et al., 1997, 1999; Hanten et al., 1991, 2000). Thus, several reasons to increase the physiotherapeutic use of pro- and retraction movement in the clinic exist. However, a lack of knowledge exists surrounding thoracic contributions to movement, i.e. what to regard as a normal reference in testing and training. Furthermore, little is known as to what degree thoracic movements are minimized with a backrest, and whether or not total head excursion remains unaffected. The main aims of this study were to determine the regional distribution of anterior/posterior and vertical directed spinal movements, as they appear from skin markers, during head pro- and retraction, in addition to the effects of two different sitting positions on movement in healthy women. We hypothesized that a more restrained erect sitting position with thoracic/lumbar support would increase the cervical, while minimizing the thoracic contribution to total head excursion.

2. Materials and methods Fourteen healthy adult women aged 30–48 years, participated in this study. Inclusion criteria were no pain in the spinal column, head, cheeks or upper limbs, no treatment during the last year due to spinal problems and the full ability to sit and stand without pain or difﬁculties. The mean (SD) sitting length was 87.8 cm (1.7 cm). The mean (SD) thoracic ﬂexion in sitting, measured with a kyphometer (Protek AG, Berne, Switzerland), was 34.41 (7.61) and the extension 18.71 (8.71). The subjects received written information regarding the procedure, and informed consent was obtained from each subject. The ethics committee of Huddinge University Hospital, Stockholm, approved the study. To facilitate the movement recording a special chair was constructed, with a ﬁrm thin horizontal thoracic backrest together with a detachable stick for lumbar contact. The seating height was adjusted to 901 in knee and hip angles by wooden plates, placed on the seat or under the feet. A two-camera optoelectronic system (ELITE, BTS, Milan) (Ferrigno and Pedotti, 1985) was used to record the head and spine movements. The setup is shown schematically in Fig. 1, and includes the position of the cameras, the coordinate system and marker locations. The sampling frequency was 100 Hz and the recording time was 7 s. The digitised data were stored for further processing. Under the prevailing experimental conditions, the explored ﬁeld was 2 2 m, the accuracy thus being 0.8 mm. A motion less than 1 mm was not reported. Subjects wore underwear or a bikini, and fourteen reﬂective markers were attached to the following anatomical landmarks on the right side of the body and on the spine (Fig. 1): (1) the corner of the eye; (2) tragus; (3) C7 spinal process, deﬁned as the spinal process remaining when the above adjacent vertebrae disappeared during extension; (4) T4 spinal process, deﬁned according to the CervicoThoracic Ratio (CTR) method (Norlander et al., 1995), i.e. 12 cm below the C7 spinal process; (5) the apex of the thoracic kyphosis, deﬁned as the most prominent dorsal thoracic point with the subject in upright sitting, inspected from above; (6) T12 spinal process, deﬁned according to the method of Tully and Stillman (1997); (7) L4 spinal process; (8) S2, palpated according to Kapandji (1974); (9) the anterior superior iliac spine (ASIS); (10) the greater trochanter; (11) the lateral femoral condyle; (12) the lateral malleolus; (13) the heel; and (14) the ﬁfth metatarsal bone. The markers on T12, L4 and S2 were spherical and glued to the top of a plastic cone, 35 mm long, to assure detection by the cameras. The markers on T4 and the apex of the thoracic kyphosis were glued to square corks, 20 mm high. In addition, two markers were attached to the chair (15; 16) for spatial reference. The 14 body markers

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Y

2 1 3 4 5 6 7

9

8 10 15

11

16

12 13

14

X

Z

Camera 1

Camera 2

Fig. 1. Experimental set-up showing the global reference system and body links.

deﬁned the positions of 12 body links and were used for kinematic analysis. The subjects received a demonstration of the movement, verbal instructions and practise trials. In addition, subjects received the following instruction: ‘‘Move only your head as far as you can forward and then backward and then return to your starting position. Keep your head horizontal and ﬁxate your eyes at a point just below eye level 5 m in front of you. Do not move your head up and down’’. The task was performed in two blocks of seven trials in each sitting position. In block one, the subjects were instructed to ‘‘sit in a self-selected comfortable position with contact only against the thoracic back rest’’. This was referred to as the less restrained position. In block two, the subjects were instructed to ‘‘strictly keep contact with the thoracic and lumbar back rests of the chair’’, this being the more restrained position. The trials were initiated alternately with protraction and retraction.

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Recordings of kinematic data were transformed into ASCII ﬁles and analysed for peak amplitudes in anterior/posterior and vertical directions using Axograph (Axon Instruments), a Macintosh-based software package. Before analysis, digital ﬁltering for signal smoothing was performed for all signals. The ﬁrst six trials per subject and sitting position that were free of technical problems were analysed. Peak amplitudes were computed for anterior/posterior and vertical directions respectively, as changes relative to marker positions occurred in the initial sitting position, the zero line (Fig. 2). A spinal unit was deﬁned as the region between two adjacent markers. The unit displacements were then deﬁned as the difference in displacement between two adjacent marker displacements. The onset of a movement was calculated when the marker curve described an obvious continuous change of position, greater than 1 mm.Thus, the following units were analysed in the anterior/posterior and vertical directions during the pro- and retraction movement of the head: (1) cervical unit: the difference between the tragus marker and the C7 marker; (2) cervicothoracic unit: the difference between the C7 marker and the T4 marker; (3) middle thoracic unit: the difference between the T4 marker and the marker on the apex of the thoracic kyphosis; (4) lower thoracic unit: the difference between the apex marker of the thoracic kyphosis and the T12 marker. In addition, the total head excursion was calculated as peak displacements of the tragus marker. Fig. 2 illustrates total head excursion and the cervical and cervicothoracic displacements in the anterior/ posterior direction. Resting head posture is the position the head assumes within the protraction to retraction range of motion, and is expressed as the distance from full head retraction to the resting position, divided by total head excursion (Hanten et al., 1991). Protraction and retraction end ranges were also calculated as tan1 ¼ vertical/anterior or posterior displacement, relative to the initial sitting position, and referred to as the craniovertebral angle. A motion less than 1 degree was not reported. The individual mean of the peaks of six trials was calculated in each sitting position. Thereafter, the means and standard deviations for all subjects were pooled for each condition. Comparisons of the means of subgroups were performed using t-tests for depenaent samples. The a level of 0.05 was Bonferroni adjusted for ﬁve displacement variables to 0.01 ( ¼ 05/5). Correlations were tested by means of the Pearson product–moment correlation test, r. Thirteen out of fourteen individual means were computed in the more restrained position

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122

Protraction

100

Retraction

Start

A/p displacement (mm)

80 60

Cervical unit

40

Cervico thoracic unit

20

Total head excursion

0 Tragus C7 T4

-20 Cervical unit -40 -60 -1000

0

1000

2000

3000

4000

5000

6000

Time (ms) Fig. 2. Graphic representation of real-time motion from one trial in which the subject begins with protraction. An example of total head excursion and two spinal units. Total head excursion is calculated as the difference between the tragus protraction and retraction peaks. Cervical unit displacement is calculated as the difference between the tragus displacement peak and the simultaneous displacement of the C7 marker. Cervicothoracic unit displacement is calculated as the difference between the displacements of C7 and T4 markers, when tragus reaches its displacement peak.

Table 1 Contribution of the different spinal units; cervical unit (Cerv), cervicothoracic unit (Cth), middle thoracic (Mth) and lower thoracic unit (Lth) in anterior-posterior (ant/post) and vertical displacements to total head excursion in absolute (mm) and relative (%) values mean (SD) Spinal units

Less restrained position, n ¼ 14

More restrained position, n ¼ 13

Ant/post

Ant/post

mm Cerv Cth Mth Lth Total head excursion

81 40 11 7 139

Vertical %

(14) (14) (6) (8) (23)

58 29 8 5

(11) (7) (4) (5)

mm

%

52 (12) 3 (12) 15 (8) 7 (7) 26(11)

63 11 18 8

mm (7) (8) (7) (7)

72 33 8 4 117

Vertical %

(11) (10) (7) (7) (15)

62 28 7 3

mm (13) (6) (5) (6)

46 4 8 8 23

Sign level* %

(11) (8) (4) (7) (6)

72 8 10 10

(20) (7) (9) (7)

Ant/post

Vertical

0.027 0.039 0.063 0.053 0.005

0.041 0.088 0.005 0.911 0.122

*t-test. Negative values represent caudal direction and positive values represent cranial direction in absolute vertical displacements. Relative vertical displacement is based on total displacement, disregarding direction.

due to missing markers. Statistical analysis was performed using STATISTICA for Windows (StatSoft Inc. 2000) and Microsoft EXCEL 97.

3. Results The difference in total head excursion anterior– posterior direction between the two sitting positions was statistically signiﬁcant, t12 ¼ 3:45, p ¼ 0:005 (Table 1). There were no statistically signiﬁcant differences between the sitting positions for anterior–posterior spinal unit displacements. The cervical unit contributed to anterior–posterior total head excursion with 62% in the more restrained and 58% in the less restrained position,

the cervicothoracic unit with 28% and 29%, the middle thoracic unit with 7% and 8% and the lower thoracic with 3% and 5%, respectively. Anterior/posterior displacements were always associated with vertical displacements (Fig. 3). T-tests for vertical displacements showed a statistically signiﬁcant difference between sitting positions for the middle thoracic unit, t12 ¼ 3:43, p ¼ 0:005 (Table 1), with a smaller displacement in the more restrained position. The craniovertebral angle decreased in protraction, 191 in the less and 201 in the more restrained position and remained unchanged in retraction in both positions. Protraction was signiﬁcantly smaller in absolute values in the more restrained position compared with the less restrained position, t12 ¼ 3:77, p ¼ 0:003. The

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Vertical displacement(mm)

y

x

Ant/post displacement (mm)

mm

Protraction

More restrained position Less restrained position

50

25

Retraction

0

-25

-50 Cervical unit -75

Cervical thoracic unit

Middle thoracic unit

and the middle thoracic unit were moderate, r ¼ 0:65 and 0.68 and between total head excursion and the lower thoracic unit were low or moderate, r ¼ 0:45 and 0.61. The Pearson correlation coefﬁcient between CTR and the cervical and cervicothoracic unit displacements in the different positions varied from 0.13 to 0.08, with the exception of a non-signiﬁcant (p ¼ 0:142) r ¼ 0:43 for cervical displacement in the more restrained position.

10 mm/div

Fig. 3. XY-plot demonstrating an example from one subject trial on concurrent vertical and anterior/posterior displacement in mm for tragus with axis values from the global reference system. Movement direction from starting point (arrow) is protraction.

75

123

Lower thoracic unit

Fig. 4. Anterior/posterior displacements in mm (mean and SD) in a more or less restrained sitting position during pro- and retraction of the head. Negative values represent retraction and positive values protraction. Less restrained n ¼ 14 and more restrained n ¼ 13.

lower thoracic unit protraction was signiﬁcantly smaller in relative values in the more restrained position as compared with the less restrained position, t12 ¼ 3:13, p ¼ 0:009. There were no statistically signiﬁcant differences in retraction amplitude between the different sitting positions. Resting head posture, i.e. retraction, was 45% of total head excursion in the more restrained and 44% in the less restrained position. Spinal unit proand retraction in the two sitting positions are presented in mm in Fig. 4. Within-group correlations between total head excursion and the cervical unit displacements were low or absent (Munro et al., 1986), r ¼ 0:40 and 0:07 for the less restrained and the more restrained position, respectively, while there were high correlations between total head excursion and the cervicothoracic unit, r ¼ 0:79 and 0:85. Correlations between total head excursion

4. Discussion Measurements of simultaneously occurring cervical, thoracic, lumbar and pelvic movements are rare. To our knowledge, thoracic contributions below T4 to head movements have not been previously documented in the literature. The main ﬁnding of this study is the existence of movements down to T12 in the performance of sagittal head excursions in healthy women. Furthermore, the standardized more restrained position, used to ‘‘prevent’’ thoracic motion, reduced the head sagittal excursion signiﬁcantly and also the absolute cervical unit values, implying restricted excursion of Occ-C1 articular surfaces and thus, less stretching of the suboccipital muscles. These results are in agreement with results obtained from a segmental radiological study (Penning, 1992), which revealed a limited possibility of head translation with the body of T1 ﬁxed. The ﬁndings in this study on cervical unit excursion are consistent with those of previous radiographic measurements; 7.2–8.1 cm compared with 7.5–8.2 cm (Ordway et al., 1997). Radiographic measurements are considered a criterion standard, and our construct unit displacement thus appears to be valid. Grimmer (1993) reported a vertical dimension for total head excursion. Herein, the change in craniovertebral angle was found to occur in protraction and not retraction. This leads us to deﬁne total head excursion as a forward and backward gliding movement including a craniovertebral angle decrease in protraction, that is dependent on thoracic movement and inﬂuenced by the sitting position. The importance of thoracic mobility in sagittal head excursion was demonstrated by high to moderate within-group correlations with total head excursion. It is recommended clinically to prevent thoracic motion in measurements of cervical AROM (Chen et al., 1999). However, cervical motions have a thoracic contribution (White and Panjabi, 1990) and it appears that the whole thoracic spine is a functional part in sagittal head excursions. Allowing maximal physiologic range of motion during measurement has the advantage of resembling typical everyday motion (Castro et al., 2000).

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In manual orthopaedic therapy, postural exercise and advice are common techniques. Assessing thoracic mobility might be important when evaluating pro- and retraction as a basis for postural treatment. A limitation of active head excursions may be caused by limited thoracic mobility. This may also be of some importance in ergonomics, leading to near-end-range positions during sitting work. When encouraging self-treatment procedures, it might be valuable to know that upper cervical ﬂexion appears to decrease in an erect, more restrained position compared to a less restrained position. The limitations of the present study were that skin markers do not represent the spinal axis, running through the column of vertebral bodies and intervertebral discs at the site of centres of ﬂexion-extension motion. Therefore, quantiﬁcation of the contributions from different units might differ from a segmental radiological study. This study did not analyse the segmental motions, and there are, of course, possibilities of important segmental motions occurring within the spinal units. In addition, the use of skin markers to imitate skeletal motion might also be a source of error, for example, due to intervening skin and muscle motions (Burdett et al., 1986). However, the markers were not placed over muscle bulks. The correlation coefﬁcient between total head excursion and the cervicothoracic ratio, CTR (Norlander et al., 1995), was 0.16. The CTR is a measure of skin distraction from C7 to any of the upper ﬁve thoracic spinoses, occurring in ﬂexion. Correlation coefﬁcients between CTR and adjacent unit displacements did not support skin distraction as in CTR measurements. Craniovertebral angle vertical displacement occurs in protraction. If skin distraction had inﬂuenced total head excursion, the protraction would have increased on behalf of the retraction. Hanten et al. (1991) found retraction for women aged 31–50 years to be 44.4– 49.3% of the total head excursion, measured with no skin attachments. The retraction observed in the present study, 44–45% of total head excursion, is of a similar proportion. Hence, skin distraction was not a major source of error in this study. In order to avoid erroneous identiﬁcation of landmarks, the identiﬁcation of T12 and T4 was standardized using tape measurement (Norlander et al., 1995; Tully and Stillman, 1997). This might have led to the inclusion of a different number of segmental levels in spinal units between subjects, whose sitting length from the top of the head to the chair-seat ranged between 85 and 90 cm. However, Burdett et al. (1986) believed that standard distances contribute to more reliable results than palpation. Our subjects were healthy women and the validity of the results for individuals, including male subjects, with cervical complaints, clearly requires further investigation.

5. Conclusion In this study, a large proportion of total head excursion in the sagittal plane was shown to arise from the thoracic region, in healthy women aged between 30 and 48 years. Approximately 60% of sagittal head excursion originated from the cervical spine, almost 30% from the cervico-thoracic spine and approximately 10% from thoracic regions down to T12. A high correlation between total head excursion and cervicothoracic unit displacements was demonstrated. In addition, we were able to demonstrate that sagittal head excursion is a horizontal and vertical displacement, and that spinal alignment in the sitting position determined the range of active sagittal head excursions. Furthermore, thoracic end range positions inﬂuenced sagittal head excursion and limited total head excursion.

Acknowledgements The authors would like to thank Ingmarie Apel for providing technical assistance, Evert Jonsson for the construction of the chair and Joanna Tyrcha (Department of Mathematics, Stockholm University) for statistical advice. This investigation was supported by grants from Ann-Mari och Ragnar Hemborg0 s Minnesfond, Lund, Sweden, and from FYS-fonden, Legitimerade Sjukgymnasters Riksfo¨rbund, Stockholm, Sweden.

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Manual Therapy 12 (2007) 126–132 www.elsevier.com/locate/math

Original article

Mechanical Diagnosis and Therapy approach to assessment and treatment of derangement of the sacro-iliac joint Stuart John Hortona,, Anja Franzb a

School of Physiotherapy, University of Otago, Dunedin, New Zealand b Quebec, Canada

Received 14 September 2005; received in revised form 28 January 2006; accepted 31 May 2006

Abstract This case report describes the clinical reasoning and management of the sacroiliac joint, utilising the McKenzie Method of Mechanical Diagnosis and Therapy (MDT). A patient with a 2 year history of buttock and thigh pain demonstrates a directional preference for repeated anterior SIJ rotation. The MDT approach is discussed and is an ideal method for emphasising the patients involvement in managing their own back problem. r 2006 Elsevier Ltd. All rights reserved. Keywords: Sacroiliac joint; McKenzie; Exercise

1. Introduction A structural cause of low back pain (LBP) with or without radiating symptoms may be identiﬁed only in a minority of patients (Spitzer et al., 1987). In fact, the symptoms may originate from various structures of the lumbo-pelvic region (Fortin et al., 1994; Kuslich et al., 1991; Schwarzer et al., 1995). Invasive and costly paraclinical investigations are frequently prescribed to enhance diagnostic accuracy. However, the symptomatic signiﬁcance of abnormal morphology detected by high-tech imaging remains unclear (Van Tulder et al., 1997a). Thus, the majority of patients suffer from ‘‘nonspeciﬁc LBP’’ and are offered a large variety of treatment options of unknown efﬁcacy. In spite of education and avoidance of bed rest, no treatment approach has proven superior in the management of non-speciﬁc LBP thus far (Van Tulder et al., 1997b). In treatment efﬁcacy trials, patients with non-speciﬁc LBP were considered as a homogeneous group and offered one or the other treatment (Bouter et al., 1998). Corresponding author. Tel.: +64 3 479 5757; fax: +64 3 479 5161.

E-mail address: [email protected] (S.J. Horton). 1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.06.001

However, recent studies have shown that a classiﬁcation system based on symptom behaviour sub-grouping improves treatment outcomes (Fritz and George, 2000; Long et al., 2004). One sub-classiﬁcation may be pain originating from the sacro-iliac joint (SIJ). However, the prevalence of SIJ disorders varies considerably anywhere between 13% and 53% (Dreyfuss et al., 1996; Maigne et al., 1996) Fluoroscopically guided intra-articular injection or joint block which are considered the criterion standard still show a false positive rate estimated between 8% and 20% (Laslett et al., 2005) There is also a lack of validity and reliability of commonly used clinical SIJ tests (Van der Wurff et al., 1999, 2000). Many testing procedures assess the position of bony landmarks and motion abnormalities of the SIJ joint using palpation and observation (Walker, 1992) and these SIJ disorders are named according to the ﬁndings (subluxation, upslip, downslip, posterior or anterior ﬁxed innominate). Lee (2004) has proposed a complex classiﬁcation system based on an integrated model of function. Treatment techniques proposed to correct these ‘‘biomechanical dysfunctions’’ include belt ﬁxation, mobilisation and manipulation procedures. Stretching and massage are

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also purported to correct muscle imbalance together with a corrective exercise programme to restore joint position, including the hip joint. If manual techniques fail to resolve the pain then injection therapy may prove useful. (Brukner and Khan, 2001; Cibulka, 1992, 2002; DonTigny, 1985; Lee, 2004; Maitland, 1986; Walker, 1992). However, difﬁculties in detecting motion of the SIJ in either symptomatic or asymptomatic individuals challenge the clinical relevance of such ﬁndings (Freburger and Riddle, 2001; Huijbregts, 2004; Laslett and Williams, 1994; Lee and Vleeming, 2000; Sturesson et al., 2000). Laslett et al. (2003, 2005) recommends use of SIJ provocation tests within the context of the McKenzie Method clinical reasoning process to differentiate between symptomatic and asymptomatic SIJs. It is suggested that positive SIJ test be discounted when clinical evidence for discogenic pain is present. A symptomatic SIJ should be suspected only when three or more SIJ pain provocation tests provoke the concordant pain. The validity of SIJ assessment increases considerably after negative testing of the lumbar spine in this way. Huijbregts (2004) also concludes that a comprehensive examination consisting of a McKenzie evaluation and a cluster of SIJ provocation tests provides for excellent accuracy in the diagnosis of SIJ-related pain. This diagnostic process complements the philosophy of the McKenzie Method of Mechanical Diagnosis and Therapy (MDT) approach which utilises repeated movements to assess and treat musculo-skeletal disorders of the spine and extremities (McKenzie and May, 2000, 2003). The following case report is an example of the clinical application of scientiﬁc evidence provided by recent research and the MDT approach to spinal and extremity disorders.

2. Patient presentation 2.1. History A 47-year-old man presented with intermittent rightsided dominant LBP, situated in an area around the posterior superior iliac spine, radiating into the right buttock and anterior thigh (Fig. 1). This had never settled completely following a fall onto his buttocks two and a half years earlier. Functionally, the pain mainly interfered with walking, especially uphill. Lying prone and sitting were relieving factors, although rising from sitting was painful. His general health was fair, suffering migraines regularly and some angina pectoris with exertion. Relevant psychosocial factors (Kendall et al., 1997) included poor social support (the patient lived by himself in a small basement apartment), low living standards and educational level. Furthermore, the patient was off work due to his chronic cluster

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Fig. 1. Body chart depicting pain presentation.

migraines. Lumbar X-rays revealed early degeneration of T12-L3. When necessary, he would use simple analgesics to control the back pain. 2.2. Physical examination The patient was assessed using the MDT approach. Baseline range of motion assessment of ﬂexion in standing showed no loss of movement but reproduction of right LBP during the movement. There was moderate loss of extension with reproduction of right LBP. Side gliding to both sides also produced right LBP but no loss of movement. Repeated movement testing, a key component of MDT, in standing and lying, was unable to clearly identify a directional preference (McKenzie and May, 2003). Flexion, extension and lateral movements all produced back and/or thigh pain to some extent. A key ﬁnding was that ﬂexion in sitting consistently abolished the thigh pain, although there was no change to baseline tests. Conversely, sitting erect produced the symptoms. A neurological examination was normal and there were no neural tissue tension signs. It is recognised that the lumbar spine, the joints of the pelvic girdle, in particular the SIJs, and the hip may all refer pain to the location described by the patient. Testing of these other joints was deemed unnecessary on day one to avoid false-positive responses from these joints until the lumbar spine had been thoroughly tested (Laslett, 1997). Passive accessory or palpatory movement examination is not a routinely used procedure within the MDT system. The value of these procedures applied to the lumbar spine has not been proven and lack reliability (Van Trijffel et al., 2005). Therefore, it was deemed that adding these to the initial lumbar spine examination

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would add nothing further than what would be learned from the symptom responses to end range loading. 2.3. Treatment At the conclusion of the physical examination of the lumbar spine, due to the inconclusive nature of the responses, it was felt necessary to have the patient test further the effects of one movement over time in an attempt to gain more information. McKenzie and May (2003) recommend exclusion of the lumbar spine with a trial of exercise over 24–48 h before conducting other joint tests. Repeated ﬂexion in sitting was prescribed as this movement was the only one that reduced the distal symptoms. The patient was given instructions to perform this movement with ten repetitions every 2 h for the next 2 days. Appropriate warnings were given regarding worsening or signs of peripheralisation of leg symptoms. Flexion loading has been shown to create a posterior displacement of the nucleus polposus, and may therefore have a role in distortion or failure of the annulus posterolaterally (Edmonston et al., 2000; Fennell et al., 1996; Moore et al., 1996). However, ﬂexion may also produce centralisation. Although less common, a small percentage of patients with LBP centralise with ﬂexion (Donelson et al., 1991). Therefore, in case of a lumbar disc lesion, this procedure should produce changes in the symptomatic and/or the mechanical presentation (McKenzie and May, 2003). 2.4. Second visit The patient reported good compliance with the exercise, but returned with no change to the symptom behaviour. Reassessment of range of motion baselines in standing showed no change. Given that there was no change, that is, no evidence of peripheralisation, centralisation, lasting reduction or abolition of the symptoms, it was felt appropriate to test other joints. Assessment of the hip joint range of motion was normal. SIJ tests were then performed. First, a seatbelt was used to ﬁxate the pelvis during the performance of standing ﬂexion and extension. This signiﬁcantly decreased the pain felt with these two movements. Pain provocation tests were performed next. It is recommended that multiple pain provocation tests are performed and that three are positive to implicate the SIJ (Laslett and Williams, 1994; McKenzie and May, 2003). Of the recommended tests performed, Gaenslen’s test, distraction, thigh thrust and sacral thrust were positive. To complete the mechanical testing of the SIJ, symptom response to repeated end range patient selfgenerated anterior and posterior pelvic rotation was assessed (Figs. 2 and 3). It became evident that repeated anterior rotation decreased and abolished the thigh

Fig. 2. Repeated posterior SIJ rotation. Arrow depicts direction of force.

pain, with an improvement in the baseline measures in standing. A provisional diagnosis of SIJ derangement was made, and the patient was instructed to carry out the anterior rotation exercise repeatedly, ten repetitions every 2 or 3 h and return to the clinic in 4 days time. This exercise involves the patient kneeling with the knee of the symptomatic side on the ﬂoor. The patient moves forward exerting an extension motion through the hip and creating an anterior rotation on the ilium on that side (Fig. 3). 2.5. Third visit The patient returned reporting moderate compliance to the exercise. He had felt no thigh pain since leaving the clinic at the last visit, but was still experiencing the right LBP. He also reported a better ability to walk uphill with an increased stride length. Reassessment of

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Fig. 3. Repeated anterior SIJ rotation.

Fig. 4. Repeated anterior SIJ rotation with self overpressure. Arrow depicts direction of force by right hand.

standing baselines was better and in particular extension was pain free. The exercise was reviewed and with the addition of patient self-overpressure the back pain was abolished. The patient was advised to continue the same exercise and if possible add self-overpressure. The hand is placed over the posterior superior iliac spine to provide additional pressure to the movement (Fig. 4).

syndrome, reductive forces are applied repeatedly to relocate displaced tissue, and loading strategies are applied that decrease, abolish or centralise symptoms. Opposite loading strategies may cause production, worsening or peripheralisation of symptoms. Rapid and lasting changes in pain intensity and location are seen. The term ‘directional preference’ is used to describe this propensity of mechanical pain to lessen with movements in one direction and worsen with movements in the opposite direction (McKenzie and May, 2003). The conceptual model of derangement proposed by McKenzie and May (2000, 2003) involves internal articular displacement that causes a disturbance in the joint, which produces pain and impairment. In the spinal column this model is applied to the intervertebral disc. In the extremity joints it is suggested that intraarticular inclusions, like meniscoids, synovial folds, and fat pads become displaced and may block normal motion and cause abnormal stress on peri-articular tissue resulting in pain and impairment (Duparc et al., 2002; Hollander and Lidtke Lai, 1998; Jerosch and Schroder, 1996; Lahm et al., 1998). In contrast to most other synovial joints, no such structures are described in the SIJ. Whether this means that the SIJ is actually deprived of any intra-articular inclusions or if they were irrelevant to the aims of the studies remains unclear. Some authors describe the presence of joint debris in cadavers older than 40 years (Macdonald and Hunt, 1952; Bowen and Cassidy, 1981). Cyriax (1982) notes that it is possible for almost any articulation to develop loose bodies, which can cause painful locking or impairment of movement. If such debris is present, it is reasonable to conclude that it could become

2.6. Fourth–seventh visits The patient was regularly assessed over the next 4 weeks. There were a couple of ﬂare-ups of the back pain but these were easily abolished with repetition of the exercises by the patient. It was noted that the SIJ tests performed at the second visit became negative as time passed and daily activities were pain free. He was advised to continue the exercises twice daily for prevention or more frequently if necessary. With wellintegrated self-management he felt conﬁdent to be discharged.

3. Discussion The MDT Method emphasises the use of patient selfgenerated loading strategies in the assessment and management of musculoskeletal problems. Repeated movement testing is a key component of this and is used to help the trained clinician identify and sub-classify mechanical presentations of the spine and extremity joints. Derangement is deﬁned as an alteration in the normal resting position of the affected joint surfaces (McKenzie and May, 2003). In the derangement

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entrapped and hence respond to repeated movement that reduces the displacement. Furthermore, the effect of repeated end range loading can often determine the potential of a patient to respond to mechanical therapy. Once a positive response is sought, the patient can then appropriately and safely apply the movement on a regular basis. In this case, repeated movement testing of the SIJs revealed localisation of pain (McKenzie and May, 2000) with repeated anterior rotation as well as improvement of baseline measures. Repeated posterior rotation had no effect rather than to localise or peripheralise the pain. It is not always possible to conﬁrm the directional preference of a derangement symptomatically in this way, although it is often possible. Rapid change in one or more baselines indicates derangement as a provisional working diagnosis. This diagnosis was conﬁrmed over the following visits as the patient improved and became symptom free. In this case, there was no clear evidence of centralisation or peripheralisation of the symptoms in response to repeated movements of the lumbar spine, which was clariﬁed by testing over an initial 48 h period. While testing the lumbar spine in this way, it is recommended not to introduce SIJ provocation tests as these can produce false-positive responses in people without conﬁrmed SIJ pathology (Laslett, 1997). It is interesting to note that Werneke and Hart (2003) demonstrated that a percentage of patients who do not display centralisation at their initial visit may do so at subsequent visits. This is a further important reason to test the lumbar spine alone so as not to miss this important prognostic ﬁnding. Absence of centralisation/peripheralisation makes the pathology of a derangement of an intervertebral disc unlikely and improves the validity of the SIJ tests (Donelson et al., 1997; Laslett et al., 2003; Young et al., 2003). Other clinical associations considered are that patients having SIJ pain at or above the level of L5 is rare, and presence of midline pain tends to exclude the SIJ as a pain generator (Young et al., 2003). Since all the above-mentioned criteria were met, the possibility of a symptomatic SIJ was likely in this case. If a SIJ problem is not mechanical, it may be inﬂammatory, or in women may be classiﬁed as posterior pelvic pain (Ostgaard et al., 1994). Evidence to support an inﬂammatory lesion in this case was minimal, therefore repeated movements of the SIJ were deemed appropriate. Furthermore, the initial assessment revealed clearly several indicators for chronicity. The patient suffered from a longstanding condition with important functional limitations. He had little social support, low living and educational levels and was off work for cluster migraines since many years. The current literature favours a cognito-behavioural approach to chronic back pain in the presence of yellow ﬂags (Linton and Ryberg,

2001; Ostelo et al., 2005). However, the present case report demonstrates that a well-structured mechanical assessment and treatment approach should still be performed in the presence of psychosocial factors. The MDT approach in particular may be a useful tool for the clinician. In addition to being reliable and valid (Kilpikoski et al., 2002; Rasmjou et al., 2000), this method is patient-centred and uses, in most cases, lowtech self-treatment procedures.

4. Conclusion This case report demonstrates a structured and comprehensive assessment and treatment approach and is in line with MDT principles and the work of other authors on the reliability and validity of SIJ assessment. The concept of assessing and treating peripheral joints based on the MDT Method is relatively new. Thus far, no research has been published as to the prevalence of the three syndromes, i.e. postural, dysfunction and derangement syndrome, in the extremities, potential pain generators or the efﬁcacy of any proposed interventions for this group of patients. It appears, however, that the recognition of the centralisation phenomenon and symptom responses to repeated end range movements can be clinically signiﬁcant, and assist in the identiﬁcation of the affected structures. The implications from all types of studies on the SIJ suggest use of pain provocation tests and a treatment approach that emphasises the patients’ involvement in managing their own back problem (Walker, 1992). The MDT approach and clinical reasoning process appears ideal for this. The ﬁndings of psychosocial factors should not stop the clinician from a well-structured mechanical assessment. If the ﬁndings from the initial examination are inconclusive, symptom response to mechanical loading strategies need to be assessed over a few days.

Acknowledgements The authors would like to thank Robin McKenzie, Stephen May and The McKenzie Institute International Research Committee for their assistance with this paper. References Bouter LM, Van Tulder MW, Koes BW. Methodologic issues in low back pain research in primary care. Spine 1998;23:2014–20. Bowen V, Cassidy D. Macroscopic and microscopic anatomy of the sacroiliac joint from embryonic life until the eighth decade. Spine 1981;6(6):620–8. Brukner P, Khan K. Clinical sports medicine. 2nd ed. Sydney: McGraw-Hill Companies Inc; 2001.

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Walker JM. The sacroiliac joint: a critical review. Physical Therapy 1992;72(12):903–16. Werneke M, Hart DL. Discriminant validity and relative precision for classifying patients with non-speciﬁc neck and back pain by anatomic pain patterns. Spine 2003;28:161–6. Young S, Aprill CN, Laslett M. Correlation of clinical examination characteristics with three sources of chronic low back pain. The Spine Journal 2003;3:460–5.

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Manual Therapy 12 (2007) 133–138 www.elsevier.com/locate/math

Original article

Initial development of a device for controlling manually applied forces Gordon S. Waddingtona,, Roger D. Adamsb a

Physiotherapy, School of Health Sciences, University of Canberra, ACT 2601, Australia School of Physiotherapy, The University of Sydney, Australia, P.O. Box 170, Lidcombe NSW 1825, Australia

b

Received 8 August 2003; received in revised form 28 January 2006; accepted 2 June 2006

Abstract In both simulation and manual therapy studies, substantial variability has been shown when therapists attempt to replicate an applied force. Knowledge about the forces employed during treatment could reduce this variability. In the current project, a prototype for a mobilizing device incorporating a dynamometer was constructed. The prototype device was built around a conventional ‘‘hand-grip’’ dynamometer to give dial visibility during application of mobilizing forces and a moulded handle was used to increase the hand contact surface during force application. The variability of the mobilization forces produced was measured, and ratings of comfort during a simulated spinal mobilization technique were obtained from therapists. Method: Thirty physiotherapists were randomly allocated to apply either: (i) their own estimate of a grade III mobilization force using their hands in a pisiform grip or (ii) a 100 N force with the manual therapy dynamometer, and to rate comfort during the performance of both techniques on a 100 mm visual analogue scale. Results: Variance in dynamometer-dial-guided force application was always signiﬁcantly less than the variance in therapist-conceptguided force application. Repeated-measures tests showed that the mean force produced at grade III was not signiﬁcantly different from 100 N, but physiotherapist comfort ratings were found to be signiﬁcantly greater (Po0:01) when the manual therapy dynamometer was used. Conclusion: Manually applied force variability was signiﬁcantly less and therapist comfort greater when using a device with visual access to a dial giving immediate force readout. r 2006 Elsevier Ltd. All rights reserved. Keywords: Manual forces; Dynamometer; Force variation

1. Introduction Although there are studies reviewing the occurrence of hand injuries to physiotherapists who perform manual techniques (e.g. Snodgrass and Rivett, 2002; Snodgrass et al., 2003), in the domain of manual therapy to date there has been relatively little research and equipment development directed toward ‘‘ﬁtting the Corresponding author. Tel.: +61 2 6201 2737; fax: +61 2 6201 5727. E-mail addresses: [email protected] (G.S. Waddington), [email protected] (R.D. Adams).

1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.06.009

work to the physiotherapist’’ (Hignett, 1995). Instead, the available literature on preventing musculoskeletal problems arising from clinical use of the hands has tended to focus on changing the therapist, through programs of stretching, strengthening and altered therapist posture during treatment (e.g. Greene, 1995). The current investigation constitutes preliminary research on aspects of a device which might better ﬁt the work of spinal mobilization to the manual therapist, with a focus on using a device to control the mobilization forces produced, and with the condition that the device should be acceptably comfortable to the therapists’ hands (Marston and Brookes, 2005).

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In addition to the treatment effects of manually applied forces, the importance of touch in therapy has been noted both with respect to the patient–therapist relationship (Hargreaves, 1987) and in the role physical contact plays in the healing process (Kolt and Andersen, 2004). Given these factors, the preference of many patients for ‘hands-on’ therapy is not surprising. Evidence is growing, however, that for some therapists there can be a cost to their hands. The hand–wrist complex of the manual therapist is the primary site of force application during spinal mobilization/manipulation, and by Newton’s Third Law of Motion the therapist’s hands must absorb the same force as is applied to the patient. The intrinsic feedback from manual force production may not, however, provide accurate information about the loads being applied. Harms and Bader (1997) have shown there to be substantial variability in attempts to reproduce the same force. Similarly, Chester et al. (2003) found the forces produced by manual physiotherapists when simulating grades I–IV of posteroanterior oscillatory movements to have considerable overlap. When therapists informed investigators as to the grade of treatment they would use, then applied mobilization forces to patients lying on an instrumented couch, forces produced were similarly variable (Chiradejnant et al., 2002). Embedding the therapy table in a force plate, as was carried out by Triano et al. (2002) is likely to be too expensive a solution. Integrating applied force readout into a mobilization device would enable the therapist to stop force application at a predetermined point. Silverstein et al. (1985) found that the two major factors in the causation of occupational hand problems were force and repetition, and both of these are features of manual physiotherapy. Pain in the wrists and hands of physiotherapists performing manual therapy represents a signiﬁcant occupational health issue for this group. In studies of physical therapists, where approximately one-third of those surveyed reported symptoms in the wrist/hand, this region is second only to the low back as the anatomical area most frequently injured (Bork et al., 1996; Holder et al., 1999; Cromie et al., 2000; West and Gardner, 2001; Caragianis, 2002). Two widely used handgrips in manual therapy are those proposed by Maitland (1986), wherein the PA force is applied to the spine either by the thumb tips or the pisiform region of the therapist’s hand. Cromie et al. (2000) noted that thumb symptoms, in particular, were related to the performance of manipulation and mobilization techniques, and that there was a direct relationship between the prevalence of symptoms and the number of hours spent performing such techniques. This conclusion is supported by data from a survey of 122 private practice physiotherapists working in Ireland, where 79% experienced thumb signs and symptoms, and 73% attributed these symptoms to daily seeing large

numbers of patients and performing the same technique repetitively (Branton, 2003). As an initial step to reducing risk of work-related musculoskeletal injury, Cromie et al. (2001) have proposed guidelines which include the use of physical equipment where there are known ergonomic risks associated with particular postures and exertions, e.g. height-adjustable plinths, angle-adjustable work surfaces (Cromie et al., 2001). However, no speciﬁc mention of the hands was made. A search of the literature for equipment speciﬁcally designed for hand protection during manual therapy revealed only two relevant reports; an ‘equipment note’ suggesting the use of thermoplastic splints for the thumbs (Blizzard, 1991) and a study assessing two hand-held manual therapy tools (Maher et al., 2002). In response to the perceived need for a manual therapy tool to reduce the forces applied to the therapist’s wrist and hand, some devices have become commercially available, including the Superthumb and Kneeshaw devices, however, an evaluation by Maher et al. (2002) found these devices to be signiﬁcantly less comfortable than conventional manual therapy, for both the therapist and the patient. The authors suggested that this lack of comfort stemmed from insufﬁcient contact surface area when compared to the pisiform grip normally used in manual therapy. The amount of research into hand forces in manual physiotherapy is in contrast with that conducted in manufacturing or laboratory settings, where work requiring high force has been identiﬁed as a risk factor for hand–wrist cumulative trauma disorders (Silverstein et al., 1985; Barr and Barbe, 2002). In tool use, there is concern to maximize the hand–handle pressure distribution (Gurram et al., 1995), and this concern has translated to a moulded handle of a walking stick, in order to spread pressure evenly across the palm (Marston and Brookes, 2005). Accordingly, the principles guiding the development of the device described here were that it should give instantaneous force readout and maximize hand contact area.

2. Aims and hypotheses The primary aim of this study was to develop a manual mobilization device with maximum hand contact area, and to determine comfort in relation to the therapists’ application of a manual therapy technique using the pisiform grip. Accordingly, relative comfort assessment was made by therapists when performing the posteroanterior (PA) pressure to an equivalent level, manually and when holding the prototype instrument. The second aim of the current study was to compare variability in attempts at standard force production

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made using a hand-held therapy device with and without instantaneous force readout being visible. Inter-therapist variability of forces applied during the simulated PA pressure was also determined.

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3.1. Subjects Thirty physiotherapists were recruited from the staff of the Calvary and Canberra Hospitals and the ACT region by notices placed on the staff notice boards of the Physiotherapy Departments of the Hospitals and by advertisement through the ACT branch of the Australian Physiotherapy Association.

3. Materials and methods 3.2. Procedure A prototype for a manual therapy dynamometer was constructed by modifying a hand-grip strength dynamometer (Hand Dynamometer, Ausmedic Ltd., 4/37 Leighton Place, Hornsby NSW 2077, Australia). The grip handle of the dynamometer was reversed to create an internal oval shape in the device, to which a moulded plastic handle and ﬁrm rubber tip were attached (see Fig. 1). Reliability of visually guided force control using the device was determined using a set of Neopost TEP50 digital scales, Satas, France, (Australian distributor; GBC Fordigraph Pty Ltd.). A random sequence of 50, 100 and 200 N forces, applied to the scale plate and controlled by using the dynamometer dial, was followed until each force had been repeated 10 times. Upon reaching a speciﬁed force level on the mobilization dynamometer, the reading was simultaneously taken from the display on the digital scales.

Reproducing forces of different grades on a plinth using the device with dial obscured: Each therapist undertook a brief period of instruction in the use of the manual therapy dynamometer prior to its use. They were then asked to push down to an ‘‘end feel’’ mobilization force on the plinth surface, and the maximum force attained was recorded from the dynamometer dial by a researcher. Therapists then used the device to apply a randomized sequence of the standard grades I–III or IV mobilization forces to the plinth surface, until they had pushed three times at each grade. Because the dial was obscured from them throughout, the therapists were using their concept of the force appropriate for each grade to guide constant force production. Their realization of each mobilization force was recorded by an experimenter, who could observe the dynamometer dial. No feedback regarding any force applied was given to the therapist. This test procedure was repeated twice within the same measurement session. Rating comfort of grade III force applied by hand and a 100 N force applied with the device dial visible: Each therapist was randomly allocated to apply ﬁrst one, and then the other, of either; their own estimate of a grade III mobilization force applied to the plinth using their hands in a pisiform grip, or a 100 N mobilization force applied at the same location on the plinth using the manual therapy dynamometer. After each condition the therapist was asked to rate their comfort during the performance of the PA pressure on a 100 mm visual analogue scale (from very uncomfortable at 0 mm to very comfortable at 100 mm) in the manner of Maher et al. (2002).

4. Results 4.1. Reliability

Fig. 1. The prototype for the manual therapy dynamometer was constructed by modifying a hand-grip strength dynamometer (Hand Dynamometer, Ausmedic Ltd., 4/37 Leighton Place, Hornsby NSW 2077, Australia).

Manual mobilization forces produced on a plinth by the 30 physiotherapists, representing their grades I–IV and ‘end feel’ (Fig. 2), were cast into separate therapist grade matrices for each of the three attempts. Considering the ﬁve grades as targets, and the therapists as testers, the ICC(2,1) was calculated for

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Manual Mobilisation Force

300 250

Newtons

200 150 100

grades, forces produced at each of the three attempts at grades I, III and End Feel were tested against hypothesized means of 50, 100 and 200 N, respectively, and found not to be signiﬁcantly different at any value, except for the ﬁrst attempt at grade I, where the mean force produced, at 39.7 N, was signiﬁcantly less than 50 N (F 1 ;29 ¼ 5:62, P ¼ 0:02). These means and standard deviations are given in Fig. 3. 4.3. Variance in force production

50 0 Grade I

Grade II Grade III Grade IV End Feel Mobilisation Applied

Fig. 2. Means and standard deviations for manual mobilization forces produced on a plinth by the 30 physiotherapists, representing grades I–IV and ‘end feel’. The y-axis represents the force output on the digital scales. Force variability increases with force applied.

Mobilisation Dynamometer

300 250

To compare variance in concept-guided and deviceguided forces, F-ratios were formed using the variance between the mean forces generated over three attempts by 30 physiotherapists in the numerator, and the variance over 10 repetitions of visually guided force application on a set of digital scales in the denominator (Hays, 1988). The values obtained were F ð29;9Þ ¼ 973:5 for grade I (50 N), F ð29;9Þ ¼ 334:4 for grade III (100 N) and F ð29;9Þ ¼ 488:2 for End Feel (200 N) with all Pvalues o0.001. That is, the variance in dynamometerdial-guided force application was always signiﬁcantly less than the variance in therapist-concept-guided force application.

Newtons

200

4.4. Hand comfort ratings 150 100 50 0 50N

100N

200N

Dynammmeter Force Applied Fig. 3. Means and standard deviations for three forces (50, 100 and 200 N) applied 10 times using the dial readout of the dynamometer to control force application. The y-axis represents the force output on the digital scales. Force variability remains constant as force applied increases.

each occasion and found to be 0.64 (95% CI ¼ 0.370.94), 0.63 (95% CI ¼ 0.360.93) and 0.63 (95% CI ¼ 0.360.93) for force production on occasions one to three, respectively). In contrast, when three forces (50, 100 and 200 N) were applied 10 times to the digital scales, using the dial readout of the dynamometer to control force application (Fig. 3), the ICC (2,1) was 0.999 (95% CI ¼ 0.996–0.9999). Means and standard deviations for these controlled force applications are presented in Fig. 3. 4.2. Mean applied force To determine whether the therapists were using speciﬁc values as concepts of different mobilization

The mean (SD) scores for hand comfort during a PA force application using the mobilization dynamometer or the therapist’s hands alone were 8.3 (0.8) and 5 (2.0), respectively. When compared with a repeated measures ANOVA, the device was found to be signiﬁcantly more comfortable to use than the hands in the pisiform grip (F 1 ;29 ¼ 86:1, Po0:01).

5. Discussion When the therapists who participated in this study used a mobilization device without feedback to produce different grades of manually applied force, the mean values generated at grades I, III and End Feel equated closely to 50, 100 and 200 N, suggesting that, as a group, they had acquired grade concepts matching these values. However, forces produced by different physiotherapists trying to push at the same grade varied, and to a signiﬁcantly greater extent than force productions made with the same device but guided by the use of the dynamometer dial readout. Examinations of functions plotting manually applied forces against the intended force output level shows a growth in error with increasing force level. This holds for forces generated on dynamometers (Carlton and Newell, 1993), on a plate resting on four rubber squash balls (Watson and Burnett, 1990), applied to healthy subjects (Harms and Bader, 1997) and to backs of back

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pain subjects (Chiradejnant et al., 2002). Variation in forces measured from the device in the current study show a similar function. Making force readout available during force generation, however, produces a different function, with no observable growth in error over the force range studied. There are further empirical issues to be considered in respect of any spinal mobilization device, other than therapist comfort and accuracy of force control. These relate to the speciﬁcity of location of the device on the spine, the sensitivity of ‘feel’ available to the manual therapist when examining and treating, and, ﬁnally, to the need, from the patient viewpoint, for some part of a manual therapy treatment to be ‘hands-on’. Regarding the ﬁrst issue, the surface area of the rubber tip of the device represents a trade-off between patient comfort and placement speciﬁcity. Squires et al. (2000) showed that the area of the contact plate on a mechanical spinal stiffness assessment device was inversely related to patient comfort, i.e. the downwards force being applied over a small area was the most uncomfortable. In the current device, the area of the rubber tip was selected to be greater than the contact area of the average pisiform (Nicholson et al., 1998), but the selection is such that we are still able to place it over a single vertebra. Resolving the ‘feel’ and ‘hands-on’ issues in relation to the use of therapy devices will require further studies. There is little alternative however to keeping a force information source built into the device. Physiotherapy mobilization techniques require the application of speciﬁed forces across joint and soft tissue structures, yet the quantiﬁcation of these forces to determine dose–response relationships, to determine the amount of force corresponding to pain onset for reference in future treatment sessions, and to allow inter-therapist treatment comparisons, has previously only been possible with instrumented plinths (Harms et al., 1995; Triano et al., 2002). Although instrumented plinths provide a functional research tool they do not provide a practical solution to determining mobilizing forces applied by the therapist in a clinical setting. There are evident limitations to the clinical application of the prototype mobilizing device in its current form. In use the intervening dynamometer frame raises the height of the hands relative to the body, so a redesigned device, using and electronic force registration transducer rather than a hydraulic system, is needed to reduce device height. Further there are questions with respect to patients’ acceptance of the feel of the foot of the device on the spine, and with regard to the ability of therapists to discriminate stiffness when using the device. When this latter question was examined by Maher et al. (2002), these researchers found that ability to discriminate elastic stiffness with the hands was equivalent to that observed when the Kneeshaw and

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Superthumb devices were used, but sensitivity to differences remains to be examined with any new device. Lastly, even with a device found to be acceptably comfortable on the patient’s back and at the therapist’s hands, which maintained the ‘feel’ available to the hands alone, research would be required to determine if longterm use did in fact reduce the risk of hand/wrist injury to manual therapists.

6. Conclusion Manually applied force variability was signiﬁcantly less and therapist comfort is greater when using a device with visual access to a dial giving immediate force readout. To this end, continuing the process of reﬁning the design of a manual therapy tool, with the speciﬁcation that it maintains both therapist and patient comfort as well as providing the therapist with concurrent force readout, is a project worth pursuing. References Barr A, Barbe M. Pathophysiological tissue changes associated with repetitive movement: a review of the evidence. Physical Therapy 2002;82:173–87. Blizzard P. Save our thumbs. Physiotherapy 1991;77:573–4. Bork B, Cook T, Rosecrance J, Englehardt K, Thomason M, Wauford I, et al. Work-related musculoskeletal disorders among physical therapists. Physical Therapy 1996;76:827–35. Branton A. A study examining the prevalence of thumb signs and symptoms among physiotherapists working in private practice in Ireland. In: Proceedings of the 14th international WCPT congress, world physical therapy, 2003. Caragianis S. The prevalence of occupational injuries among hand therapists in Australia and New Zealand. Journal of Hand Therapy 2002;15:234–41. Carlton L, Newell K. Force variability and characteristics of force production. In: Newell K, Corcos D, editors. Variability and motor control. Chicago, IL: Human Kinetics Publishers; 1993. Chester R, Swift L, Watson M. An evaluation of therapists’ ability to perform graded mobilization on a simulated spine. Physiotherapy Theory and Practice 2003;19:23–34. Chiradejnant A, Latimer J, Maher C. Forces applied during manual therapy to patients with low back pain. Journal of Manipulative and Physiological Therapeutics 2002;25(6):362–9. Cromie J, Robertson V, Best M. Work-related musculoskeletal disorders in physical therapists: Prevalence, severity, risks and responses. Physical Therapy 2000;80:336–51. Cromie J, Robertson V, Best M. Occupational health and safety in physiotherapy: guidelines for practice. Australian Journal of Physiotherapy 2001;47:43–51. Greene L. Save your hands! Injury prevention for massage therapists. Seattle, WA, USA.: Inﬁnity Press; 1995. Gurram R, Rakheja S, Gouw G. A study of hand grip pressure distribution and EMG of ﬁnger ﬂexor muscles under dynamic loads. Ergonomics 1995;38:684–99. Hargreaves S. The relevance of nonverbal skills in physiotherapy. Physiotherapy 1987;73:685–8. Harms M, Bader D. Variability of forces applied by experienced therapists during spinal mobilization. Clinical Biomechanics 1997;12:393–9.

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Harms M, Cusick G, Bader D. Measurement of spinal mobilisation forces. Physiotherapy 1995;81:599–604. Hays W. Statistics. New York: Holt, Rinehardt & Winston; 1988. Hignett S. Fitting the work to the physiotherapist. Physiotherapy 1995;81:549–52. Holder N, Clark H, DiBlasio J, Hughes C, Scherpf J, Harding L, et al. Cause, prevalence, and response to musculoskeletal injuries reported by physical therapists and physical therapy assistants. Physical Therapy 1999;79:642–52. Kolt G, Andersen M. Psychology in the Physical and Manual Therapies. London: Churchill Livingstone; 2004. Maher C, Latimer J, Starkey I. An evaluation of Superthumb and the Kneeshaw device as manual therapy tools. Australian Journal of Physiotherapy 2002;48:25–30. Maitland G. Vertebral manipulation. London: Butterworths; 1986. Marston A, Brookes B. Evaluation of a moulded handle walking aid for older people with non-arthritic hands. International Journal of Therapy and Rehabilitation 2005;12(9):409–15. Nicholson L, Maher C, Adams R. Hand contact area, force applied and early non-linear stiffness (toe) in a manual stiffness discrimination task. Manual Therapy 1998;3:212–9.

Silverstein B, Fine L, Armstrong T. Hand wrist cumulative trauma disorders in industry. British Journal of Industrial Medicine 1985;43:779–84. Snodgrass S, Rivett D. Thumb pain in physiotherapists: potential risk factors and proposed prevention strategies. The Journal of Manual and Manipulative Therapy 2002;10(4):206–17. Snodgrass S, Rivett D, Chiarelli P, Bates M, Rowe L. Factors related to thumb pain in physiotherapists. Australian Journal of Physiotherapy 2003;49:243–50. Squires M, Latimer J, Adams R, Maher C. Indenter head area and testing frequency effects on posteroanterior lumbar stiffness and subjects’ rated comfort. Manual Therapy 2000;6:40–7. Triano J, Rogers C, Combs S, Potts D, Sorrels K. Developing skilled performance of lumbar spine manipulation. Journal of Manipulative and Physiological Therapeutics 2002;25:353–61. Watson M, Burnett M. Equipment to evaluate the ability of physiotherapists to perform graded postero-anterior central vertebral pressure type passive movements of the spine by thumb pressure. Physiotherapy 1990;76(10):611–4. West D, Gardner D. Occupational injuries of physiotherapists in North and Central Queensland. Australian Journal of Physiotherapy 2001;47:179–86.

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Manual Therapy 12 (2007) 139–143 www.elsevier.com/locate/math

Original article

Recruitment of the deep cervical ﬂexor muscles during a postural-correction exercise performed in sitting$ Deborah Fallaa,b,, Shaun O’Learya, Amy Fagana, Gwendolen Julla a

Division of Physiotherapy, The University of Queensland, Brisbane, Australia Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Aalborg, Denmark

b

Received 7 September 2005; received in revised form 6 February 2006; accepted 2 June 2006

Abstract Speciﬁc strategies to optimally facilitate postural muscles to retrain postural form are advocated in the clinical management of neck pain. The purpose of this study was to compare the activation of selected cervical, thoracic and lumbar muscles during independent and facilitated postural correction in sitting in 10 subjects with chronic neck pain. Deep cervical ﬂexor (DCF) muscle activity was recorded with custom electrodes inserted via the nose and ﬁxed by suction to the posterior mucosa of the oropharynx. Surface electrodes were placed over the thoracic erector spinae and lumbar multiﬁdus muscles. Root-mean-square EMG amplitude was measured for each muscle across two conditions. In the ﬁrst condition, subjects were instructed to spontaneously ‘‘sit up straight’’ from a slumped posture without any other guidance from the therapist. In the second condition the therapist provided speciﬁc manual and verbal facilitation to assist the patient to correct to an upright pelvic position with a neutral spinal lumbo-pelvic position. Activation of the DCF and lumbar multiﬁdus muscles (Po0.05) were signiﬁcantly greater when the therapist facilitated postural correction compared to independent sitting correction. Speciﬁc postural-correction strategies result in better facilitation of key postural muscles compared to non-speciﬁc postural advice. The results of this study highlight the need for clinical skill and precision in postural training of patients with neck pain. r 2006 Elsevier Ltd. All rights reserved. Keywords: Posture; Exercise; Neck pain; Electromyography

1. Introduction The primary function of the cervical spine is to orientate the head against the opposing forces of gravity whilst permitting multi-directional movement. To accomplish this task the cervical spine must be mechanically stable, both in static and dynamic postures. In upright neutral postures, passive resistance to cervical spine motion is minimal (Oatis, 2004) and destabilizing gravitational forces are counteracted by moments of the $ This research was undertaken in the Division of Physiotherapy, The University of Queensland, Australia. Corresponding author. Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Faculty of Engineering and Science, Aalborg University, Fredrik Bajers Vej 7D-3, DK-9200 Aalborg, Denmark. Tel.: +45 96 35 74 59; fax: +45 98 15 40 08. E-mail address: [email protected] (D. Falla).

1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.06.003

anterior and posterior cervical muscles. In particular, the deep more segmental cervical muscles such as the deep cervical ﬂexors (DCF), are important for the control and support of the cervical lordosis and maintenance of cervical spine postural form (MayouxBenhamou et al., 1994; Conley et al., 1995; Vasavada et al., 1998; Boyd Clark et al., 2001, 2002). Our previous research has identiﬁed impaired activation of the DCF muscles, longus colli and longus capitis, in people with chronic neck pain (Falla et al., 2004a, b). These ﬁndings, in addition to evidence of altered control of functional working postures in persons with neck pain (Szeto et al., 2002), has directed the use of clinical posture-correction strategies as an early therapeutic exercise intervention in the management of neck pain (Jull et al., 2004). To retrain a neutral sitting posture patients are ﬁrstly taught to achieve a neutral

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lumbo-pelvic sitting posture, followed by correction of thoracic and cervical postures with a subtle ‘sternal lift’ or ‘sternal drop’ as appropriate and a gentle ‘occipital lift’ manoeuvre to position the head in neutral. It has been proposed that frequent correction to an upright neutral postural position serves two functions (Jull et al., 2004). Firstly, that it may provide a regular reduction of adverse loads on the cervical joints induced by poor spinal, cervical and scapular postures. Secondly, it may train the deep postural stabilizing muscles of the spine in their functional postural supporting role. Patients are encouraged to perform this exercise repeatedly throughout the day, with the emphasis being on a change in postural habit (Jull et al., 2004). One early study on normal subjects using ﬁne wire electrodes (Fountain et al., 1966) found that a neck straightening manoeuvre increased the activity in the longus colli muscle. However, since that time, there has been no further use of ﬁne wire electrodes (presumably due to ethical safety reasons) or study of postural-correction techniques to determine whether or not clinical techniques of postural re-education can activate the DCF muscles. This is particularly relevant to patients with neck pain. The purpose of this study was to investigate the activation of the DCF muscles, in conjunction with the lumbar multiﬁdus and thoracic erector spinae muscles during the postural-correction sequence. More speciﬁcally, the primary aim of the study was to determine if speciﬁc re-education of sitting posture in neck pain patients is necessary to achieve recruitment particularly of the DCF muscles, or if simply instructing patients to spontaneously ‘‘sit up straight’’ would be equally effective. We hypothesized that the speciﬁc re-education of posture strategy would produce greater activation of the DCF muscles than simply an instruction for the patient to spontaneously sit up straight.

2. Methods 2.1. Subjects Ten female subjects with a history of chronic neck pain participated in this study. Subjects were recruited via advertisements in local and university press. Participants were aged between 21 and 52 years (mean 39.8, SD 11.2 years) and had a history of neck pain greater than one year (mean 13.4, SD 11.7 years). The mean and SD for average intensity of pain (score out of 10) and perceived disability rated on the Neck Disability Index (score out of a 50) were 4.572.3 and 10.572.9, respectively. Subjects were excluded if they had either undergone spinal surgery, complained of any neurological signs, had participated in a neck or back exercise program in the past 12 months or were undergoing treatment at the time of testing. Ethical approval for the

study was granted by the Institutional Medical Research Ethics Committee and all procedures were conducted according to the Declaration of Helsinki. 2.2. Electromyography EMG recordings of the DCF muscles were made unilaterally using bipolar electrodes (Falla et al., 2003). Measurements were made on the side of greatest pain for consistency between subjects. If subjects had bilateral neck pain, the more symptomatic side was tested. The apparatus consisted of silver wire electrode contacts (dimensions: 2 mm 0.6 mm, inter-electrode distance: 10 mm) attached to a suction catheter in vertical alignment (size 10FG), with a heat sealed distal end, which were inserted via the nose to the posterior oropharyngeal wall. The DCF muscles are situated posterior to the oropharyngeal wall providing an ideal location to make recordings via the mucosal wall without requiring intramuscular recording techniques (Falla et al., 2003). Placement of the electrodes ensured correct orientation along the ﬁbres of the DCF muscles, approximately 1 cm lateral to the midline at the level of the uvula (approximately the level of the C2-3 intervertebral disc) which is the level of the muscle belly of longus capitis and at which the upper portion of the longus colli muscle has its greatest cross-sectional area (Lang, 1993). Location of the electrode was conﬁrmed by inspection through the mouth. Once this position was achieved, the electrode contacts were ﬁxed to the mucosal wall with a suction pressure of 30 mmHg via a portal between the two contacts. Prior to insertion, the nose and pharynx were anaesthetized with three metered doses of Xylocaines spray (Astra Pharmaceuticals) administered via the nostril and three metered doses to the posterior oropharyngeal wall on the same side, via the mouth. Myoelectric signals were detected from the thoracic erector spinae and lumbar multiﬁdus ipsilateral to the DCF electrode using surface electrodes (20 mm Ag/Ag Cl disc electrodes, inter-electrode distance ¼ 20 mm, Grass Telefactor, Astro-Med, Inc.) following careful skin preparation. Electrodes for the lumbar multiﬁdus muscles were positioned immediately adjacent to the spinous process of the ﬁfth lumbar vertebrae (Ng et al., 2003). Electrodes for the thoracic erector spinae were positioned approximately 5 cm lateral to the spinous process of the tenth thoracic vertebrae such that the electrodes overlaid the thoracic portion of the longissimus thoracis muscle. A ground reference was placed over the upper thoracic spine. EMG data were ampliﬁed (Gain ¼ 1000), band pass ﬁltered between 20 Hz–1 kHz and sampled at 2 kHz. Data were sampled with Spike software (Cambridge Electronic Design, Cambridge, UK) and converted into a format suitable for signal

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2.3. Procedure Participants were asked to sit in a comfortable position on the treatment couch such that their feet were ﬂat on the ﬂoor and their buttocks were fully supported on the couch. The couch was set to a height so that with the feet ﬂat on the ﬂoor, the participant’s thighs were inclined slightly downwards from the horizontal so that the hips were approximately in 1001 of ﬂexion. This starting position was adopted so that hypomobility in the posterior hip structures in some patients would not prevent them from comfortably anteriorly rotating the pelvis at the hip joints required to achieve a neutral lumbar spine posture. Participants were ﬁrst asked to sit in this position in a slouched posture as they felt comfortable, and to focus on a marker on the wall directly in front of them. Participants were then asked to ‘‘sit up straight the best way they knew how’’ and to ‘‘maintain this position’’ for a 10 s duration during which EMG recordings were made. Following this, participants were instructed to slouch again and were then taught, with verbal and manual guidance, the corrected neutral postural position sequence by the therapist. Participants were instructed on three main elements. They were ﬁrstly asked to gently roll their pelvis forward such that they were sitting on top of their ischial tuberosities with resumption of the lumbar lordosis. Secondly, they were instructed that their thorax should move slightly upwards and forwards to follow the motion of the pelvis to encourage a slight sternal lift without excessive thoraco-lumbar extension. Lastly, the participant was asked to gently and minimally lift their occiput to position their head from any upper cervical extension position to a more neutral position. During this training period participants were given the appropriate manual facilitation by the musculoskeletal physiotherapist at the lumbo-pelvic region, the sternum, or the occiput as required by the individual to achieve the desired positions. This postural-correction sequence was practiced twice. Participants were then instructed to slouch again, and then to actively correct their posture into the upright neutral position with the verbal and manual facilitation provided by the therapist. The participant was then asked to maintain this corrected position for 10 s as EMG signals were acquired. No subject reported any pain with the postural correction procedures.

MathWorks, Inc. Natick, MA, USA). Reporting the data as absolute EMG amplitude precludes a betweenmuscle comparison for the two different conditions due to the various factors which inﬂuence EMG such as amplitude electrode location, thickness of the subcutaneous tissues and distribution of motor unit conduction velocities (Farina et al., 2004). For this reason, Wilcoxon signed-ranks tests were conducted to assess for change in RMS values across the two conditions for each muscle. Statistical analyses were performed using SPSS 10.0 for Windows. A value of Po0.05 was used as an indicator of statistical signiﬁcance.

3. Results As demonstrated in Figs. 1 and 2, when patients with neck pain were speciﬁcally facilitated into an upright neutral posture, the EMG amplitude of the DCF (Po0.05) and lumbar multiﬁdus (Po0.05) muscles were signiﬁcantly greater compared to the condition of unfacilitated spontaneous upright sitting. No difference in EMG amplitude for the thoracic erector spinae muscles (P40.05) between the two test conditions was recorded.

4. Discussion Retraining of neutral sitting postures is considered an important component of the rehabilitation of patients with neck pain. It has been hypothesized that speciﬁc correction of spinal postural form performed regularly throughout the day may assist training of the deep cervical stabilizing muscles in their functional postural supporting role (Jull et al., 2004). In favour of this hypothesis, the results of this study demonstrate greater activation of the DCF muscles with speciﬁc correction of spinal posture compared to independent erect sitting in patients with chronic neck pain. This ﬁnding highlights the need for clinical skill and precision in the 0.8 DCF EMG amplitude (µV)

processing with Matlab software (The MathWorks, Inc. Natick, MA, USA).

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*

0.7 0.6 0.5 0.4 0.3 0.2 0.1 0

2.4. Data analysis and statistics To obtain a measure of EMG signal amplitude, maximum root mean square (RMS) was calculated over 1 s epochs for each muscle using Matlab software (The

Un-facilitated

Facilitated

Fig. 1. Data for deep cervical ﬂexor (DCF) EMG during postural correction in sitting. Maximum root-mean-square values for the DCF muscles obtained for un-facilitated and facilitated postural correction in sitting. * denotes signiﬁcant difference (Po0.05).

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EMG amplitude (µV)

Multifidus 0.08

Thoracic ES

*

0.06 0.04 0.02 0

Un-facilitated

Facilitated

Un-facilitated

Facilitated

Fig. 2. Data for multiﬁdus and erector spinae EMG during postural correction in sitting. Maximum root-mean-square values for the lumbar multiﬁdus and thoracic erector spinae (ES) muscles obtained for un-facilitated and facilitated postural correction in sitting. * denotes signiﬁcant difference (Po0.05).

postural rehabilitation for patients with neck pain to achieve optimal beneﬁts of this self-help exercise strategy. 4.1. Muscle activation associated with corrected sitting posture Historically clinicians have instructed and encouraged patients to move out of slumped postures and to sit and stand in neutral spinal postures with the understanding that this minimizes mechanical load on the musculoskeletal system and may facilitate recruitment of the deep stabilizing muscles of the spine. Despite the absence of a deﬁnitive indicator or measure of neutral spine posture, clinically, a neutral sitting spine posture is encouraged by facilitating the formation of the normal lumbar and cervical lordoses, and a thoracic kyphosis, to a position in which all regions are neither ﬂexed or extended, a position that is subjectively judged by the therapist for an individual patient. The ﬁndings of this study are in accordance with those of Fountain et al. (1966). In particular, the results indicate that the longus capitis/colli can be facilitated with a speciﬁc clinical postural manoeuvre in neck pain patients. Additionally, the ﬁndings in the trunk muscles agree with those of O’Sullivan and colleagues (2002) who described activation of the lumbar multiﬁdus, thoracic erector spinae and the internal oblique muscles with assumption of an erect neutral sitting posture compared to slouch sitting. We concur with O’Sullivan et al.’s (2002) suggestions that instructing patients with low back pain to adopt an erect posture will facilitate key lumbo-pelvic stabilizing muscles, resulting in a more effective load sharing within the muscle system, reducing focal end range stress on the sensitized passive structures. The important extension of knowledge from this current study was the ﬁnding of signiﬁcantly greater activation of the DCF with adoption of a neutral lumbo-pelvic, cervical and cranio-cervical posture in patients with neck pain. A common clinical observation of patients with neck pain, when asked to assume an upright sitting posture, is

a movement strategy which appears to be initiated with and dominated by thoracolumbar extension rather than with the formation of a lumbar lordosis, with ‘over activation’ of the thoracolumbar extensors. When subjects were merely instructed to ‘‘sit up straight the best way they knew how’’ in this study, there was signiﬁcantly less lumbar multiﬁdus and DCF muscle activation compared to facilitation of the ‘ideal’ neutral postural position. However, there was no difference in the activation levels of the thoracic erector spinae muscles between the two sitting conditions. Thus, it appears that the patients do not use lesser thoracolumbar extensor activity in assuming a neutral lumbopelvic position, rather there is a pattern of synergistic use of both the lumbar multiﬁdus and thoracolumbar erector spinae. It is possible that the difference between the contributions of the lumbar and thoracic extensors may have been identiﬁed if other parameters of the EMG signal were analysed. For example, an investigation of the muscle recruitment order may have demonstrated different onset of muscle activation with the facilitated sitting posture compared to independent erect sitting. Further research is warranted to clarify this. 4.2. Clinical implications The beneﬁt of regular correction to an upright neutral posture has not been investigated in isolation in people with neck pain. However, there is evidence which indicates that speciﬁc postural re-education exercise as described in this study, in the context of an active muscle stabilization program is effective in the management of patients with chronic neck pain and headache (Jull et al., 2002). Speciﬁc postural re-education exercise which is initiated with the formation of a neutral lumbopelvic posture should therefore be viewed at this time as a component of rehabilitation which provides a simple means for the patient to recruit the deep postural muscles of the cervical spine in a functional way regularly throughout the day. Further research investigating the beneﬁts and mechanisms of speciﬁc

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postural-correction exercise alone both on patient symptoms and on postural form is warranted. 4.3. Study considerations It must be acknowledged that in this study we measured muscle EMG activity during sitting posturecorrection tasks, which involved manual and verbal facilitation provided by the therapist. Additional research is necessary to conﬁrm that the exercise is effective in recruiting the postural muscles when facilitation is either withdrawn by the therapist or is self-applied by the patient. This study was conducted on a group of female volunteers. Additional research is warranted to identify whether similar results would be obtained in male participants. Moreover, in future studies the use of concurrent movement analysis together with examination of the cervical extensor and axio-scapular muscles may provide a more complete picture about the biomechanical loadings of the spine.

5. Conclusion Postural re-education is recommended practice for the management of patients with cervical spine dysfunction. The results of this study demonstrate that re-education of sitting posture to an upright neutral spinal position promotes activation of the DCF muscles. Whilst further research is necessary to appreciate the beneﬁts of this exercise on patient symptoms and postural form, the results highlight the need for clinical skill and precision in the postural rehabilitation for patients with neck pain to achieve optimal effects of this self-help exercise strategy.

Acknowledgements Deborah Falla is supported by a Fellowship received from the National Health and Medical Research Council of Australia (ID 351678) and by a John J. Bonica Fellowship received from the International Association for the Study of Pain. This study was funded by a grant (ID 252771) received from the National Health and Medical Research Council of Australia.

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References Boyd Clark LC, Briggs CA, Galea MP. Comparative histochemical composition of muscle ﬁbres in a pre- and a postvertebral muscle of the cervical spine. Journal of Anatomy 2001;199:709–16. Boyd Clark LC, Briggs CA, Galea MP. Muscle spindle distribution, morphology, and density in longus colli and multiﬁdus muscles of the cervical spine. Spine 2002;27(7):694–701. Conley MS, Meyer RA, Bloomberg JJ, Feeback DL, Dudley GA. Noninvasive analysis of human neck muscle function. Spine 1995;20(23):2505–12. Falla D, Jull G, Dall’Alba P, Rainoldi A, Merletti R. An electromyographic analysis of the deep cervical ﬂexor muscles during craniocervical ﬂexion. Physical Therapy 2003;83:899–906. Falla D, Jull G, Hodges PW. Patients with neck pain demonstrate reduced electromyographic activity of the deep cervical ﬂexor muscles during performance of the craniocervical ﬂexion test. Spine 2004a;29(19):2108–14. Falla D, Jull G, Hodges PW. Feedforward activity of the cervical ﬂexor muscles during voluntary arm movements is delayed in chronic neck pain. Experimental Brain Research 2004b;157: 43–8. Farina D, Merletti R, Enoka RM. The extraction of neural strategies from the surface EMG. Journal of Applied Physiology 2004;96: 1486–95. Fountain FP, Minear WL, Allison RD. Function of longus colli and longissimus cervicis muscles in man. Archives of Physical Medicine and Rehabilitation 1966;47:665–9. Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002;27(17):1835–43. Jull G, Falla D, Treleaven J, Sterling M, O’Leary S. A therapeutic exercise approach for cervical disorders. In: Boyling JD, Jull G, editors. Grieve’s modern manual therapy: the vertebral column. Elsevier: United Kingdom; 2004. Lang J. Clinical anatomy of the cervical spine. Thieme Medical Publishers: New York; 1993. Mayoux-Benhamou MA, Revel M, Vallee C, Roudier R, Barbet JP, Bargy F. Longus Colli has a postural function on cervical curvature. Surgical and Radiologic Anatomy 1994;16:367–71. Ng JK-F, Parnianpour M, Kippers V, Richardson C. Reliability of electromyographic and torque measures during isometric axial rotation exertions of the trunk. Clinical Neurophysiology 2003; 114(12):2355–61. Oatis CA. Kinesiology: the mechanics and pathomechanics of human movement. Lippincott Williams & Wilkins: Philadelphia; 2004. O’Sullivan PB, Grahamslaw KM, Kendell M, Lapenskie SC, Moller NE, Richards KV. The effect of different standing and sitting postures on trunk muscle activity in a pain-free population. Spine 2002;27(11):1238–44. Szeto GPN, Straker L, Raine S. A ﬁeld comparison of neck and shoulder postures in symptomatic and asymptomatic ofﬁce workers. Applied Ergonomics 2002;33:75–84. Vasavada AN, Li S, Delp SL. Inﬂuence of muscle morphometry and moment arms on the moment-generating capacity of human neck muscles. Spine 1998;23(4):412–22.

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Manual Therapy 12 (2007) 144–152 www.elsevier.com/locate/math

Original article

Direct, quantitative clinical assessment of hand function: Usefulness and reproducibility Alexander Goodsona, Alison H. McGregora,, Jane Douglasb, Peter Taylorb a

b

Musculoskeletal Department Kennedy Institute of Rheumatology, Faculty of Medicine, Imperial College London, Charing Cross Hospital Campus, London W6 8RF, UK Received 26 January 2005; received in revised form 6 February 2006; accepted 2 June 2006

Abstract Methods of assessing functional impairment in arthritic hands include pain assessments and disability scoring scales which are subjective, variable over time and fail to take account of the patients’ need to adapt to deformities. The aim of this study was to evaluate measures of functional strength and joint motion in the assessment of the rheumatoid (RA) and osteoarthritic (OA) hand. Ten control subjects, ten RA and ten OA patients were recruited for the study. All underwent pain and disability scoring and functional assessment of the hand using measures of pinch/grip strength and range of joint motion (ROM). Functional assessments including ROM analyses at interphalangeal (IP), metacarpophalangeal (MCP) and wrist joints along with pinch/grip strength clearly discriminated between patient groups (RA vs. OA MCP ROM Po0.0001), pain and disability scales were unable to. In the RA there were demonstrable relationships between ROM measurements and disability (R2 ¼ 0.31) as well as disease duration (R2 ¼ 0.37). Intra-patient measures of strength were robust whereas inter-patient comparisons showed variability. In conclusion, pinch/grip strength and ROM are clinically reproducible assessments that may more accurately reﬂect functional impairment associated with arthritis. r 2006 Elsevier Ltd. All rights reserved. Keywords: Hand function; Arthritis; Disability; Cochin scale; Pinch; Grip; Range of motion

1. Introduction Hand function plays an essential role in carrying out activities of daily living (ADL). Both rheumatoid (RA) and osteoarthritis (OA) are known to affect hand function through inﬂammatory and degenerative processes, resulting in joint stiffness, pain, swelling, deformity and weakness (Smith, 2002). To be able to assess disease progression or clinical effectiveness a tool is required for documenting hand function and disability. A plethora of scoring scales exist (Jebsen et al., 1969; Chung et al., 1999; van Lankveld et al., 1999; Poiraudeau et al., 2000; Bellamy et al., 2002; Light et al., Corresponding author. Tel.: +44 20 8383 8831; fax: +44 20 8383 8835. E-mail address: [email protected] (A.H. McGregor).

1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.06.002

2002; Leeb et al., 2003) but many of these are based upon functional tests or questionnaires related to ADLs, whilst others are of a more physical nature, each has its own inherent beneﬁts and limitations. Few incorporate physiological function and the effect of deformities as a result of disease processes. The primary concern of hand functional disability questionnaires is the concept that they are subjective reﬂecting the subject’s perception of ability rather than their actual ability. A further problem is the concept or belief that hand function and functional ability are the same (van Lankveld et al., 1999). Therefore, measures of functional disability are not representative of physiological hand function and vice versa. This is exempliﬁed by rheumatoid patients who make compensatory adaptations in the way they perform ADLs despite high levels of impaired physiological joint function (Apley

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and Solomon, 1993). Many ADL tasks only register the time taken, thus impaired grip or a deformity is ignored if it does not inﬂuence the time to complete a task. In this way, changes in disease severity may not affect the level of ‘functional disability’ (Fowler and Nicol, 2001, Light et al., 2002), this has is particularly the case for RA patients. Similarly functional disability scoring scales frequently are insensitive to subtle changes in disease status that are more pronounced in physiological factors associated with hand function such as range of joint motion or grip strength (Burton and Wright, 1983). These limitations need to be addressed if targeted treatments for conditions such as RA are to evolve or indeed if we are to understand the disease progression pathway. Pinch and grip strength have been shown as the most important factors related to hand function (Turner and Ebrahim, 1992, Vliet-Vlieland et al., 1996). Fowler and Nicol’s (2001) noted that pinch and grip strength along with ROM measurements were able to provide a robust alternative to detailed biomechanical measures with the additional beneﬁt of being efﬁcient in terms of cost and time. Goniometric measurements of joint range of motion have undergone exponential development, from simple clinical tools to more complex systems such as the Shefﬁeld Instrumented Glove (Williams et al., 2000). As with the questionnaire based assessments these too have their beneﬁts and limitations, often with accuracy being sacriﬁced in response to clinical practicality and time constraints. Thus the clinical assessment of hand function and disability remains complex and controversial. This study explored the use of a commercially available system, the Biometric E-Link Evaluation Systemr V9OOS (Gwent UK) for determining hand function in RA and OA patients, in terms of its reproducibility and practicability. A secondary aim was to explore the relationship of measures of hand physiological function, i.e. range of motion, grip and pinch strength with a standardized and validated scale of disability, in this case the Cochin Scale (Duruoz et al., 1996, Poiraudeau et al., 2000).

2. Methods 2.1. Study population Ten patients with RA of the hand (9 female, 1 male, mean age 5871.4 years, 9 right hand dominant), 10 with OA of the hand (all female and right hand dominant, mean age 6871.9 years), and 10 healthy control subjects (9 female, 1 male, all right hand dominant, mean age 5871.6 years), were recruited from the Rheumatology Department at Charing Cross Hospital. Written informed consent was obtained from all subjects following approval by Riverside Research Ethics Committee.

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RA and OA patients were selected upon the inclusion criteria of a deﬁnite diagnosis of either RA or (nontraumatic) OA of the hand and currently experiencing pain in either/both hands. Diagnoses were based on routine clinical and laboratory tests and were conﬁrmed by a consultant or specialist registrar. Exclusion criteria included previous hand surgery, signiﬁcant hand trauma, co-existing musculoskeletal disease at the hand, dermatological conditions that may affect hand function and/or hand pain (e.g. cellulitis, excessive scarring), Dupytren’s contracture, Carpal Tunnel Syndrome and any documented evidence of neuropathy at the hand. The control group comprised of 10 healthy subjects recruited from hospital staff and partners of arthritic subjects. In addition to the above exclusion criteria control subjects who presented with arthritic conditions affecting the hands were excluded as were those who complained of pain in the hands, stiffness or any other abnormalities. Reproducibility testing was carried out in ﬁve of the control subjects and ﬁve of the RA subjects. The two dates of testing were between 1 and 2 weeks apart in all subjects. 2.2. Questionnaire data All patients completed the Cochin scale (Poiraudeau et al., 2000, 2001), a pain distribution chart (adapted from Mann et al., 1993) and pain visual analogue scales (VAS) documenting average and worst pain during the preceding week as well as pain prior to and during testing (Aitken, 1969). 2.3. Impairment of physiological hand function For assessment of hand function, the V900S evaluation system (Biometrics Ltd, UK) was used. For strength testing, three prehensile patterns were used: Key grip, Pinch and Power grip (Fig. 1). Pinch (opposition of thumb tip with ipsilateral ﬁnger tips) strength was assessed in each ﬁnger separately. Key grip and pinch were measured using the pinchmeter. Power grip was assessed using the grip dynamometer. All dynamometry measurements were taken in standardized positions as described by Mathiowetz et al. (1985), (Fig. 1). The value noted was the best value attained out of 3 measures. ROM measurements were based on the total range from maximum ﬂexion to maximum extension of each joint. ROM at the interphalangeal joints and metacarpophalangeals was measured using the small goniometer. ROM at the wrist was measured using the large goniometer (Fig. 2). The goniometer was applied superﬁcially at the dorsum of each respective joint and angles of ﬂexion and extension were measured relative to a position of zero degrees.

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A. Goodson et al. / Manual Therapy 12 (2007) 144–152

Fig. 1. Prehensions tested for strength: Power grip (top), [Index] Pinch (bottom left), Key grip (bottom right).

3. Results Reproducibility: Since no signiﬁcant difference was noted between the left and right hands in either population, the data from both hands was combined. Reproducibility was determined using Bland & Altman’s technique (Bland and Altman, 1986) and are presented in Table 1. Questionnaire findings: VAS pain ratings appeared to be different amongst the OA and RA groups. OA subjects experienced greater day-to-day pain (present pain in OA’s 49.878.8, average 59.077.3, worst pain 79.874.6, compared to present 46.576.8, average 50.377.9, worst 64.475.1 in RA’s, mean and standard errors provided), but this did not reach signiﬁcance. In contrast for the Cochin Score, RA patients reported similar if not higher disability scores (RA Mean Cochin Score72S.E. ¼ 32.4710.2, compared to 26.673.4 in OAs), and during testing RA patients tended to experience greater levels of pain as a result of the tests (Fig. 3). Disability did appear to relate to pain in the OA group (R2 ¼ 0.38), but not in the RA group.

Of the ﬁnger joints (MCP, PIP, DIP) in the RA group, pain was predominantly distributed amongst the ﬁnger MCP- and PIP-associated pain drawing zones, respectively contributing to 33% and 25% of total reported hand pain. In the OA group, PIP- and DIPassociated zones were more frequently affected at 34% and 19%, respectively. In the RA group, the most frequently reported zone of pain was the dorsal right index MCP-associated zone (freq ¼ 9). In the OA group, pain was most frequently reported (freq ¼ 8) in zones representing the base of the right thumb (on the palmar aspect of the MCP), and the dorsal zones associated with the right middle ﬁnger and ring ﬁnger PIPs. Strength testing: Fig. 4 presents the key and pinch grip means for the three groups. Similar ﬁndings were seen with respect to the power grip (controls left 32.47 1.3 kg, right 33.771.8 kg; OAs left 13.071.6 kg, right 14.071.8 kg; and RA’s left 8.871.1 kg, right 10.77 1.6 kg). Analysis of variance (ANOVA) in the strength test results showed signiﬁcant differences amongst the three groups in all tests (Po0.0001). These differences

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147

Fig. 2. ROM testing at the MCPs (top left), PIPs (top right), DIPs (centre) and Wrist (ﬂexion: bottom left, extension: bottom right).

were explored further using Student t-tests with Bonferroni corrections (Fig. 5). Key grip: Signiﬁcant differences were seen between the OA and control groups (Po0.001), and the RA and control group (Po0.0001), with greater differences being noted in the right hand in both groups. No signiﬁcant difference was seen when comparing the left hands of RA and OA patients although a signiﬁcant difference was seen when comparing right key grip between the two groups (Po0.001).

Pinch: For Ring pinch and little pinch grips only 6 of the 10 RA patients were able to complete testing in the right hand, only 8 for left hand. For all pinch tests, signiﬁcant differences were shown between OAs and controls (Po0.01) and RAs and controls (Po0.001). No signiﬁcant differences were seen between RA and OA values except for results from Little pinch testing where signiﬁcant differences in strength were seen (in both hands) between RA and OA patients (Po0.05).

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Table 1 ROM reproducibility data for Control and RA groups. (ROM range of motion, MD mean difference, LA limits of agreement)

MCP thumb ROM MCP index ROM MCP middle ROM MCP ring ROM MCP little ROM IP thumb ROM PIP index ROM PIP middle ROM PIP ring ROM PIP little ROM DIP index ROM DIP middle ROM DIP ring ROM DIP little ROM Wrist Fl/Ex ROM Key Grip Pinch Index Pinch Middle Pinch Ring Pinch Little Pinch Power Grip

Control (n ¼ 10) MD (7SD)

LA

RA (n ¼ 10) MD (7SD)

LA

Control and RA combined (n ¼ 20) MD (7SD) LA

0.3712.7 1.076.7 3.276.1 2.779.9 2.479.0 2.4713.9 0.776.1 0.272.8 2.077.2 0.879.4 1.576.0 3.075.8 2.777.0 1.576.8 3.0711.5 0.872.3 0.970.6 0.170.8 0.270.2 0.070.3 0.972.5

25.6–25.0 14.5–12.5 15.4–9.0 22.4–17.0 15.6–20.4 30.2–25.4 13.0–11.6 5.8–5.4 16.3–12.3 18.0–19.6 13.5–10.5 14.7–8.7 16.7–11.3 15.0–12.0 26.0–20.0 3.8–5.5 2.1–0.4 1.7–1.4 0.7–0.2 0.6–0.7 6.0–4.1

1.2715.1 3.376.6 2.077.9 4.1713.6 10.2713.7 4.2720.6 2.3710.8 0.179.1 0.679.1 3.177.8 1.674.9 2.277.8 2.877.3 1.779.7 1.7713.0 0.270.4 0.170.4 0.170.7 0.170.3 0.170.2 0.972.1

31.3–28.9 16.6–10.0 13.9–17.9 23.2–31.4 17.1–37.5 36.9–45.3 19.2–23.8 18.0–18.2 17.7–18.9 12.6–18.8 8.3–11.5 13.3–17.7 11.9–17.5 17.7–21.1 24.4–27.8 0.7–1.0 0.9–0.8 1.4–1.6 0.5–0.6 0.2–0.4 3.2–5.0

0.8713.6 2.276.6 0.677.4 0.7712.1 6.3712.0 0.9717.4 0.878.7 0.176.5 0.778.1 2.078.5 0.175.6 0.477.2 0.177.5 0.178.3 0.7712.2 0.571.7 0.470.7 0.070.7 0.170.3 0.070.3 0.172.4

27.9–26.4 15.4–11.1 15.4–14.2 23.5–24.9 17.6–30.2 33.9–35.7 16.5–18.1 13.1–13.0 16.9–15.5 15.1–19.0 11.1–11.2 14.8–14.0 15.0–15.1 16.5–16.7 25.1–23.8 2.8–3.8 1.7–0.9 1.5–1.5 0.7–0.5 0.5–0.6 4.8–5.0

Comparison of mean VAS pain scores (and S.E.) between RA and OA groups for each strength test. 80.0 RA

OA

70.0

60.0

VAS score

50.0

40.0

30.0

20.0

10.0

0.0 Left Key pain score

Left Index pinch pain score

Left Middle pinch pain score

Left Ring pinch pain score

Left Little pinch pain score

Left Power pain score

Right Key pain score

Right Index pinch pain score

Right Middle pinch pain score

Right Ring pinch pain score

Right Little pinch pain score

Right Power pain score

Fig. 3. VAS scores during testing in RA and OA groups.

Power grip: Power grip showed highly signiﬁcant differences (Po0.0001) between RA and control subjects, as well as OA and control subjects. When comparing RA and OA subjects differences in strength values in the right hand were not strongly signiﬁcant (P ¼ 0.19) but those in the left were (Po0.05). MCP ROM: In the non-dominant hand, there were signiﬁcant differences in ROM between all groups

(Po0.01), more speciﬁcally RA patients have less motion than controls (Po0.0001) and OA subjects (Po0.0001). Similar observations were seen in the dominant hand. It was noted that ROM in the MCP of OA was reduced compared to controls but this only approached statistical signiﬁcance (P ¼ 0.057). PIP & DIP ROM: There was a signiﬁcant difference in PIP and DIP ROM in the RA versus control group

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149

Mean Pinch and S.E. in RA, OA and CONTROL groups. 9.0 RA

OA

CONT ROL

Mass equivalent of force produced (kg)

8.0

7.0

6.0

5.0

4.0

3.0

2.0

1.0

0.0 L Key

L Index Pinch

L Mid Pinch

L Ring Pinch

L Little Pinch

R Key

R Index Pinch

R Mid Pinch

R Ring Pinch

R Little Pinch

Pinch test type

Fig. 4. Key grip and pinch in all three groups.

Mean ROM and S.E. in MCP, PIP, DIP and Wrist Joints of the CONTROL, RA and OA groups. 160 Mean finger MCP ROM Mean finger PIP ROM

140

Mean Finger DIP ROM Mean wrist ROM

Mean ROM (degrees)

120

100

80

60

40

20

0 CONTROL non dom

CONTROL dom

RA non dom

RA dom

OA non dom

OA dom

Fig. 5. ROM of speciﬁc joint types in all three groups.

and OA vs. control group (Po0.0001). Compared with the OA group, RA PIP ROM was reduced in the dominant hand (P ¼ 0.034) only and no difference was observed in the DIP joint between groups.

Wrist ROM: There was a signiﬁcant difference in wrist ROM between all groups (Po0.05), apart from in the dominant wrist of OA patients compared with controls (P ¼ 0.053). The most signiﬁcant differences

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150

Degree of impairment in ROM of each joint type with RA and OA 1.00 mean finger MCP ROM

0.90

0.91

mean finger PIP ROM

0.93 0.88

0.86

mean finger DIP ROM

ROM as a proportion of control's value

mean wrist ROM

0.80

0.76

0.70

0.72 0.71

0.70

0.68

0.74

0.72

0.63

0.60

0.59 0.55 0.51

0.50

0.45

0.40 0.30 0.20 0.10 0.00 RA non-dom

RA dom

OA non-dom

OA dom

Hand Fig. 6. ROM impairment as a proportion of mean control values.

were observed between RA patients and controls (Po0.0001). Impairment of joint groups: When comparing the RA group with control subjects, the joint noted to have the greatest reduction in ROM was the MCP (Po0.0001), followed by the wrist and PIP (Fig. 6). However, when comparing the OA group with controls, the joint found to have the greatest reduction in ROM was the DIP (Po0.0001), followed by the PIP. Relationship between strength and ROM: No relationship was found between combined strength test values and combined ROM in either the control or RA groups. However, a strong relationship existed between combined strength score and combined ROM score in the OA group (R2 ¼ 0.49). Effect of lateral dominance on strength and ROM: Lateral hand dominance was noted to have no signiﬁcant effect on pinch and grip strength. Power grip strength appeared to be greater in the dominant hand of RA subjects, but this did not reach statistical signiﬁcance. Lateral hand dominance had no signiﬁcant effect on joint ROM in controls and OA patients. In RA patients, mean values suggest the dominant hand to have a reduced overall ROM compared to the nondominant hand, however this did not reach signiﬁcance (P40.05). Effect of pain during strength testing: VAS scores representing severity of pain encountered during strength testing do not correlate with strength values,

except for Power grip testing in the RA group (R2 ¼ 0.30). Pain distribution and joint ROM impairment: In the RA group, frequency of pain reported at a zone associated with a speciﬁc joint had a strong negative correlation with that joint’s ROM (R2 ¼ 0.46). This relationship was negligible in the OA group (R2 ¼ 0.18). Functional strength vs. disability, day-to-day pain and time-course of disease: Both RA and OA groups show only a notable, but weak relationship between pinch/ grip strength and disability. This is most apparent with Power grip in RA group (R2 ¼ 0.26) and with Little ﬁnger Pinch strength in the OA group (R2 ¼ 0.21). In both RA and OA groups, pinch/grip strength was not related to day-to-day pain based on ‘average pain over the last week’ VAS scores. Pinch/grip strength is not signiﬁcantly related to ‘time since initial diagnosis’ in either RA or OA patients. Functional joint ROM vs. disability, day-to-day pain and time-course of disease: In the OA group, joint ROM did not correlate with Cochin disability scores, day-today pain (‘average pain over the last week’ VAS scores) or ‘time since initial diagnosis’. In the RA group, ROM of the MCP joints (the joint group with the greatest ROM impairment) showed relationships of relevance with Cochin disability scores (R2 ¼ 0.31) and ‘time since initial diagnosis’ (R2 ¼ 0.32). Wrist ROM showed a stronger relationship with time since diagnosis (R2 ¼ 0.37).

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4. Discussion Impairments in hand function are well-known features of RA and OA, however, their scientiﬁc quantiﬁcation remains an area of debate. This study sought to evaluate a new tool, the V900S evaluation system (Biometrics Ltd, UK), for determining hand function in the clinical setting. Reproducibility data in RA patients is thought to be inﬂuenced by the nature of the disease process particularly the diurnal variability of pain and joint stiffness. This is reﬂected in the poor reproducibility of ROM measures in the RAs observed in this study. However, with respect to strength the RA group demonstrated greater reproducibility, suggesting that either strength measurements are more reliable in RA patients compared to controls, or that measurements of strength are not inﬂuenced by the diurnal variations in RA symptoms. In terms of the patient groups, the RA and OA patients presented with different perceptions of their own hand disability. In the OA group, day-to-day (average) pain shares a relatively close relationship with the level of disability assessed by the Cochin score, this was not the case with the RA group. Thus duration and intensity of pain is not reﬂected in disability level, further supporting the view that disability may result more from pain-related fear behaviour leading to fear avoidance (Denison et al., 2004). Interestingly, OA patients perceived themselves to have worse pain levels even though functional disability scores were relatively equal between groups. This further demonstrates the limitations of pain scales and disability scores, suggesting that these assessments are not suitable measures for indicating impairment in hand function, and consequently quality of living as suggested by Fowler and Nicol (2001). The distribution of pain in both groups was representative of the certain joints known to be commonly involved in each of the two diseases (MCPs in RA, PIPs/ DIPs in OA) (Smith, 2002). RA patients showed very strong correlations between frequency of reported pain at an area associated with a speciﬁc joint and that joint’s impairment in ROM, this was not so clear in the OA group. This suggests that the source of pain is much more closely related to joint impairment in the RA compared to OA population. Clear differences in strength were seen between the patient groups and controls. Despite this, pinch/grip strength did not relate to the time-course of either disease or the day-to-day (average) pain and showed only a weak relationship with disability scores. This contradicts Adams et al. (2004), who suggest that grip strength is an accurate indicator of upper limb ability in RA. The discrepancies between impaired strength, functional disability scores and pain scores demonstrate the complexity of interpreting the effect of RA and OA

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on hand function, and isolating a tool to quantify function. In the OA group, ROM showed no relationships with day-to-day pain scores, time-course of the disease or disability scores. This contradicts ﬁndings from studies of OA in the knee and hip where restricted joint ROM has been shown to be an important determinant of disability (Steultjens et al., 2000). However, it may reﬂect the difference in weight bearing nature of the hand compared to the hip and knee. In the RA group MCP and wrist ROM did show relevant relationships with day-to-day pain scores, time course of the disease and disability scores. This suggests the role of these ROM measures as ‘temporal landmarks’ in the progress of RA from a mild through to severe debilitating state. Further work is required to determine if ROM could be used as a clear marker of disease progression. ROM testing by goniometry consistently showed signiﬁcantly different levels of ROM impairment in each joint type between RA and OA groups. The difference in type and pattern of joints impaired shows the potential for ROM measures to differentiate between RA and OA of the hand and could prove valuable in the early onset of disease. Although strength and ROM are two completely different parameters of hand function in the OA group there is suggestion that they are intrinsically linked, with a strong correlation between mean ROM and mean strength scores (R2 ¼ 0.49). Such a relationship has not been previously noted. To summarize, pinch, grip and ROM measurements are simple and quick to perform and the ﬁndings of this study support the routine clinical use of these measures as proposed by Fowler and Nicol (2001) and Wessel et al. (1999). For this study patients were questioned regarding pain and disability, underwent 12 individual dynamometric tests and thirty individual measures of joint ROM within a typical time period of 40 min. Clearly this is not feasible for larger studies of clinical practice. However, using selected strength and ROM measures appropriate to the study population and based on this study’s ﬁndings, a comprehensive battery of testing of no more than 10 min duration could be developed for assessing outcome, and disease progression. To establish such measures as gold standard however, would require further research into the validity of the measures, particularly ROM measures and the precision of the equipment.

5. Conclusion Assessment of functional impairment of the hands in RA and OA is complex. Direct measures of hand function provide invaluable information which reﬂects characteristic disease pathology.

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References Adams J, Burridge J, Mullee M, Hammond A, Cooper C. Correlation between upper limb functional ability and structural hand impairment in an early rheumatoid population. Clinical Rehabilitation 2004;18(4):405–13. Aitken RC. Measurement of feelings using visual analogue scales. Proceedings of the Royal Society Medicine 1969;62(10):989–93. Apley AG, Solomon L. Apley’s system of orthopaedics and fractures, 7th ed. Butterworth-Heinemann Ltd.; 1993. Bellamy N, Campbell J, Haraoui B, Gerecz-Simon E, Buchbinder R, Hobby K, et al. Clinimetric properties of the AUSCAN osteoarthritis hand index: and evaluation of reliability, validity and responsiveness. Osteoarthritis Cartilage 2002;10(11):863–9. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986: 307–10. Burton KE, Wright V. Advances in assessing rheumatoid arthritis: functional assessment. British Journal of Rheumatology 1983; 22(3):44–7. Chung KC, Hamill JB, Walters MR, Hayward RA. The Michigan Hand Outcomes Questionnaire (MHQ): assessment of responsiveness to change. Annals of Plastic Surgery 1999;42(6):619–22. Denison E, Asenlo¨f P, Lindberg P. Self-efﬁcacy, fear avoidance, and pain intensity as predictors of disability in sub-acute and chronic musculoskeletal pain patients in primary health care. Pain 2004; 111:245–52. Duruoz MT, Poiraudeau S, Fermanian J, Menkes CJ, Amor B, Dougados M, et al. Development and validation of a rheumatoid hand functional disability scale that assesses functional handicap. Journal of Rheumatology 1996;23(7):1167–72. Fowler NK, Nicol AC. Functional and biomechanical assessment of the normal and rheumatoid hand. Clinical Biomechanics 2001;16: 660–6. Jebsen RH, Taylor N, Trieschmann RB, Trotter MJ, Howard LA. An objective and standardized test of hand function. Archives Physical Medicine and Rehabilitation 1969;50(6):311–9. Leeb BF, Sautner J, Andel I, Rintelen B. SACRAH: a score for assessment and quantiﬁcation of chronic rheumatic affections of the hands. Rheumatology 2003;42:1173–8.

Light CM, Chappell PH, Kyberd PJ. Establishing a standardised clinical assessment tool of pathologic and prosthetic hand function: normative data, reliability and validity. Archives of Medicine Rehabilitation 2002;83:776–83. Mann NH, Brown MD, Hertz DB, Enger I, Tompkins J. Initialimpression diagnosis using low-back pain patient pain drawings. Spine 1993;18(1):41–53. Mathiowetz V, Kashman N, Volland G, Weber K, Dowe M, Rogers S. Grip and pinch strength: normative data for adults. Archives of Physical Medicine Rehabilitation 1985;66(2):69–74. Poiraudeau S, Lefevre-Colau MM, Fermanian J, Revel M. The ability of the Cochin rheumatoid arthritis hand functional scale to detect change during the course of disease. Arthritis Care and Research 2000;13(5):296–303. Poiraudeau S, Chevalier X, Conrozier T, Flippo RM, Liote´ F, Noe¨l E, et al. Reliability, validity and sensitivity to change of the Cochin hand functional disability scale in hand osteoarthritis. Osteoarthritis and Cartilage 2001;9:570–7. Smith P. Lister’s The Hand, 4th ed. Churchill: Livingstone; 2002. Steultjens MPM, Dekker J, Van Baar ME, Oostendorp RAB, Bijlsma JWJ. Range of joint motion and disability in patients with osteoarthritis of the knee or hip. Rheumatology 2000;39:955–61. Turner DP, Ebrahim S. Relation between handgrip strength, upper limb disability and handicap among elderly women. Clinical Rehabilitation 1992;6:117–23. Vliet-Vlieland TPM, van der Wijk TP, Jolie IMM, Zwinderman AH, Hazes JMW. Determinants of hand function in patients with rheumatoid arthritis. Journal of Rheumatology 1996;23(5):835–40. Van Lankveld WGJM, Graff MJL, Van’t Pad Bosch PJI. The short version of the sequential occupational dexterity assessment based on individual tasks’ sensitivity to change. Arthritis Care and Research 1999;12(6):417–24. Wessel J, Kaup C, Fan J, Ehalt R, Ellsworth J, Speer C, et al. Isometric strength measurements in children with arthritis: reliability and relation to function. Arthritis Care and Research 1999;12(4):238–46. Williams NW, Penrose JMT, Caddy CM, Barnes E, Hose DR, Harley P. A goniometric glove for clinical hand assessment; construction, calibration and validation. Journal of Hand Surgery (British and European volume) 2000;25B(2):200–7.

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Manual Therapy 12 (2007) 153–160 www.elsevier.com/locate/math

Original article

Neurodynamic responses in children with migraine or cervicogenic headache versus a control group. A comparative study Harry J.M. von Piekartza,, Sara Schoutenb, Geert Aufdemkampec a

Department of Rehabilitation Science and Physiotherapy for Craniofacial Dysfunction and Pain, Stobbenkamp 10, 7631 CP Ootmarsum, The Netherlands b Private Practice for Physical Therapy, Van Diemenstraat 356, 1013 CR Amsterdam, The Netherlands c University of Professional Education, Department of Health, Faculty Chair of Health and Lifestyle and Department of Physical Therapy, Bolognalaan 101, 3584 CJ Utrecht, The Netherlands Received 14 October 2004; received in revised form 9 February 2006; accepted 2 June 2006

Abstract Headache in children with unknown aetiology is an increasing phenomenon in industrial countries, especially during growth spurts. During this growth phase, the Long Sitting Slump (LSS) can be a useful tool for measurement of neurodynamics and management. This study investigated the difference in cervical ﬂexion and sensory responses (intensity and location) during the LSS tests in children (n ¼ 123) aged 6–12 years, between a migraine (primary headache group ¼ PG), cervicogenic headache (secondary headache group ¼ SG) and control group (CG). The results indicated that the intensities of the sensory response rate were highest in the PG and SG when compared to CG. The responses in the legs were predominantly found in the PG (81.9%) and responses in the spine in the SG (80%). The sacrum position varied signiﬁcantly between both headache groups (PG and SG) and the CG (po0.0001), but there was no signiﬁcant difference between the CG and the PG (p40.05). No signiﬁcant difference in the neck ﬂexion range was measured in LSS, nor in standardized knee ﬂexion between the PG and CG (p40.05). The cervical ﬂexion ranges differed signiﬁcantly (po0.0001) between the SG on the one hand and the PG and CG on the other. The biggest difference in neck ﬂexion during knee extension was between the SG and CG. r 2006 Elsevier Ltd. All rights reserved. Keywords: Children; Headache; Migraine; Cervicogenic; Nervous system; Musculoskeletal manipulation

1. Introduction Chronic pain in children is an increasingly common phenomenon in industrialized countries. Headache is one of the most frequently occurring symptoms (Perquin et al., 2000) and can be classiﬁed as follows:

Primary headache: Headache that manifests without apparent structural disorder and occurs in all age categories. Migraine and tension headache are the most frequently used terms here. Secondary headache: The headache is associated with the consequences of structural disorder or pathology

Corresponding author. Tel.: +31 541294001; fax: +31 541294002.

E-mail address: [email protected] (H.J.M. von Piekartz). 1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.06.004

such as sinusitis, ear infection, tumours, epilepsy or following (cervicogenic) trauma (Kan et al., 2000; Garcia-Mendez, 2003). In a cross-sectional study including 2358 children aged between 10 and 17 years, it was found that 21% of the boys and 26% of the girls experienced headache or facial pain once per week on average (Bandell-Hoekstra et al., 2001). A similar study indicated that there has been a 6% increase in the number of children experiencing headache once per week on average between 1985 and 2001 (Passchier and Orlebeke, 1985). Where the recurrent headache group is concerned, it is often difﬁcult to provide suitable therapy that follows clear guidelines (Perquin et al., 2000; Hershey, 2003; Gladstein, 2004). One of the reasons for this might be

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the difﬁculty in adequately classifying headache in children. In a study by Maytal et al. (1998), an extensive questionnaire administered to 253 children and adolescents suffering from migraine, was compared to the International Headache Society (IHS) classiﬁcation. The results showed that 92.4% (high speciﬁcity) of the children without migraine were correctly classiﬁed, while only 27.3% of the children with migraine (poor sensitivity) were correctly classiﬁed. The overall conclusion from this study was that the IHS criteria (IHS, 1988 ﬁrst edition) could not be adequately applied to children with migraine (Maytal et al., 1998). A similar type of study carried out by Viswanathan et al. (1998) among 150 children in the United Kingdom conﬁrmed these results. Wober-Bingol et al. (1996) investigated the validity of the IHS classiﬁcation among 156 children and adolescents aged from 6 to 16 years, diagnosed with tension headaches. The ﬁndings of the study indicated that the IHS shows only a low sensitivity for tension headaches in children (Wober-Bingol et al., 1996). It would therefore appear that the use of the IHS classiﬁcation as a diagnostic instrument has only limited usefulness in the particular instance of primary headache in children. The IHS classiﬁcation 2004 of secondary headache in section 5 (‘‘Headache attributed to head and/or neck trauma’’) and section 11 (‘‘Headache or facial pain attributed to disorders of cranium, neck, eyes, ears, nose, sinus, teeth, mouth or other facial or cranial structures’’) is lacking a speciﬁc interpretation for children (IHS, 2004). It might be that a number of (unknown) mutually interfering aetiological factors might be the underlying causes here (Kan et al., 2000; Kondev and Minster, 2003). Also included in this category are children with headache as a result of cervicogenic dysfunction. Occipito-atlanto-axial injury has also been cited as a cause of cervicogenic headache in a number of case studies (Sacher, 2003). Such injury might have been sustained prior to or during birth. The signiﬁcant high-risk factors associated with these injuries are extended labour, forceps delivery, vacuum extraction, caesarean section and multiple births (Biedermann, 2001). Two types of dysfunctions are shown on radiological assessment: a shift of the atlas to one side or extreme rotation of the atlas around the sagital axis (Gutmann, 1983; Biedermann, 1999, 2004). The primary ideas and work are based on clinical observation supported by X-rays in babies and young children (Gutmann, 1983). In the literature clinicians describe different patterns of cervical dysfunctions in early infancy (babies) compared to adults, e.g. extended crying, restlessness, feverishness, intestinal colic, torticollis and cranial asymmetry, opisthotonus, hypotonus and delayed motor development (Biedermann, 2001). From exploratory longitudinal studies of children it appears that more than 40% of these symptoms

disappear spontaneously but may return during school years in children from 6 to 12 years. Descriptive literature has estimated that 60% of these children with a history of cervical dysfunctions tend towards a scoliotic posture, general stiffness, ‘‘woodenness’’, sensory motor retardation, hyperactivity inadequate static and dynamic coordination and a reduced sense of spatial orientation during the years of schooling (Biedermann, 1999, 2004). Frequent headaches are also reported regularly (Terrett and Davies, 2000). Abnormal positioning of the atlas and/or axis is also often found in anterior/posterior (A/P) radiographic images or specialized magnetic resonance (MRI) scans (Biedermann, 1995).

2. The long sitting slump test The Long Sitting Slump test (LSS) is a modiﬁcation of the standard slump test in which both legs are placed symmetrically in a bilateral straight leg raise (BSLR) with dorsal ﬂexion of the feet. This test has a good anatomical basis for inﬂuencing the entire longitudinal aspect (cranial, dura to ﬁlum terminale) of the nervous system (Goddard and Reid, 1965; Adam and Logue, 1971; Breig, 1978; Louis, 1981). A number of similar tests based on measurements of the hamstrings were earlier described. Kendall described the classical responses obtained using this ‘‘hamstrings length’’ test over the various age groups in the 1940s (Kendall, 1948; Kendall et al., 1999). A striking feature was that trunk ﬂexion mobility declined sharply during the 9–14 years of age period and later increased again in adolescence. The explanation given for this was an increasing shortening of the hamstring group. Hamstring ﬂexibility in response to various interventions in the evaluation of the effects of the slump test in healthy adult volunteers and patients with hamstring injury showed variation of hamstrings ﬂexibility which suggests altered tension in the nervous system. This occurs especially during trunk and neck ﬂexion (Johnson and Chiarello, 1997; Turl and George, 1998; Webright et al., 1997). However, little information is available regarding neurodynamic testing of children. A search of the literature using MEDLINE, COCHRANE and CINAHL employing combinations of the key words: neural, tissue, children, SLR and Slump Test, yielded only two studies. The ﬁrst was by Idota and Yoshida (1991). Their conclusion from a study of 1244 children aged 7–16 years was that the increased ‘‘tension’’ during the SLR test correlated positively with accelerated skeletal growth. The second was by White and Pape (1992), who investigated the slump test in more than 200 children with central neurological disorders and concluded that the slump test reﬂects an overall impression of neurodynamic patterns in this group of patients.

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3.2. Inclusion and exclusion criteria

200

PERCENT OF ADULT SIZE

155

LYMPHOID

NEURAL

100

GENERAL

GENITAL 0 0

5

10 YEARS

15

20

Fig. 1. Percentage of adult-growth attained at 20 years of age (Scammon, 1930).

Functional improvement was positively correlated to the improvement of the Slump Test itself, which could now be carried out easily in a wheelchair (White and Pape, 1992). Classical growth studies describe the differences in growth rates between nerves, muscles and the skeletal system (Profﬁt, 1993). A classical survey in this ﬁeld is that of Scammon, which is still cited as an example even today (Scammon, 1930) (Fig. 1). In the present study three groups of children aged between 6 and 12 were sequentially subjected to a modiﬁed LSS (control group (CG), primary headache and secondary headache groups (PG and SG)) adopting the following hypothesis: clear differences in sensory and physical responses were to be expected in the cervicogenic headache group during the modiﬁed LSS when compared to the migraine and CGs. A clear difference was also expected in sensory and physical responses within the two headache groups.

3. Materials and method 3.1. Subjects A total of 123 children participated in the study in a random sample involving the cooperation of 23 paediatric physiotherapy practices in the Netherlands. Of this group, 44 children (24 male and 20 female) with an average age of 8.571.5 were in the CG, 39 children (14 male and 25 female) with an average age of 9.371.9 were in the migraine group (PG) and 40 children (19 male and 21 female) with an average age of 7.671.5 were in the cervicogenic headache group (SG).

Children in the CG were assessed beforehand by a house- or school doctor. These children had to be free of headache at the time of the study and had never suffered from headaches in the past. They were also required to be without previous history of craniocervical trauma. Children in the migraine group (PG) to have had a headache for a minimum of once a week over a minimum period of six months and also had to comply with the modiﬁed IHS classiﬁcation for children as proposed by Olesen (1997) (see Table 1). Children in the cervicogenic headache group (SG) must have had a headache at least once a week for more than six months. The neck movements of the craniocervical region (C0– C3) were assessed blind for segmental motion and pain by the examiner, with a orthopaedic manual therapy training with 7 years of experience and who was not involved in the rest of the research. This assessment consisted of passive physiological intervertebral motion (PPIVMs) and passive accessory intervertebral motion (PAIVMs) tests (Maitland et al., 2001; Petty and Moore, 2001). When three or more clinical responses such as stiffness and or pain were detected, the child was included in the study. Because the IHS 2004 describes cervicogenic headache (IHS-code M99) in section 11 but it was not related to children and it was impossible to reconstruct all the criteria of the IHS for young children (IHS, 2004), the European Workgroup of Manual Medicine (EWMM) Questionnaire was used. It is a standard measurement for recognition of the clinical pattern of cervicogenic dysfunctions in babies and young infants. The questionnaire, which is only available in German and Dutch, has 37 questions which have to be answered by the parents with ‘‘yes’’ or ‘‘no’’. When

Table 1 Group Control group (CG) N ¼ 43 Average age 8.5 (SD 1.8) 24 male, 19 female Primary headache group (PG) N ¼ 35 Average age 9.3 (SD 1.9) 10 male, 25 female Secondary headache group (SG) N ¼ 39 Average age 7.6 (SD 1.5) 18 male, 21 female

Inclusion criteria

Age 6–12 years No headache in their life No history of craniocervicogenic dysfunction Age 6–12 years At least once a week headache Criteria adapted classiﬁcation of the HIS (Olesen, 1997) Age 6–12 years At least once a week headache Criteria of the EWMM questionnaire has to be fulﬁlled

Exclusion criteria: all groups had no previous physiotherapeutic healthcare for the last year.

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50% or more of the answered questions (19 questions) are answered with ‘‘yes’’, a history of cervicogenic dysfunction, is moderate to high (Biedermann and Koch, 1996). An English translation of this questionnaire is shown in Table 2. In this study a minimum of 75% (26 questions) or more of the answered questions in the Dutch version of the questionnaire drawn up by the EWMM needed to have been answered in the afﬁrma-

Table 2 Anamnestic-questionnaire (EWMM) 1. Your family: Are there any known spinal diseases (e.g. scoliosis, deformities, one leg shorter) Are there any cervical and lumbar dysfunctions (e.g. neck pain/headaches, migraine) 2. Pregnanciest: breech delivery or other abnormal positions multiple pregnancy 2. Birth: forceps, vacuum extractor Cesarian Birth traumata 4. Particularities: Our child had problems going to sleep Our child woke up frequently (more than 6 times in a week) A certain sleeping position was preferred Breast feeding was difﬁcult on one side As a baby, our child did not feed well It was dribbling and spitting a lot It was screaming a lot It suffered from 3 months colic Our child has got a sensitive neck (e.g. when getting dressed) It keeps pulling his hair 5. Other health problems: Our child suffered (suffers) from: throat infections Neurodermatitis allergies headaches Neurological diseases Our child needs glasses It keeps its mouth open 6. Retarded development Posture and movement Speech and understanding Concentration/social competence 7. Asymmetry, posture dysfunctions: We have noticed it not immediately after birth It took a while until we noticed it Somebody pointed it out to us (doctor, midwife, physiotherapist) 9. We particularly noticed that the baby: Only looked to the right/left Moved only to the right/left Moves both arms asymmetrically Moves both legs asymmetrically The face is smaller on one side The back of the head seems ﬂat on one side The back of the head is bald on one side

yes/no yes/no

yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no

yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no

yes/no yes/no yes/no yes/no yes/no yes/no yes/no

tive. If more than ﬁve questions could not be answered, the child was excluded from this study. The exclusion criteria for all groups were: no physiotherapy treatment the previous year, no neuromuscular skeletal dysfunctions, amputations, open wounds, etc., present that might affect the measurements. 3.3. Materials The measuring instruments used in this study were the LSS test and a coloured analogue scale (CAS). A restraining belt was needed for the LSS, which was applied above the knees in order to keep the knees at maximum extension during the test. A specially constructed angle meter with a spring and a goniometer was used for the remaining sacrum position in relation to the horizontal. A Cervical Range of Motion (CROM) apparatus was used for the different ﬂexion measurements of the cervical spine. The CAS was selected for measuring the intensity of the responses. This analogue scale is a specially designed scale for children age ﬁve years and above and was tested for its concurrent and construct validity. It was found to be an accurate and valid measuring instrument for measuring pain in children (McGrath et al., 1996).

4. Examiners Two researchers participated in the study. Both had been working as physiotherapists for a minimum of three years; one had completed an IFOMT recognized education in manual therapy and the second researcher was at the time of the study in training. Both were given 2 h of training in carrying out a trial of the research procedure and in completing the research protocol. They were then asked to carry out the procedure in their own practices with a minimum of 40 children each. The research procedure and protocol was ﬁnally revised in a 60 min meeting four weeks later.

5. Procedure The modiﬁed LSS was assessed for inter-rater reproducibility. Fifteen child volunteers between 7 and 12 years were involved in blind and independent tests by the two researchers. Letters were subsequently sent out to 76 randomly selected paediatric physiotherapy practices in the Netherlands. Twenty-three of these practices were willing to collaborate in the study. The paediatric physiotherapists were given extensive information on the procedure for the study in their own practices. A third research member of staff was available to provide support and answer questions via the internet or by phone. A total of 152 children were invited to take

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part, of which 29 were unable or unwilling to participate due to illness, alternative arrangements or appointments not kept. The test procedure was as follows:

The test subjects were seated in a long sitting position on the couch with feet in active dorsi ﬂexion against a small wooden plank mounted on the couch. A CROM apparatus was placed on the head of the child and calibrated. A restraining belt was placed 10 cm above the base of the patella to ensure that the posterior aspect of the knee made contact with the couch (Fig. 2a). The child was asked to ﬂex the trunk actively for 5 s. The position of the sacrum with respect to the horizontal was measured using the specially designed sacrum goniometer (Fig. 2b). Active cervical ﬂexion was performed next. The number of degrees was measured by means of the CROM apparatus and the child indicated the

157

intensity and the location of the sensory responses immediately. The intensity was measured by means of the CAS and the location was scored on a ﬁve-point scale (head/back/legs/other areas/none). The test subject was required to make a single choice from these categories. The same procedure was repeated using a 10 cm high standardized block. The sacrum position during the ﬁrst test was set and the vertical ﬂexion was measured twice using the CROM apparatus. The measurement of sensory responses was omitted here due to the large amount of information the young test subject was required to process.

6. Statistical analysis The reproducibility of results between the two testers was analysed by means of an ICC (two-way mixed model with a consistency option). The standard error of measurement (SEM) and the smallest detectable differences were also calculated as expressions of both the reproducibility and the responsiveness of the modiﬁed LSS. Differences between the three groups were tested either by means of ANOVA (with a Tukey–Kramer multiple comparisons test when signiﬁcant) or a Kruskal–Wallis test (with Dunn post hoc analysis when signiﬁcant). All calculations were performed in SPSS version 12.01 for Windows or GraphPad Instat version 3.01. The two-sided level of signiﬁcance was set at 0.05. 7. Results

Fig. 2. (a) Test position of the LSS in a 8-year-old child. (b) Measurement of the sacrum position during LSS with a specially developed goniometry-set.

The reproducibility of the modiﬁed LSS test was ICC ¼ 0.96 (95% CI 0.89–0.99). The SEM was 2.831 and the smallest detectable difference was 7.91. Signiﬁcant differences in sacrum positions (in degrees) were noted during the execution of the test with the 123 test subjects in both of the headache groups (primary 25.0 SD 4.4, secondary 24.7 SD 5.20) as compared to the CG (30.3 SD 2.6) (po0.001). There was, however, no signiﬁcant difference between the PG and SG (p40.05). There was a small, yet statistically signiﬁcant difference in degrees between the CG (84.7 SD 7.8) and the PG (77.8 SD 1.2) (po 0.001) for the ﬁrst neck ﬂexion measurement (NF [a]). There was a greater difference between the CG and the PG, and the CG and the SG (23.0 SD 2.4) (po 0.001). The results of the second neck ﬂexion measurement (NF [b]) were 101.1 (SD 8.7) for the CG; 85.2 (SD 12.1) for the PG and 36.2 (SD 1.4) for the SG. There was a statistically signiﬁcant difference between the CG and the PG (po 0.001), with a more marked difference between the CG and the PG on the one hand, and the SG on the other (po 0.001).

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158

Localisation of sensory responses 90 CG

80

PG 70

SG

frequency

60 50 40 30 20 10 0 Head

Spine

Legs

Other

None

Fig. 3. The frequency and location of the sensory responses during the LSS in the control (CG), primary headache (PG) and secondary headache (SG) group.

The sum of the neck ﬂexion with extension of the knees NF (A) and in knee ﬂexion (NF (b)) was 16.6 (SD 5.7) for the CG, 17.8 (SD 8.6) for the PG and 5.6 (SD 4.7) for the SG. There is a signiﬁcant difference between the CG and the PG (po 0.001) and a more marked difference between the PG and the SG (po 0.001). The results of the intensity of the sensory responses that were subsequently measured using the CAS were 0.9 (SD 0.85) for the CG and 5.4 (SD 2.3) and 5.5 (SD 1.7), respectively, for the PG and SG. The difference between both headache groups and the CG was signiﬁcant (po0.05), whilst there were no signiﬁcant differences between the two headache groups. In 82% (n ¼ 29) of the PG, the sensory response was clearly felt in the legs. In 80% (n ¼ 31) of the SG, the sensory responses were felt particularly in the spinal column (Fig. 3). In the CG 36% of the responses were felt in the legs (n ¼ 15) while 46% (n ¼ 20) felt absolutely nothing during the LSS. A total of 18% (n ¼ 12) of the test subjects felt their responses in the head, ﬁve of these children being in the PG and seven in the SG. In only two children belonging to the PG and three children belonging to the SG did the responses coincide with what for them was their ‘‘well-known’’ headache.

8. Discussion In the present study the EWMM Questionnaire was used for detecting cervicogenic aetiology in babies and infants. The authors of this questionnaire (Biedermann and Koch, 1996) performed a prospective study of more than 1000 babies and young children up to the age of ﬁve. By deﬁning the symptoms together with abnormal

positioning of the atlas and/or axis by A/P radiography images the questionnaire was completed retrospectively. As far as the authors know it is the only questionnaire in this ﬁeld. Therefore, we restricted the inclusion to those children who answered a minimum of 75% of the questions with ‘‘yes’’, and excluded children if their parents could not answer ‘‘yes’’ or ‘‘no’’ to ﬁve or more questions. The release of dorsi ﬂexion of the feet in the LSS position was the movement of choice to provide support for the existence of a neurodynamic mechanism (Beith et al., 1995; Butler, 2000; Shacklock, 2005) in the subjects tested. During the trials, in which a pilot study (n ¼ 40) was performed before the study, application of dorsi ﬂexion resulted in increased sensory responses in most children (76%) when this was combined with the experimental posture changes. Maintaining the standardized sacrum position and measurement of the cervical ﬂexion by the CROM during this dorsi ﬂexion manoeuvre was impossible. Therefore, a 10 cm high standardized block under the knees was suggested as a structural differentiation manoeuvre. There was statistically signiﬁcantly more cervical ﬂexion in the PG than in the SG in both the extension and ﬂexion phases during the LSS position. The sensory responses in the PG were predominantly in the legs and in the SG these responses were mainly indicated as being in the spinal column with a statistically signiﬁcantly higher intensity than in the CG. This suggests different pathophysiological mechanisms in both headache groups. From animal studies and through mechanisms of nociception and neurogenic inﬂammation, it is thought that movement of the dura may evoke pain (Groen et al., 1988; Kumar et al., 1996; Bove and Moskowitz, 1997) and neurogenically inﬂamed

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(craniocervical) dura may lead to changes of the contractile state of the blood vessels in the head which may lead to headache (Moskowitz, 1993). The present study concerns itself with children who experience distinct headaches at least once a week. From a prevalence study by Van Duin et al. (2000) among 1254 children between 6 and 16 years, it appears that such children account for 9% of all children studied. These are also children who regularly need medical help (Van Duin et al., 2000), a fact that increases the likelihood that they will see a number of help-providers, including manual therapists. During the study it was interesting that the cervical ﬂexion of the SG during the knee ﬂexion phase improved less than in the case of the PG and the CG. This may be explained by anatomical differences. It is postulated that the majority of the cervical ﬂexion (even in children) takes place between the atlas and axis (Gutmann, 1983; Biedermann, 1999). The atlas is not attached to the dura as a rule, which means that the neurodynamic positions have less inﬂuence on the arthrokinematics of the atlas (Gutmann, 1983; Lang and Kehr, 1983). This does not mean that it can be concluded that neurodynamic effects on cervical ﬂexion in the SG can be ruled out. Clear differences in the intensity of the local responses measured using the CAS were observed in the CG on the one hand and in both headache groups on the other. This conﬁrms observations in the literature that children with recurrent headaches generally have increased levels of sensitivity (McGrath and Koster, 2001), but it may also be related to changed neurodynamics which contributes to a higher neural sensitivity (Groen et al., 1988; Bove and Moskowitz, 1997).

9. Conclusion This study showed clear differences between measurements (neck ﬂexion, location and intensity of sensory responses) of a modiﬁed LSS in a PG, SG and CG of children between the ages of 6 and 12 years. These results suggest (i) different pathophysiological mechanisms of headache and (ii) different biomechanical patterns of the craniocervical region. Further research of these mechanisms is required to optimize assessment and management strategies.

Acknowledgement The Neuro-orthopedic Institute Australia (NOI), the Cranial Facial Therapy Academy (CRAFTA)—Research Foundation Group and Ronel Jordaan, PhD, PT, South Africa are acknowledged for the support to the authors.

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Original article

Measurement of lumbar multiﬁdus muscle contraction with rehabilitative ultrasound imaging Kyle B. Kiesela,, Tim L. Uhlb, Frank B. Underwoodc, Donald W. Roddd, Arthur J. Nitza,e a

Department of Rehabilitation Sciences, Rehabilitation Sciences Doctoral Program, University of Kentucky College of Health Sciences, 900 South Limestone, CHS 126, Lexington, KY 40536-0200, USA b Department of Rehabilitation Sciences, Division of Athletic Training, University of Kentucky, USA c Department of Physical Therapy, University of Evansville, USA d Department of Human Kinetics and Sport Studies, University of Evansville, USA e Department of Rehabilitation Sciences, Division of Physical Therapy, University of Kentucky, USA Received 7 March 2005; received in revised form 14 February 2006; accepted 2 June 2006

Abstract Rehabilitative Ultrasound Imaging (RUSI) has been validated as a noninvasive method to measure activation of selected muscles. The purpose of this study was to determine the relationship between muscle thickness change, as measured by ultrasonography, and electromyography (EMG) activity of the lumbar multiﬁdus (LM) muscle in normal subjects. Bipolar ﬁne wire electrodes were inserted into the LM at the L4 level of ﬁve subjects. Simultaneous EMG and RUSI data (muscle thickness) were collected while subjects performed increasingly demanding postural response tasks thought to activate the LM muscle. To determine the relationship between muscle thickness change and EMG activity, the normalized EMG data were correlated to normalized RUSI data. To determine if the tasks increased the demand on the LM, the mean EMG data were compared over each of the four tasks. Muscle thickness change as measured by RUSI was highly correlated with EMG activity of LM in asymptomatic subjects (r ¼ :79; Po:001). Mean EMG data showed increasing levels of activation across tasks (19–34% of maximum voluntary isometric contraction (MVIC)). The results of the repeated measures ANOVA demonstrated theses differences were signiﬁcant (F 3;12 ¼ 25:39; Po:001). Measurement of muscle thickness change utilizing RUSI is a valid and potentially useful method to measure activation of the LM muscle in a narrow range (19–34% of MVIC) in an asymptomatic population. r 2006 Elsevier Ltd. All rights reserved. Keywords: Rehabilitation; Electromyography; Ultrasonography

1. Introduction Lumbar paraspinal musculature plays a key role in providing stability during dynamic tasks (Cholewicki and McGill, 1996). Of particular interest in the literature of late has been study of the lumbar multiﬁdus (LM) muscle. Several abnormal characteristics have been Corresponding author. Department of Physical Therapy, University of Evansville, Evansville, IN 47714. Tel.: +812 479 2646; fax: +812 479 2717. E-mail address: [email protected] (K.B. Kiesel).

1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.06.011

identiﬁed in the LM in low back pain subjects. Structural abnormalities include histological changes, where fatty inﬁltrates replace LM muscle tissue (Weber et al., 1997; Zhao et al., 2000; Yoshihara et al., 2003), and atrophy (Kader et al., 2000; Hides et al., 2001). Motor control deﬁcits including altered recruitment patterns (Hodges and Richardson, 1997; Danneels et al., 2002) as well as endurance deﬁcits (Biedermann et al., 1991) have also been reported. Quantiﬁcation of multiﬁdus activation in those with low back pain may be helpful in determining effective

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intervention. The gold standard measurement tool used to assess muscle activation is electromyography (EMG). EMG measures the electrical activity in the muscle and can be interpreted to represent muscle activation. To ensure a reliable signal is obtained from the multiﬁdus, an indwelling electrode should be used (Stokes et al., 2003). RUSI offers a noninvasive method to measure muscle activation (Hodges et al., 2003; McMeeken et al., 2004) and has gained popularity in various aspects of low back pain rehabilitation (Hides et al., 1992, 1996, 1998, 2001; Critchley, 2002; Bunce et al., 2004). ‘‘RUSI is a procedure used by physical therapists to evaluate muscle and related soft tissue morphology and function during exercise and physical tasks. RUSI is used to assist in the application of therapeutic interventions aimed at improving neuromuscular function. This includes providing feedback to the patient and physical therapist to improve clinical outcomes. Additionally, RUSI is used in basic, applied, and clinical rehabilitative research to inform clinical practice. Currently, the international community is developing education and safety guidelines in accordance with World Federation for Ultrasound in Medicine and Biology (WFUMB)’’ (Teyhen, 2006). RUSI utilizing high-frequency sound waves to evaluate tissue properties such as thickness. Ultrasound examination is considered low risk. According to the safety committee of the European Committee for Medical Ultrasound (ECMUS), ‘‘Based on scientific evidence of ultrasonically induced biological effects to date, there is no reason to withhold scanning for any clinical application’’. It is known that muscle thickness changes when the muscle is activated (Hodges et al., 2003). The amount of thickness change that occurs with muscle activation can be quantiﬁed with the use of RUSI by comparing resting muscle thickness values to those obtained during muscle activation. Measurement of muscle thickness change compared to EMG activity has been performed on the gastrocnemius muscle (Maganaris et al., 1998), on the transverse abdominis (McMeeken et al., 2004) and on other trunk and peripheral muscles (Hodges et al., 2003). To our knowledge this type of study has not been performed on the LM. The purpose of this study is to determine the relationship between muscle thickness change, as measured by RUSI, and EMG activity of the LM muscle in normal subjects.

2. Methods 2.1. Subjects Five healthy subjects, three of which were female (mean age ¼ 28.0 years SD 5.6, mean height ¼ 170.7 cm, SD 9.4, mean weight ¼ 70.3 kg SD 15.9) volunteered for this study. Subjects were excluded if

they had current or recent history (within 6 months) of LBP or hip pain, a history of lumbar/sacral surgery, congenital lumbar/sacral condition such as spondylolithesis, or spina biﬁda, or boney pathology such as a fracture. All volunteering subjects signed an institutional-review-board-approved consent form following verbal instructions of the procedure. 2.2. Procedures Subjects were positioned in prone on a standard plinth. An inclinometer was placed longitudinally over the lumbo/sacral junction and pillows were used to ﬂatten the lumbar curve to less than 101. Subjects were then oriented to and practiced the maximum voluntary isometric contraction (MVIC) procedure which was performed with the elbows ﬂexed to approximately 901 and shoulders abducted to approximately 1201. Subjects then lifted their head, trunk, and upper extremities and held with maximum effort against a load applied at the elbow by one of the researchers. The contralateral upper extremity lifting movement, used to activate the multiﬁdus, was then practiced. It consisted of the upper extremity lift with four levels of graded resistance as described below. To study the multiﬁdus muscle, ﬁne wire (California Fine Wire Company, Grover Beach, CA) electrodes were fabricated from pairs of nylon coated 50 mm wires which were inserted into a 27 ga hypodermic needle. Approximately 1–2 mm of coating was removed from the tip of the wire, the tips were bent back at 2–3 and 3– 4 mm, respectively, and the needle and wires were sterilized. The L4 spinous process was identiﬁed, and the needle was inserted just lateral to the spinous process to the depth of the lamina, then withdrawn, leaving the electrode in the deepest portion of the LM muscle. A surface ground electrode was placed over the subject’s lateral malleolus. The ultrasound images were generated at 25 Hz utilizing computerized ultrasonography (Sonosite 180plus, Sonosite Inc, Seattle, WA). The primary investigator operated the ultrasound unit and did all the scanning for this study. A 70 mm 5-MHz curvilinear transducer was placed longitudinally along the spine with the mid-point over the L4 spinous process. It was moved laterally and angled slightly medially until the L4/5 zygapophyseal joint could be identiﬁed (Richardson et al., 1999) (Fig. 1). This scan point is directly over the LM multiﬁdus and a measurement from this landmark to the plane between the muscle and subcutaneous tissue was used for the linear measurement of the LM (Richardson et al., 1999) at rest (Fig. 2a) and during activation (Fig. 2b). An on-screen caliper was used to obtain the resting measurement (Fig. 2a and b), captured simultaneously with resting EMG data. The reliability of capturing LM images and

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Fig. 1. Position of transducer for imaging of the lumbar multiﬁdus muscle.

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represents reliability of measuring the same image between raters and was found to be excellent (ICC3,1 ¼ .95). The muscle thickness measurements obtained during each task were normalized to the resting measurement and the percent change from rest was calculated (ActivityRest/Rest 100). This percentage change in muscle thickness from rest to activation represented muscle activation as measured by RUSI. The MVIC data were collected as the subject performed the maximum upper extremity and trunk lift as described above. Two trials of 5 s each were performed and the greatest root mean square (RMS) peak amlitude was used to normalize the EMG activity. Normalization provides a standard reference of electrical activity and all data are reported as a percentage of the MVIC (Bamman et al., 1997). The contralateral arm lifting tasks were performed in the same plane as the MVIC’s. The subjects were instructed to lift their extremity straight up off of the table approximately 5 cm and hold for approximately 8 s which allowed enough time to capture two images of the contracted LM muscle. Two trials each of the four levels of increasingly demanding upper extremity lifting tasks were performed while EMG data and the images were obtained simultaneously. The ﬁrst level (no load) had resistance of only the limb; the next three levels (low, medium, and high load) had graded resistance based on the subject’s body weight (Table 1). The average of the two trials for each task was used for

Table 1 Graded resistance levels for upper extremity lifting tasks in kilograms

Fig. 2. (a) Ultrasound image of the lumbar multiﬁdus muscle at the L4/5 level with caliper measurement of the muscle thickness at rest. (b) Ultrasound image of the lumbar multiﬁdus muscle activation during the contralateral arm lift.

measuring them on the screen was established in a pilot study of eight asymptomatic subjects (ICC3,1 ¼ .85). Subsequent images taken during the arm lifting tasks were saved and printed for off-screen manual measurement. The reliability of the manual measurement was calculated by having a second researcher, blinded to the grade of activation, measure the muscle thickness. This

Subject mass (kg)

Low

Medium

High

o68.2 68.2–79.5 79.5–90.9 490.9

.45 .45 .45 .45

.68 .68 .90 .90

.90 1.14 1.14 1.36

Table 2 Mean and standard deviation values for the lumbar multiﬁdus muscle during rest and each of the lifting task conditions

Rest

No load

Low

Medium

High

Ultrasound Mean 2.48 SD .19

3.28 .35

3.50 .29

3.60 .33

3.68 .29

EMG Mean SD

19.50 5.94

25.31 7.15

32.21 7.58

34.31 8.85

na na

Ultrasound values are thickness measured in centimeters and EMG values are expressed as a percent of MVIC.

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analysis. See Table 2 for mean ultrasound and EMG data. 2.3. EMG analysis The EMG data were sampled at 2000 Hz using the Biopac II Student Lab Pro (Biopac System, Inc. Santa Barbara, CA) ampliﬁed 1000 and ﬁltered at 30– 500 Hz. The Biopac has a signal-to-noise ratio of 490 dB and an input impedance of 1.0 MO. The data were saved and imported to a PC for analysis with Datapac software (Run Technologies, Mission Viejo, CA). RMS peak amplitudes were calculated for each .5 s period. Data from the middle three seconds of each trial was averaged and expressed as a percent of MVIC. The average of the two trials for each task was used for analysis. 2.4. Statistical analysis To determine if a correlation exists between the EMG and RUSI data points, a Pearson’s correlation coefﬁcient was calculated. To determine if the individual tasks adequately increased muscle activation, a repeated measures analysis of variance with a Bonferroni post hoc analysis (a level .05) was performed on the EMG data.

3. Results The results of the Pearson’s product moment correlation coefﬁcients revealed that LM muscle thickness change as measured by RUSI correlated highly (r ¼ :79; Po:001) with LM EMG activity (Fig. 3).

Fig. 3. Correlation of EMG activity and thickness change of lumbar multiﬁdus as measured by RUSI during each of the four graded activation tasks.

The repeated measures ANOVA for the EMG data demonstrated that the tasks studied were signiﬁcantly different from each other (F 3;12 ¼ 25:39; Po:001). Post hoc analysis revealed signiﬁcant differences between the no-load and medium and high load tasks and between low load and high load tasks.

4. Discussion Our main ﬁnding was that a high correlation exists between EMG activity and thickness change in the LM muscle during typical contractions. This adds to the limited body of knowledge related to the use of RUSI as a measurement tool for muscle activation. We demonstrated a linear relationship between thickness change in the LM muscle and EMG activity during the graded contralateral upper extremity lifting tasks. Previous research assessing the relationship between muscle thickness change and EMG activity in the transverses abdominis muscle utilized volitional activation matched to percent of MVIC (Hodges et al., 2003; McMeeken et al., 2004) through a large range of activation levels. The tasks we chose produced average activation from 19% to 34% of MVIC, a narrow range. Analysis of variance showed a signiﬁcant difference between tasks, with post hoc testing demonstrating a difference between no-load and medium and high load tasks and between low load and high load. Although not statistically signiﬁcant, the difference between the no load and low task was 5%, which is consistent with increases between levels of activation in previously cited studies of the transverse abdominis. Isolated volitional activation of the LM is discussed in the literature (Hides et al., 1996), studying subjects trained to perform this activity may be a method for future research to study a broader range of activation levels. Direct comparison of our EMG results is not possible as we did not locate earlier studies that isolated EMG activity of the multiﬁdus during contralateral limb movement in the prone position. Arokoski et al. in two separate papers (Arokoski et al., 1999, 2001) studied a variety of stabilization exercises and reported an average 41% MVIC for the LM during a standing, alternating shoulder ﬂexion movement with an average load of 1.5 kg. Our average load across each task was .8 kg, which produces an average output of 28% of MVIC. Despite these methodological differences, research to measure multiﬁdus activity during various lumbar stabilization exercises, involving loaded limb movements, has shown somewhat similar activation levels to our study. Previous studies measuring thickness change and EMG activity of other muscles have reported conﬂicting results. Hodges et al. (2003) compared EMG activity to architectural change measured by RUSI in several

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muscles across a broad range of activation levels. This study measured thickness change and EMG activity of the tibialis anterior, biceps brachii, brachialis, internal oblique and transverse abdominis and reported a curvilinear relationship where RUSI could detect changes at low levels of contraction (up to approximately 20% of MVIC) and higher levels of contraction produce little further thickness change. McMeeken et al. (2004) measured the transverse abdominis during abdominal hollowing from 5% to 80% of MVIC and demonstrated a linear relationship between thickness change and EMG activity across all levels of activation measured. Our methods differed somewhat from similar research in that we did not match a volitional contraction to a set level of activation; rather we chose tasks thought to activate the LM at progressively greater levels. This resulted in measurement in a narrow range of muscle activation and is a limitation of our study. We cannot assume a linear relationship exists across the entire range of muscle activation as we tested a narrow range. We demonstrated RUSI can detect changes in LM EMG activity from and average of 19% of MVIC (no load) to of 34% of MVIC (high load). Further research is needed to determine if RUSI is a valid measure of LM activation across a greater range of activation levels, and in those with low back pain. If RUSI can be validated as a noninvasive measurement of LM muscular activity in the low back pain population, this may be useful for clinicians who use therapeutic exercise as an intervention in this population. RUSI could be used to measure potential LM activation impairment and how various interventions effect the impairment.

5. Conclusion These results provide preliminary data on the potential use of RUSI in the measurement of LM muscle activation. The measurement of muscle thickness change utilizing RUSI is valid noninvasive method to measure activation of the LM muscle as it is highly correlated with EMG in a limited range (19–34% of MVIC) in an asymptomatic population.

Acknowledgments The authors would like to thank the University of Evansville’s Undergraduate Research Committee for funding this study. The authors would like to thank ProRehab PC in Evansville, IN for the use of the sonography equipment used in this study.

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histochemical and electromyographic study. Orthopedics 2003; 26(5):493–5. Zhao WP, Kawaguchi Y, Matsui H, Kanamori M, Kimura T. Histochemistry and morphology of the multiﬁdus muscle in lumbar disc herniation: comparative study between diseased and normal sides. Spine 2000;25(17):2191–9.

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Original article

Attitudes to back pain amongst musculoskeletal practitioners: A comparison of professional groups and practice settings using the ABS-mp Tamar Pincusa,, Nadine E Fosterb, Steven Vogelc, Rita Santosa, Alan Breend, Martin Underwoode a

Department of Psychology, Royal Holloway University of London, Egham, Surrey, TW20 0EX, UK b Primary Care Sciences Research Centre, Keele University, UK c The Research Centre, British School of Osteopathy, UK d Institute for Musculoskeletal Research and Clinical Implementation, AECC, Parkwood Road, Bournemouth BH5 2DF, UK e Centre for Health Sciences, Barts and The London, Queen Mary University of London, UK Received 19 May 2005; received in revised form 6 February 2006; accepted 2 June 2006

Abstract Chiropractors, osteopaths and physiotherapists play key roles in the management of low back pain (LBP) patients in the UK. We investigated the attitudes of these three professional groups to back pain using a recently developed and validated questionnaire, the Attitudes to Back Pain Scale for musculoskeletal practitioners (ABS-mp). A cross-sectional questionnaire survey was sent to 300 of each professional group ðn ¼ 900Þ. Responses were analysed from 465 practitioners: 132 chiropractors (28%), 159 osteopaths (34%) and 174 physiotherapists (37%). Overall, all three groups endorse a psychosocial approach to treatment, and see re-activation as a primary goal. However, physiotherapists and osteopaths tend to endorse attitudes towards limiting the number of treatment sessions offered to LBP patients more than chiropractors, and chiropractors endorse a more biomedical approach than physiotherapists. When practice setting (NHS versus private practice) was considered (in physiotherapists alone), physiotherapists working for the NHS endorsed limiting the number of treatment sessions more than those working in the private sector and would also less frequently advise their patients to restrict activities and be vigilant. The results may help explain current clinical practice patterns observed in these groups and their uptake of clinical guideline recommendations. r 2006 Elsevier Ltd. All rights reserved. Keywords: Attitudes; Back pain; Chiropractors; Osteopaths; Physiotherapists

1. Introduction 1.1. Need to assess clinician’s attitudes After general practitioners, the three professional groups of chiropractors, osteopaths and physiotherapists see most low back pain (LBP) patients in the UK (Maniadakis and Gray, 2000). LBP patients account for Corresponding author. Department of Psychology, Royal Holloway University of London, Egham, Surrey, TW20 0EX. E-mail address: [email protected] (T. Pincus).

1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.06.005

approximately half their workload (Breen, 1977; Burton, 1981; Pringle and Tyreman, 1993; Pedersen, 1994; Foster et al., 1999; Gracey et al., 2002; Waddell, 2004). It has been suggested that these three groups, referred to as musculoskeletal practitioners (MPs) throughout this paper, share similar approaches to the management of LBP (Harvey et al., 2003). In national clinical practice guidelines, they have been considered as a collective clinical group (CSAG, 1994; Waddell et al., 1996, 1999). Findings from randomized controlled trials provide little convincing evidence to inform their approaches to LBP management although they generally support

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active interventions above no treatment (van Tulder et al., 2000; Assendelft et al., 2003; Cherkin et al., 2003; UK BEAM, 2004; Hay et al., 2005). Despite these ﬁndings, patients’ positive choice for musculoskeletal hands-on therapy (i.e. the traditional care provided by physiotherapists, osteopaths and chiropractors) has been documented. In UK studies, patients receiving an intervention, including manual therapy delivered by physiotherapists, reported enhanced perceptions of beneﬁt (Frost et al., 2004) and patients were more satisﬁed after consultation with osteopaths than general practitioners (Pincus et al., 2000). In a USA trial, patients were more satisﬁed with chiropractic care than the comparison interventions (Cherkin et al., 1998). One method to inform clinical decision-making is through the use of clinical practice guidelines (Grimshaw et al., 2004). Implementation of the available UK guidelines for acute LBP has proved difﬁcult in general practice (Little et al., 1996; Barnett et al., 1999), with suggestions that they have made little impact on primary care (Langworthy and Breen, 2003). We have argued elsewhere that clinician factors need investigating to better understand the complexity of professional practice behaviour and how to improve implementation of guidelines in LBP management (Foster et al., 2003). Clinicians have been shown to hold a range of beliefs and attitudes about pain (Rainville et al., 2000; Linton et al., 2002; Ostelo et al., 2003), and these appear to be related to the recommendations and treatment they give to patients (Houben et al., 2005a,b). Previous research has suggested that the uptake of guidelines by these professional groups is related to practitioners’ beliefs and attitudes (Evans et al., 2003; Daykin and Richardson, 2004; Houben et al., 2004; Linton et al., 2002). These beliefs could contribute to the development of chronic spinal disability in a number of ways, including over or under treating, failing to use effective pain control or reactivation strategies, reinforcing patients’ unhelpful illness perceptions by advising increased spinal vigilance and restricting normal activities (Bishop and Foster, 2005; Goubert et al., 2003; Linton et al., 2002; Di Iorio et al., 2000; Houben et al., 2005a). Our research has suggested that there may also be a problem with a minority of clinicians providing extended treatment for LBP patients, without evidence of clinical progress. We found that over 10% of MPs’ report that they continue to treat people with sub-acute back pain, even if it is not responding as well as expected (Pincus et al., 2006a), and there was some data suggesting that this was an underestimate. It is clear from this area of research that we need a better understanding of the attitudes and beliefs of MPs about LBP and its management. It is likely that practitioners’ beliefs inﬂuence their clinical behaviour towards and interactions with patients and, therefore, contribute to the success or failure of interventions (Rainville et al., 2000; Houben et al., 2005a).

1.2. Tools to assess practitioners’ attitudes Almost all the quantitative measurements developed to assess practitioners’ attitudes and cognitions about back pain have been developed originally for, and with, patients. For example, the Health care providers’ Pain And Impairment Relationship Scale (HC-PAIRS) (Rainville et al., 1995, 2000) aims to measure beliefs of health-care providers about the relationship between pain and impairment, and reports suggest that it has acceptable psychometric properties. There is some evidence that HC-Pairs scores relate to practitioners’ recommendations about work and physical activity (Rainville et al., 2000; Houben et al., 2004). Practitioners’ beliefs about fear of movement in patients have been investigated (Linton et al., 2002), and found to be related to the belief that sick leave is a good treatment. Physiotherapists’ beliefs about fear of movement, pain catastrophizing, back beliefs, and beliefs about physical activity and work have been found to differentiate between therapists with a behavioural orientation and those with a biomedical orientation (Ostelo et al., 2003; Houben et al., 2005a). However, these studies are limited by investigating beliefs identiﬁed largely in patient groups and extrapolating these to practitioner samples, and by focusing mainly on the physiotherapy profession with some limited attempts to include adequate numbers from other professional groups. To address this problem, we developed a new questionnaire tool to measure attitudes to back pain in MPs. The development of this tool has been reported elsewhere (Pincus et al., 2006b). Our aim in this paper is to present and compare the results of the questionnaire survey for each of the three professional groups of MPs and, where possible, to explore the differences between practice settings (National Health Service (NHS) versus private practice). Knowing more about the similarities and differences in attitudes to the management of LBP between these professional groups with different conceptual frameworks will inform future provision of back pain services. Given that healthcare for LBP may occur in either the NHS or private sectors in the UK, the inﬂuence of practice settings on the attitudes of MPs might help explain current clinical practice and willingness to follow recommendations within clinical guidelines.

2. Method 2.1. Practitioner sample To develop the ABS-mp questionnaire we sent a postal questionnaire with a postal reminder to nonresponders to the registered address of a random sample of 300 members from the professional register of each

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group; 900 in total. In addition to the ABS-mp development questionnaire, participants provided information on their age, gender, years in practice and practice settings (Private or NHS setting/Urban or rural, Primary or Secondary care). The secondary analysis reported here was carried out on scores from the ﬁnal version of the questionnaire, using all suitable responses from our sample of 900 practitioners.

(Cohen’s dÞ were calculated. To investigate the role of practice setting, we tested the differences between those within the professional groups, who worked only in private settings. Again, we used ANOVA and effect sizes (Cohen’s dÞ. Correlations were computed between demographic factors and responses on the ABS-mp.

2.2. The ABS-mp questionnaire tool

3. Results

The ABS-mp contains two sections, labelled Personal Interaction and Treatment Orientation. Personal interaction consists of four factors:

3.1. Response and demographics

Limitations on sessions, items about practitioners’ policy towards limiting the length of treatment (four items). Psychological, items measuring practitioners’ willingness to engage with psychological issues with their patients (four items). Connection to healthcare system, items measuring practitioners’ perception of the health-care system and provision of available services (three items). Confidence and concern, items measuring practitioners’ conﬁdence and concern about treatment and clinical limitations in themselves and others (two items).

Treatment orientation consists of two factors:

Re-activation, items that concern return to work and to daily activity and increasing mobility (three items). Biomedical; items that concern advice to restrict activities and to be vigilant, and the belief that there is an underlying structural cause of back pain (3 items).

In total, 546 out of 900 practitioners (61%) responded. Excluded questionnaires were deﬁned as missing ðn ¼ 68Þ if at least two items were not completed. These were not clustered in any particular category or on any single item/items. Outliers, deﬁned as more than 3 standard deviations from the mean of the group for any given item ðn ¼ 13Þ were also excluded. After the exclusion of outliers and analysis of missing values, data from 465 participants were used for analysis, of which 132 were chiropractors (28%), 159 were osteopaths (34%) and 174 were physiotherapists (37%). Of these 465 participants, 74% ðn ¼ 342Þ reported working in private settings, 63% ðn ¼ 293Þ reported working mainly in primary care, and 61% ðn ¼ 282Þ were professionally located in urban settings (Table 1). Overall, the osteopaths tended to be slightly older in age and had been in clinical practice for longer than the other professional groups. Only 15% of physiotherapists were male compared with 60% and 53%, respectively, for the chiropractors and osteopaths. As expected, few osteopaths ðn ¼ 2Þ and none of the chiropractors were currently working within the National Health Service (NHS), whereas 61% ðn ¼ 107Þ of the physiotherapy responders were working within the NHS.

2.3. Analysis 3.2. Comparisons between professional groups The analyses were performed using the Statistical Package for the Social Sciences (SPSS; Coakes and Steed, 2001). Several multivariate analyses of variance (ANOVA) were performed in order to investigate the group differences on the studied variables, using effect size analyses to quantify the results. Effect sizes are conventionally described as small (0.2 or less, interpreted as 58% of the population of one group will fall below the average members’ score in the comparison group), medium (0.5, in which 69% would fall below) or large (0.8 in which 79% fall below) (Cohen, 1988, 1992). To compare the differences between professional groups (chiropractors, osteopaths and physiotherapists) on the dimensions of the ABS-mp, an analysis of variance (ANOVA) was performed, and the effect sizes

Although the three groups appeared to share some attitudes about back pain, signiﬁcant differences were found between them for some of the dimensions of the ABS-mp questionnaire. Analysis was originally carried out on the total sample. The analysis was then repeated between the three groups based in private settings, (excluding the NHS based clinicians n ¼ 130 chiropractors, n ¼ 57 physiotherapists, n ¼ 155 osteopaths) with a separate analysis comparing physiotherapists based in private versus NHS settings. Apparent differences between the professional groups on the dimensions ‘Connection to the health-care system’ and ‘Re-activation’ were no longer signiﬁcant when practice setting was taken into account. There were insufﬁcient individuals working in NHS settings amongst the osteopaths

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Table 1 Demographics for the professional groups

Age mean (SD)* Years in practice, mean (SD)* Male (%) NHS practitioners (%) Clinical setting Primary care (%) Secondary care (%) Both (%) Location Inner city (%) Urban (%) Rural (%) *

Chiropractic ðn ¼ 132Þ

Osteopathy ðn ¼ 159Þ

Physiotherapy ðn ¼ 174Þ

39 (10.6) 9 (7.6) 78 (59) 0/130 (0)

46 (8.7) 19 (8.0) 84 (53) 2/157 (1%)

40 (7.53) 16 (7.3) 26 (15) 107/164 (65%)

92 (72) 3 (5) 33 (26)

90 (61) 12 (8) 45 (31)

111 (66) 34 (20) 22 (13)

18 (15) 75 (61) 29 (21)

20 (14) 93 (63) 35 (24)

21 (12) 114 (67) 36 (21)

Po0:001.

and chiropractors for analysis. Comparisons between groups on the total sub-scales and subsequent post-hoc analysis on each item in the questionnaire are presented in Table 2. 3.2.1. Personal interaction attitudes The Limitations on Sessions dimension differed signiﬁcantly between the three groups ½F ð2; 338Þ ¼ 64:246; Po:001, Post hoc tests showed that physiotherapists reported they limited the number of treatment sessions more than the chiropractors (Po:001; very large effect size d ¼ 1:7, indicating that the mean of the physiotherapist group is at the 95th percentile of the chiropractic group) and osteopaths (Po:001; large effect size d ¼ :8, indicating that the mean of the physiotherapists is at the 79th percentile of the osteopaths). Osteopaths reported limiting sessions more than chiropractors (Po:001; large effect size d ¼ 0:9, indicating that the mean of the osteopaths was in the 82nd percentile of the chiropractors). All the items that make up this sub-scale contributed signiﬁcantly to the effect (Table 2, Fig. 1). On the psychological sub-scale, high endorsement of the psychological items was found for all three groups, indicated by means around 5 out of a possible 7. There were, however, signiﬁcant differences between the groups ½F ð2; 340Þ ¼ 7:767; Po:001. Both physiotherapists (Po:01; medium effect size d ¼ 0:5) and chiropractors (Po:05; medium effect size d ¼ 0:4, indicating that the means of these groups are in the 69th and 66th percentile of the osteopaths, respectively) reported more willingness to engage in psychological issues with their back pain patients than osteopaths. Physiotherapists responses showed a greater perception of connection to a wider health system and provision of other available services than chiropractors (Po:05; medium effect size d ¼ :5), and no signiﬁcant differences were found between osteopaths and either of

the other professional groups. However the item by item analysis showed that both physiotherapists (Po:001; large effect size d ¼ .68) and osteopaths (Po:001; medium effect size d ¼ :48, indicating that physiotherapists and osteopaths means are at the 76th and 69th percentile of the chiropractors) had a greater perception of connection to a wider health system and provision of other available services than chiropractors, as measured by a single item. No signiﬁcant differences were found between physiotherapists and osteopaths. More conﬁdence in themselves and concern about treatment by others was shown by osteopaths compared to physiotherapists (Po:01; showing a medium effect size d ¼ 0:4), but no signiﬁcant differences were found between chiropractors and either of the other professional groups. However, item by item analysis indicated that chiropractors endorsed items representing conﬁdence in themselves less than the other two groups (Po:05; showing a small effect size d ¼ :23, indicating that chiropractors’ mean is in the 58th percentile of the other two groups), whose scores did not differ. Physiotherapists were signiﬁcantly less concerned about the quality of treatment their referred patients received than the other two groups. 3.2.2. Treatment orientation attitudes No signiﬁcant differences were found for the dimension re-activation, which was highly endorsed by all three groups. Signiﬁcant differences were found for the dimension biomedical ½F ð2; 337Þ ¼ 4:50; Po:01 between the three professional groups (Table 2). Physiotherapists’ scores on the Biomedical factor were signiﬁcantly lower than the scores from the chiropractors (Po:05; large effect size d ¼ :92, indicating that the chiropractors’ mean is in the 82nd percentile of the physiotherapists), while the osteopaths did not differ from either of the other groups. These differences were due to chiropractors endorsing the item about teaching

Table 2 Differences between professional groups (private sector only)

4.18 1.3 1.6 1.7 1.5

64.24 134.645 102.167 50.130 79.873

.000 .000 .000 .000 .000

21.16b 5.32b 5.57b 3.43 5.66a

2.78 1.0 .9 1.2 .9

6.60 14.258 6.532 2.356 3.815

.002 .000 .002 .096 .023

3.2 1.2 1.5 1.6

13.16a 4.56 3.50 3.28a;b

3.33 1.2 1.5 1.5

4.47 1.912 1.459 18.570

.012 .149 .234 .000

10.81a 5.49a 5.21b

1.9 1.1 1.5

9.66a 5.56b 4.49a;b

1.9 1.1 2.0

6.64 6.554 8.616

.001 .002 .000

3.3 1.21 1.3 1.5

14.66 5.40b 5.35 3.92

2.5 1.0 .9 1.3

15.50 5.87a;b 5.63a 4.12

2.1 .7 .9 1.4

2.03 10.581 4.266 .836

.132 .000 .015 .434

2.3 .9 1.4 1.5

13.24 5.32b;c 4.55b 3.39b

2.4 .9 1.5 1.3

12.41a 4.82a;c 3.73a;b 2.49a;b

2.9 1.5 1.7 1.2

4.50 23.553 15.821 21.949

.012 .000 .000 .000

Physiotherapists

Mean

SD

Mean

SD

Mean

SD

Limitations on sessions (range 4–28, where 28 ¼ support unlimited sessions. Items 6 and 18 reversed) 13.I keep seeing patients on and off I can prevent relapse 9. I believe in continuing to treat the patient after the back pain has been resolved, to prevent its return 6. Regular treatment by a physical therapist does not help prevent back pain 18. If I keep seeing patients on and off, they might never learn to manage their back problem themselves

21.06a;b 5.08a;b 5.44a;b 2.61a;b 2.87a;b

3.2 1.0 1.1 1.3 1.3

18.05a;c 4.42a;c 4.04a;c 3.09a;c 3.31a;c

3.6 1.2 1.4 1.4 1.3

14.77b;c 2.87b;c 3.08b;c 4.31b;c 4.78b;c

Psychological (range 4–28, where 28 ¼ support psychological approaches. Item 11 reversed). 5. It is essential that I know about my patients’ psychological difﬁculties 1. I explore the psychological problems that my patient is facing 11. I try to avoid probing into my patients’ personal problems 2. I often ﬁnd myself providing psychological support to patients

20.71a 5.43a 5.53a 3.68 5.44

2.6 .9 .8 1.2 .8

19.77a;b 4.84a;b 5.21a;b 3.68 5.40a

2.9 1.0 1.1 1.1 .9

Connection to health-care system (range 3–21, where 21 ¼ feel connected) 19. When referring patients I am conﬁdent they will receive good treatment 7. When I refer my patients I know they will be seen within a suitable time frame 15. I don’t see myself as connected to a health system of resources that I can access

11.57a 4.28 3.73 4.37a

3.3 1.3 1.6 1.6

12.10 4.38 3.78 4.04b

Conﬁdence and concern (range 2–14, where 14 ¼ conﬁdent) 12. I don’t believe that there is anyone out there who could help my back pain patients more than I do 3. I am concerned about the quality of treatment my referred patients receive

10.22 5.07a;b 5.17a

2.1 1.4 1.6

Re-activation (range 3–21, where 21 ¼ support re activation) 10. Return to normal daily activities is the most important consequence of treatment 14. My objective is to get my patients back to work quickly 8.The most important goal of treatment is to increase mobility

14.70 5.46a 5.30a 4.02

Biomedical (range 3–21, where 21 ¼ support biomedical approach) 16. I often ﬁnd I have to teach patients to be vigilant about their backs 4. If you look hard enough you can ﬁnd a structural reason for most patients’ back pain 17. I advise back pain patients to restrict their life-style

13.63a 5.76a;b 4.63a 3.31a

Means sharing subscripts are statistically different. The responses to each item were scored on response scale, where 1 ¼ completely disagree and 7 ¼ completely agree. Some dimensions include items scores in reverse when adding up to dimension score. Bold indicates sub-scales in the questionnaire.

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F

Chiropractors

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Sessions ½F ð2; 457Þ ¼ 20:99; Po:001 and Biomedical ½F ð2; 457Þ ¼ 20:03; Po:001, showing that physiotherapists working for the NHS (M ¼ 11:67; SD ¼ 4:09) endorsed limiting the number of treatment sessions more than those working in the private sector (M ¼ 14:77; SD ¼ 4:18). The private physiotherapists endorsed advising their patients to restrict activities and be vigilant (M ¼ 12:41; SD ¼ 2:98) (more so than those working in the NHS M ¼ 10:10; SD ¼ 3:18).

Limitations on Sessions

7

Response scale (1-7)

6 5 4 3 Chiropractors

2

Osteopaths

1

Physiotherapists 0 Item 13 7

Item 9

Item 6

Item 18

Biomedical

The only statistically signiﬁcant correlations were physiotherapists’ number of years in practice and the ABS-mp Biomedical dimension (r ¼ :161; Po:05), and osteopaths’ age and the ABS-mp psychological dimension (r ¼ :181; Po:05), both with very small effect sizes. These are indicative of small relationships between the variables and may be chance ﬁndings of statistical signiﬁcance due to the large number of comparisons made.

Response scale (1-7)

6 5 4 3 Chiropractors

2

Osteopaths 1

3.4. Relationship between practitioner attitudes, age and numbers of years in practice

Physiotherapists

0 Item16

Item 4

Item 17

Fig. 1. Endorsement of unlimited sessions and of a biomedical approach. Note. Item 13: I keep seeing patients on and off I can prevent relapse. Item 9: I believe in continuing to treat the patient after the back pain has been resolved, to prevent its return. Item 6: Regular treatment by a physical therapist does not help prevent back pain. Item 18: If I keep seeing patients on and off, they might never learn to manage their back problem themselves. Item 16: I often ﬁnd I have to teach patients to be vigilant about their backs. Item 4: If you look hard enough you can ﬁnd a structural reason for most patients’ back pain. Item 17: I advice back pain patients to restrict their life-style.

‘vigilance’ more than the other groups; and both chiropractors and osteopaths endorsing items about recommending restricting daily activities and, believing that there is an underlying structural cause of back pain more often than physiotherapists. All three items that made up this dimension differed signiﬁcantly between the groups when studied independently (Fig. 1). 3.3. Influence of gender, clinical environment and work location No signiﬁcant effects were found within each group for the factors gender, clinical environment (primary and secondary care, and both), and work location (inner city, urban and rural) on the dimensions of the ABS-mp questionnaire dimensions. The only group with enough participants in both NHS and the private sector that would allow comparisons for the workplace on the dimensions on the ABS-mp were the physiotherapists. Signiﬁcant differences were found in the dimensions Limitations on

4. Discussion We investigated the attitudes of MPs towards LBP and its management using the recently developed and validated Attitudes to Back Pain Scale (the ABS-mp), initially without taking practice settings into account. A striking ﬁnding was the extent of similarity of attitudes between the three groups towards re-activation and referral. However, the results also suggest that physiotherapists endorse limiting the number of treatment sessions offered to LBP patients more than osteopaths, who in turn endorse limiting sessions more than chiropractors. We also found that the chiropractors held a more biomedical approach than physiotherapists. All three groups endorsed the psychological items highly, which might indicate an acceptance of the psychosocial approach. However, moderate differences were found between the groups on their willingness to engage in psychological problems; both physiotherapists and chiropractors endorsed these items signiﬁcantly more highly than osteopaths. Physiotherapists also felt more integrated within a wider health-care system, but this ﬁnding was limited to a single item. Although we could not examine attitudes to reactivation in osteopaths and chiropractors working in the NHS versus those practicing in private settings, it appears physiotherapists in the NHS endorse limitation on sessions, and advise vigilance and restricting life style less often than those in private practice. Attitudes to limitations on sessions might be inﬂuenced by the pressure and waiting times within the UK NHS. This is in contrast to the private setting in which

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most osteopaths and chiropractors practice, in which waiting lists are more likely to result in the employment of further staff and increases in practice size, than limiting treatment sessions. However, the ﬁnding appears to be at least partly independent of setting, as we found the differences between our groups even when examined only in the same setting (i.e. private clinicians only). Fig. 1 illustrates clearly that even within private practice alone, in this sample, there are marked differences between the groups on their attitudes towards limiting sessions. Differences might also result from the focus of the different educational pathways of these professional groups. Perhaps physiotherapists are more likely to follow the self-care, exercise and rehabilitation messages for LBP patients, resulting in a greater tendency to limit sessions, whereas osteopaths and chiropractors prefer to monitor patient progress beyond the immediate presenting problem and have the freedom, within private practice, to do so. NHS physiotherapists’ disagreement with advice to restrict life-style might be explained by a greater awareness of the recommendations of current clinical guidelines for LBP. However, it is particularly pertinent to note that within the privately practicing practitioners, the professional groups did not differ on the dimension of re-activation, which was highly endorsed by all. This suggests that they share at least some common educational/philosophical approaches. In line with current guidelines, all three groups agreed that re-activation was a primary goal in their treatment. Whether these reported attitudes affect behaviour and decision-making remains unclear. There is little research to date which compares implicit and explicit attitudes of health-care practitioners and the work that is available (Houben et al., 2005b) shows that these are only weakly related to each other, but that both are related to treatment recommendations. In earlier work, Houben et al. (2004) suggested that practitioners’ attitudes and beliefs were consistently associated with recommendations for work and physical activity for patients (based on clinical vignettes). Hence, there is some support that practitioners’ beliefs and attitudes inﬂuence their behaviour (such as the information they provide to patients) and ongoing research will further inform this debate (Evans et al., 2005).

clinical experiences (Elstein and Schwarz, 2002). Traditional professional education in healthcare tends to concentrate on the biomedical model which leads to a focus on the search for ‘physical’ explanations for musculoskeletal problems, yet most common musculoskeletal problems demonstrate few of these that can be objectively veriﬁed. Where there is evidence, it has seldom been shown to relate to symptoms and the association between the results of diagnostic tests and presenting symptoms is often unclear. Practitioners themselves then, may add to the problem that they seek to address. For example, biomedical or psychosocial attitudes to the care of patients with back pain will be reﬂected in important initial decisions during patient care encounters. These attitudes could determine whether practitioners emphasize physical factors for causation and perpetuation, or the need to change perceptions of the condition and solve associated problems. The current study also has important implications for the implementation of clinical guidelines. Implementation strategies for speciﬁc guidelines need to address the beliefs and attitudes of practitioners, since it is clear that at least some practitioners will hold beliefs that do not agree with guideline recommendations. Future research is needed to explore such attitudes and beliefs and the inﬂuence of professional background on the uptake of guideline recommendations.

4.1. Implications of the study

This study identiﬁes attitudinal similarities and differences between the main MPs who treat LBP within the UK, namely chiropractors, osteopaths and physiotherapists. However, our results only relate to their attitudes and not to their actual behaviour. Overall, it appears that all three groups showed support for a psychosocial approach to their patients, and saw reactivation as the primary goal of treatment. Nevertheless, the physiotherapists tended to endorse limiting

We need to know more about the origins of beliefs and attitudes of health-care practitioners about back pain, the degree to which these attitudes might be modiﬁable and what the inﬂuential factors in that process are. Numerous factors are likely to be involved in the attitudes, beliefs and decision-making of MPs, such as their professional training, traditions and

4.2. Limitations of the current study The ABS-mp questionnaire measures a number of factors underlying practitioner beliefs about the management of back pain. The extent to which these relate to actual clinical behaviour (or behaviour in response to a clinical vignette) is as yet untested. In addition, the same practitioners were used to determine the factor structure of the ABS-mp and to compare the attitudes of the three groups of chiropractic, osteopathy and physiotherapy. Future work should use a different sample of health-care practitioners to re-examine the issues raised in this study and conﬁrm the construct validity of the factors within the scales.

5. Conclusions

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treatment sessions more than the osteopaths, who in turn endorsed such limitations more than the chiropractors. The chiropractors tended to endorse biomedical attitudes more than the physiotherapists. It appears that at least for physiotherapists, some of these differences are explained by practice setting in that those who work within the public health-care sector (the UK NHS) appear to support restricting sessions, and disagree with advice to limit life-style more than their private practice colleagues. Professional grouping therefore seems to explain only some of the differences we have seen in these practitioners’ attitudes and beliefs.

Acknowledgements This study was supported by a project grant from the Economic and Social Research Council. We would like to thank all of the health-care practitioners who gave their time to participate in this study. References Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies. Annals of Internal Medicine 2003;138:33. Barnett AG, Underwood MR, Vickers MR. Effect of UK national guidelines on services to treat patients with acute low back pain: follow up questionnaire survey. British Medical Journal 1999;318:919–20. Bishop A, Foster NE. Do physical therapists in the United Kingdom recognise psychosocial factors in patients with acute low back pain? Spine 2005;30:1316–22. Breen AC. Chiropractors and the treatment of back pain. Rheumatology and Rehabilitation 1977;16:46–53. Burton AK. Back pain in osteopathic practice. Rheumatology and Rehabilitation 1981;20:239–46. Cherkin DC, Deyo RA, Battie M, et al. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. New England Journal of Medicine 1998;339:1021–9. Cherkin D, Sherman K, Deyo R, Shekelle P. A review of the evidence for the effectiveness, safety and cost of acupuncture, massage therapy and spinal manipulation for back pain. Annals of Internal Medicine 2003;138:898–906. Coakes SJ, Steed LG. SPSS: analysis without anguish: version 10.0 for windows. Brisbane: Wiley; 2001. Cohen J. Statistical power for behavioural sciences. 2nd ed. New York: Academic Press; 1988. Cohen J. A power primer. Psychological Bulletin 1992;112:155–9. Clinical Standards Advisory Group (CSAG). Clinical Standards Advisory Group Report on Back Pain. London: HMSO; 1994. Daykin AR, Richardson B. Physiotherapists’ pain beliefs and their inﬂuence on the management of patients with chronic low back pain. Spine 2004;29:783–95. Di Iorio D, Henley E, Doughty A. A survey of primary care physician practice patterns and adherence to acute low back problem guidelines. Archives of Family Medicine 2000;9:1015–21. Elstein A, Schwarz A. Clinical problem solving and diagnostic decision-making: selective review of the cognitive literature. British Medical Journal 2002;324:729–32.

Evans DW, Foster NE, Vogel S, Breen AC. Implementing evidencebased practice in the UK physical therapy professions: do they want it and do they feel they need it? Presented at the Linkoping international forum vi for primary care research on low-back pain, Linkoping, Sweden, 23–25 May 2003. Evans DW, Foster NE, Underwood M, Vogel S, Breen AC, Pincus T. Testing the effectiveness of an innovative information package on practitioner reported behaviour and beliefs. The UK Chiropractors, Osteopaths and Musculoskeletal Physiotherapists Low Back Pain Management (COMPLeMENT) Trial. [ISRCTN77245761]. BMC Musculoskeletal Disorders 6: 41 (20 July 2005). Foster NE, Thompson KA, Baxter GD, Allen JM. Management of nonspeciﬁc low back pain by physiotherapists in Britain and Ireland. A descriptive questionnaire of current clinical practice. Spine 1999;24:1332–42. Foster NE, Pincus T, Underwood MR, Vogel S, Breen AC, Harding G. Treatment and the process of care in musculoskeletal conditions; a multidisciplinary perspective and integration. Orthopedic Clinics of North America 2003;34:239–44. Frost H, Lamb SE, Dol HA, Carver PT, Stewart-Brown S. Randomised controlled trial of physiotherapy compared with advice for low back pain. British Medical Journal 2004;329:708. Goubert L, Crombez G, Hermans D, Vanderstraeten G. Implicit attitude towards pictures of back-stressing activities in pain-free subjects and patients with low back pain: an effective priming study. European Journal of Pain 2003;7:33–42. Gracey JH, McDonough SM, Baxter GD. Physiotherapy management of low back pain: a survey of current practice in Northern Ireland. Spine 2002;27:406–11. Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L, et al. Effectiveness and efﬁciency of guideline dissemination and implementation strategies. Health Technological Assessment 2004;8(6). Harvey E, Burton AK, Klaber-Moffett J, Breen AC. Spinal manipulation for low-back pain: a treatment package agreed by the UK chiropractic, osteopathy and physiotherapy professional associations. Manual Therapy 2003;8:46–51. Hay EM, Mullis R, Lewis M, Vohora K, Main CJ, Watson P, et al. Comparison of physical treatments versus a brief pain-management programme for back pain in primary care: a randomised clinical trial in physiotherapy practice. Lancet 2005;365:2024–30. Houben RMA, Vlaeyen JWS, Peters M, Ostelo RWJG, Wolters PMJC, Stomp-van den Berg SGM. Health care providers attitudes and beliefs towards common low back pain: factor structure and psychometric properties of the HC-PAIRS. Clinical Journal of Pain 2004;20:37–44. Houben RMA, Ostelo RWJG, Vlaeyen JWS, Wolters PMJC, Peters M, Stomp-van den Berg SGM. Health care providers’ orientations towards common low back pain predict perceived harmfulness of physical activities and recommendations regarding return to normal activity. European Journal of Pain 2005a;9:173–83. Houben RMA, Gijsen A, Peterson J, deJong PJ, Vlaeyen JWS. Do health care providers’ attitudes towards back pain predict their treatment recommendations? Differential predictive validity of implicit and explicit attitude measures. Pain 2005b;114:491–8. Langworthy J, Breen A. Auditing the management of acute back pain in primary care: too late to preserve the momentum? Proceedings of the 32nd annual scientiﬁc meeting of the society for academic primary care, Manchester, July 2003. Linton SJ, Vlaeyen J, Ostelo R. The back pain beliefs of health care providers: are we fear-avoidant? Journal of Occupational Rehabilitation 2002;12:223–32. Little P, Smith L, Cantrell T, Chapman J, Langridge J, Pickering R. General practitioners’ management of acute back pain: a survey of reported practice compared with clinical guidelines. British Medical Journal 1996;312:485–8.

ARTICLE IN PRESS T. Pincus et al. / Manual Therapy 12 (2007) 167–175 Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain 2000;84:95–103. Ostelo RW, Stomp-van denBerg SG, Vlaeyen JW, Wolters PM, deVet HC. Health care providers attitudes and beliefs towards chronic low back pain: the development of a questionnaire. Manual Therapy 2003;8:214–22. Pedersen P. A survey of chiropractic practice in Europe. European Journal of Chiropractic 1994;42:1–28. Pincus T, Vogel S, Savage R, Newman S. Patients’ satisfaction with osteopathic and GP management of low back pain in the same surgery. Complement Therapy Medicine 2000;8:180–6. Pincus T, Vogel S, Breen A, Foster N, Underwood M. Persistent back pain? why do physical therapy clinicians continue treatment? A Mixed methods study of chiropractors, osteopaths and physiotherapists. European Journal of Pain 2006a;10(1):67–76. Pincus T, Vogel S, Santos R, Breen A, Foster N, Underwood M. The attitudes to back pain scale in musculoskeletal practitioners (ABSmp); the development and testing of a new questionnaire. Clinical Journal of Pain 2006b;22(4):378–86. Pringle M, Tyreman S. Study of 500 patients attending an osteopathic practice. British Journal of General Practice 1993;43: 15–8. Rainville J, Bagnall D, Phalen L. Health care providers’ attitudes and beliefs about functional impairments and chronic back pain. Clinical Journal of Pain 1995;11:287–95.

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Rainville J, Carlson N, Polatin P, Gatchel RJ, Indahl A. Exploration of physicians recommendations for activities in chronic low back pain. Spine 2000;25:2210–20. UK BEAM Trial Team. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial; effectiveness of physical treatments for back pain in primary care. British Medical Journal 2004; 329:1377–85. van Tulder M, Malmivaara A, Esmail R, Koes B. Exercise therapy for low back pain: a systematic review within the framework of the cochrane collaboration back review group. Spine 2000;25:2784–96. Waddell G, Feder G, McIntosh G, Lewis M, Hutchinson A. Low back pain evidence review. London: Royal College of General Practitioners; 1996. Waddell G, Feder G, McIntosh A, Lewis M, Hutchinson A. Low back pain evidence review. London: Royal College of General Practitioners; 1999. Waddell G. The back pain revolution. 2nd ed. Edinburgh: Churchill Livingstone; 2004.

Further reading Pincus T, Burton K, Vogel S, Field A. A systematic review of psychological risk factors for chronicity/disability in prospective cohorts of low back pain. Spine 2002;27:109–20.

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Manual Therapy 12 (2007) 176–180 www.elsevier.com/locate/math

Original article

Findings of interest from immunology and psychoneuroimmunology Les Alford University of East Anglia, Queens Building, Norwich NR4 7TJ, UK Received 24 November 2005; received in revised form 19 February 2006; accepted 2 June 2006

Abstract The biopsychosocial paradigm is now the main model when dealing with most human health disorders. One of the strengths of this model is that it encourages broader thinking when assessing and managing patients. It also encourages broader reading into areas not traditionally associated with manual therapy. Immunology and neuroscience are amongst the fastest growing medical sciences. These ﬁelds come together in the relatively new area of psychoneuroimmunolgy. This article examines some ﬁndings from these ﬁelds that are not widely discussed in the physical therapy professions. These ﬁndings are of relevance to many of the disciplines within the physical therapies. It is the authors aim to stimulate further interest in the relevant, yet often under explored areas of immunology and psychoneuroimmunology. r 2006 Elsevier Ltd. All rights reserved. Keywords: Biopsychosocial; Psychoneuroimmunology; Physiotherapy; Healing

1. Introduction Therapists working with musculoskeletal patients are always seeking knowledge to better understand the conditions they treat. This can improve patient management and help explain the variety of patient responses to treatment. Advances in immunology and its closely linked ﬁeld of psychoneuroimmunology (PNI) are having a marked impact across many areas of medicine. The aim of this article is to review some of these ﬁndings that are of relevance to therapists working with musculoskeletal patients. PNI deals with the interactions between the central nervous system (CNS), immune and endocrine systems (Glaser, 2005). It is a ﬁeld that has grown out of the observation that psychological factors play a role in the course of many conditions (Masek et al., 2000). KiecoltGlaser et al. (2002) note that research has now conﬁrmed that psychological processes can alter immune system functioning. This pathway also works in reverse creating bi-directional communication between Tel.: +44 1603 593318; fax: +44 1603 593166.

E-mail address: [email protected]. 1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.06.007

the immune system and the brain. It is not the objective of this article to give a detailed overview of the physiology and anatomy of these systems, although aspects of this will be touched upon. Good overviews are available elsewhere and for a gentle introduction the author recommends Bauer-Wu (2002). In this article, the author will discuss how ﬁndings from PNI and immunological research are inﬂuencing the understanding of tissue healing, pain, management of auto-immune disorders and the biopsychosocial model. The purpose of this article is not to give a detailed review of these topics but to serve as a primer to stimulate further interest in these developing and clinically relevant areas.

2. Tissue healing Physiotherapists treat many patients with damaged tissues following surgery or traumatic injury. Healing consists of several overlapping phases that involve a complicated range of vascular, cellular and neural responses (Ebrecht et al., 2004; Gajendrareddy et al.,

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2005). There are many variables that can either facilitate or hamper this process (Cole-King and Harding, 2001; Gajendrareddy et al., 2005). Of these, physiotherapists are well acquainted with the concept that repairing tissues require graded movement/loading for optimal recovery (Buckwalter, 1996). Less familiar may be the effect that psychological stress can have on healing. In both animal and human models the deleterious effects of psychological stress on healing have been repeatedly demonstrated. Rodents have been used in numerous highly controlled studies investigating this phenomenon (Padgett et al., 1998; Rojas et al., 2002; Detillion et al., 2004; Gajendrareddy et al., 2005; Horan et al., 2005). These studies consistently demonstrate delayed cutaneous wound healing of 25% or more in stressed rodents. The advantage of these studies is that possible confounding variables—such as diet, sleep and smoking—can be controlled. Findings in animal models cannot automatically be assumed to hold true in humans. In response to this, several studies have explored this effect on human subjects assessing a variety of wounds and psychological stressors. Marucha et al. (1998) used standardized wounds to the hard palate on students 3 days prior to an important examination. They then compared healing times between this and an equivalent wound made during their summer holiday break. They found that the pre-exam wound healed 40% more slowly than the holiday equivalent. Kiecolt-Glaser et al. (1995) reported similar ﬁndings when comparing 13 female caregivers with matched controls. Long-term care giving is linked by several authors with a prolonged stress response (Kiecolt-Glaser et al., 2002; Prolo et al., 2002). Standardized wounds were made on the forearms of all subjects. Caregivers took on average 24% longer to heal than controls. This equated to a difference of 9 days, which is a clinically signiﬁcant margin. Cole-King and Harding (2001) found that in 53 subjects with chronic leg ulcers, delayed healing was associated with higher anxiety and depression scores as measured by the Hospital Anxiety and Depression scale. Yang and Glaser (2002) and Glaser (2005) summarize a possible explanation behind these responses. Proinﬂammatory cytokines such as IL-1, IL-8, IL-6 and TNF-alpha play a major role in tissue repair. They protect the wound from infection and attract macrophages and ﬁbroblasts to the area. These cytokines are thus important in activating the clearing of the wound site and stimulating the cells that provide subsequent repair. It has been found that they are present in reduced levels at wound sites of stressed individuals (Glaser et al., 1999; Kiecolt-Glaser, 2005). This may be associated with increased cortisol levels recorded in these individuals (Glaser, 2005). These studies could potentially be of signiﬁcance for physiotherapists. Any researcher looking at physiother-

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apy modalities would be pleased with a result that improved recovery time by 24–40%. If high stress levels can result in such marked decreases in tissue healing, anything a physiotherapist can do to reduce an excessive stress response may potentially improve recovery time. Physiotherapists should be positive but realistic about the level of recovery, explain and demystify the condition and rehabilitation process, and give the patient a chance to talk about other factors that might be worrying them. These are not new recommendations—research from PNI just reinforces their importance.

3. Pain Interest in the pain sciences has grown markedly over recent decades (Gifford and Butler, 1997). Pain is one of the main symptoms that motivate patients to seek out treatment. Greater understanding of the science behind pain helps to explain some of the confusing symptoms and responses of patients. Recent research ﬁndings demonstrating closer links between the CNS and immune system add to this knowledge base. WieselerFrank et al. (2005) review the recent research ﬁndings in the area of immunological pain modulation. The following is a synopsis of some of the key points from that paper. Glia (microglia and astrocytes) are the immunocompetent cells of the CNS. This means they can be activated by viruses, bacteria and trauma. It is now known that they can also be activated by neurons in the spinal cord. Once activated, glia can release proinﬂammatory cytokines. Within the spinal cord, the effect of these substances is to sensitize and facilitate pain. Woolf (2004) notes that glial cytokine and chemokine release may be one of the triggers for alteration of gene transcription within spinal neurons. It is clear that through this, and other effects, glia play an important role in synaptic plasticity. These changes can contribute to the recalcitrant allodynia and hyperalgesia that can present in many chronic pain patients (Wieseler-Frank et al., 2005). The implications of these ﬁndings may be new, more effective analgesic medications. Traditional medications are aimed primarily at neurons. A trial by Milligan et al. (2003) demonstrated that a drug directed at blocking glial activity stopped hyperalgesia without blocking normal pain processing. For physiotherapists it might be helpful to think of glia as having a ‘‘volume control’’ role in their pain modulatory capacity (Wieseler-Frank et al., 2005). Therapists dealing with chronic pain patients will be very familiar with the ﬂuctuating pain levels of their patients. It is often difﬁcult to pinpoint speciﬁc physical or mechanical reasons for these changes. Understanding that changes in immune func-

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tion can alter glial activity and thus sensitivity of the nervous system offers another explanation of the sometimes confusing pain variations observed in these patients (Wieseler-Frank et al., 2005).

4. Morning stiffness and autoimmune diseases Immune system functioning is often discussed in terms of cellular (T-helper cell Type 1) and humoral (T-helper cell Type 2) components (Elenkov, 2004). Type 1 (Th1) tends to be effective against intracellular pathogens such as viruses and some bacteria. Type 2 (Th2) is activated by and effective against parasitic worms and most other bacteria (Clow and Hucklebridge, 2001; Miyazaki et al., 2005). Th1 involves macrophage activation and inﬂammation and this system plays an important role in healing after soft tissue injury (Schiepers et al., 2005). Although both systems are vital for a fully functioning immune system they tend to be counter regulatory, thus as the activity of one increases—the other decreases (Elenkov and Chrousos, 1999; Clow and Hucklebridge, 2001). Th1/Th2 balance can be affected by numerous factors. The brain releases a variety of hormones that can directly or indirectly tip the balance to either arm. (Dimitrov et al., 2004a; Cutalo et al., 2005). Cortisol, growth hormone, prolactin and melatonin have all been implicated as mediators in this see-sawing effect. There is a marked circadian rhythm to the release of these hormones and it is thought that alterations in their circulating levels, during the early stages of sleep, push the immune system toward a Th1 proﬁle (Dimitrov et al., 2004a, b; Cutalo et al., 2005). This is a highly adaptive process because Th1 activation is associated with inﬂammatory processes. These can be physically debilitating because of the pain and stiffness associated with inﬂammation (Clow and Hucklebridge, 2001; Petrovsky, 2001). During the ﬁrst 30–45 min after waking, cortisol levels rise by 50-150% (Thorn et al., 2004). Cortisol shifts the balance towards a Th2 bias and away from a proinﬂammatory proﬁle (Elenkov and Chrousos, 1999; Cutalo et al., 2005). This is one of the reasons why patients with an inﬂammatory component to their pain report being stiffer and sorer ﬁrst thing in the morning. Rheumatoid Arthritis patients are considered to lean towards a Th1 proﬁle. This means inﬂammatory processes are not blunted after waking resulting in prolonged inﬂammatory symptoms (van Roon and Bijlsma, 2002). Many disorders are associated with Th1/Th2 imbalance. Along with rheumatoid arthritis other disorders that have been associated with a Th1 proﬁle include multiple sclerosis, psoriasis and Crohns disease. Disorders associated with a dominant Th2 proﬁle include asthma, atopic dermatitis, and possibly ankylosing

spondylitis (van Roon and Bijlsma, 2002; Elliott et al., 2005). Weinstock et al. (2004) outline some interesting epidemiological ﬁndings that are triggering some unorthodox treatment approaches in autoimmune disorders. They point out that as countries undergo development there is a marked rise in diseases associated with aberrant immune responses. A variety of factors could be implicated, including changes in diet, housing and sanitation. However, several separate pieces of epidemiological data suggest that one explanation is the loss of helminths (deworming) that accompanies development (McInnes et al., 2003; Weinstock et al., 2004). Our bodies (thus immune systems) and helminths have co-evolved and adapted to each other over millennia (Weinstock et al., 2004). Helminths exert powerful controls over our immune system by blunting the Th1 response through stimulation of Th2 immunity. The picture however is more complicated as helminths also seem to protect against Th2 disorders. This may be because helminths stimulate the production of large amounts of IL-10 that can inhibit both arms of the immune system (Weinstock et al., 2004; Elliott et al., 2005). Two studies that have assessed these ﬁndings in relation to possible therapies for human autoimmune disorders took very different approaches. McInnes et al. (2003) used an immunomodulatory protein derived from parasitic ﬁlarial nematodes and found that this suppressed experimentally induced inﬂammatory arthritis in mice. Summers et al. (2005) used intestinal porcine whipworms on humans with Crohn’s disease. This initial, small, open label study had very positive results and will be followed up with a much larger double blind controlled trial. There is scope for these results to be replicated with other autoimmune disorders in humans. In a futuristic Rheumatology clinic, an extended scope physiotherapist may reach for a worm-based treatment that sits beside a long dormant wax bath.

5. The biopsychosocial model George Engel during the 1970s ﬁrst described the concept behind the ‘‘biopsychosocial model’’ (Engel, 1977). The main theme of this model is that mechanistic biological explanations cannot account for all health outcomes. To fully explain the aetiology and progress of many conditions an understanding of the interplay between biological, psychological and social factors, is required. The biopsychosocial approach was erected as a competing paradigm to the biomedical model (BorrellCarrio et al., 2004). One of Engel’s main criticisms was that the biomedical model encouraged separation of mind and body. In the biomedical model the body is viewed as a machine to be ﬁxed and is separate from emotions. Engel and his colleagues considered that this

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was leading to the dehumanization of medicine. They considered that patients were being seen as objects to be ﬁxed and their subjective experiences were of no relevance to assessment and management decisions (Borrell-Carrio et al., 2004). Getting the balance right between the various components of the biopsychosocial model continues to be illusive. Waddell (2004, pp. 457– 459) discusses this issue concluding that in relation to back pain emphasis has swung too far towards psychosocial issues to the detriment of physical aspects. Within the ﬁeld of physiotherapy the role of psychological and social components continues to be debated. Two opposing views are framed by the papers of Zusman (2002) and Wallis et al. (1997). Zusman (2002) argues that growing evidence suggests that psychological factors make a signiﬁcant contribution to initiating centrally mediated pain states and modulate the level of pain perception within the sensitized state. This would help explain the current management trend towards early psychosocial or ‘‘yellow ﬂag’’ assessment and management. This approach has been particularly prominent in low back pain and whiplash literature/ management guidelines. In contrast, Wallis et al. (1997) in their study on whiplash patients argue that psychological changes are purely a result of pain and will disappear once the organic cause of the pain is ﬁxed. They suggest that this means that psychological approaches or therapy are only necessary when pain cannot be completely relieved through speciﬁc tissue based medical interventions. Lutgendorf and Costanzo (2003) outline two mechanisms that may allow psychosocial factors to inﬂuence biological processes. The ﬁrst is through health modulating behaviours such as nutrition, exercise and smoking. These behaviours are strongly driven by psychological factors. An example of this mechanism that is relevant to physiotherapists is fear avoidance beliefs. For a patient this would mean inappropriately believing that a pain response always means more tissue damage is occurring. Pain in the acute phase of an injury serves a protective role to injured tissues. In this scenario pain is appropriately interpreted as a signal to avoid excessive loading and thus further damage to an injured part of the body. However, therapists deal with a signiﬁcant number of patients with pain responses from tissues that have long passed into and beyond the remodelling phase of healing. Interpreting pain in the same way in this situation will prevent the necessary movement/loading/exercise to rehabilitate the affected part of the body. As well as local effects, inappropriate avoidance of activity could result in decreased conditioning in other areas and systems of the body. The second mechanism outlined by Lutgendorf and Costanzo (2003) is through direct inﬂuence from the brain. Psychological factors can alter functioning of he hypothalamic pituitary adrenocortical, sympathoadre-

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nomedullary and hypophyseal pituitary gonadal axes. These and other systems allow the brain to alter many physiological responses including aspects of immune system functioning (Petrovsky, 2001; Kim and Maes, 2003). Alterations to these systems can have numerous positive or negative effects in the aetiology and clinical course of a wide range of disorders. Some examples include the common cold, atherosclerotic diseases, athletic overtraining syndrome and occupational health problems (Armstrong and Van Heest, 2002; Cohen et al., 2003; Kop, 2003; Feuerstein et al., 2004; Lundberg, 2005). Work in this area is at an early stage but promises to bring many disparate ﬁelds closer together as the subtle, complicated links between the many body systems are observed and quantiﬁed (Kop, 2003).

6. Summary Wise therapists realize there is much they do not know and much they cannot explain. Although this situation can never be fully resolved, it is our professional responsibility to keep trying. For therapists, research into the closely linked ﬁelds of immunology and PNI offer new knowledge to better understand many of the conditions and phenomena that are witnessed in our patients. Continuing progress in these ﬁelds is likely to bring further changes to our understanding of the clinical presentation and management of musculoskeletal patients. The author hopes that this article will serve as a stimulus for the reader to investigate these fascinating ﬁelds further.

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Case report

The use of a mechanism-based classiﬁcation system to evaluate and direct management of a patient with non-speciﬁc chronic low back pain and motor control impairment—A case report W. Dankaertsa,b,, P.B. O’Sullivana, A.F. Burnetta, L.M. Strakera a

School of Physiotherapy, Curtin University, Bentley 6102, WA, Australia Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium

b

Received 20 September 2005; received in revised form 17 March 2006; accepted 16 May 2006

1. Introduction Low back pain (LBP) is one of the most common and costly musculoskeletal pain syndromes, affecting up to 80% of people at some point during their lifetime (Katz, 2002; van Tulder et al., 2002; Ehrlich, 2003; Woolf and Pﬂeger, 2003). It is reported that in spite of the large number of pathological conditions that can give rise to LBP, 85% of these are without a detected pathoanatomical/radiological abnormality. This population is classiﬁed as having ‘non-speciﬁc’ (NS) LBP (Waddell, 1987, 2004; Dillingham, 1995) which often develops into a chronic ﬂuctuating problem with intermittent ﬂares (Croft et al., 1998; Burton et al., 2004). Optimal treatment for patients with NS-CLBP remains largely enigmatic. Randomized Controlled Trials (RCTs) have failed to ﬁnd consistent evidence for improved outcomes (Goldby et al., 2000; Cairns et al., 2002; Assendelft et al., 2004; Frost et al., 2004). One explanation offered for the inability to identify effective treatments is the lack of success in deﬁning sub-groups of patients who are most likely to respond to a speciﬁc treatment approach (Leboeuf-Yde et al., 1997; Borkan et al., 1998; Bouter et al., 1998). Indeed, it has been proposed that the ‘LBPgroup’ conceals a large heterogeneous group of patients (McKenzie, 1981; Spitzer, 1987; Borkan et al., 1998; Corresponding author. WD, School of Physiotherapy Bld 408, Curtin University of Technology, GPO Box U1987, Perth WA 6845, Australia. Tel.: +61 08 9266 3667; fax: +61 08 9266 3699. E-mail address: [email protected] (W. Dankaerts).

1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.05.004

Bouter et al., 1998; Leboeuf-Yde and Manniche, 2001). Any speciﬁc treatment applied to a falsely assumed homogenous sample may result in improvement, failure to respond or aggravation of the disorder (Binkley et al., 1993; Fritz et al., 2000; Leboeuf-Yde and Manniche, 2001; Fritz et al., 2003). The shift from thinking about LBP as a pathoanatomical disorder, to viewing LBP as a multi-factorial bio-psycho-social disorder is now well accepted (Borkan et al., 2002; McCarthy et al., 2004; Waddell, 2004). Consequently, the different dimensions relevant to classifying the domain of LBP include patho-anatomical, signs and symptoms, psychological and social (Waddell, 1987; Ford et al., 2003). For LBP, several classiﬁcation systems (CSs) from a multitude of perspectives have been proposed. A recent review highlights that the multi-dimensional nature of LBP is not reﬂected in most CSs (Ford et al., 2003; McCarthy et al., 2004). While it is well recognized that altered motor control exists with LBP disorders, the changes in motor control in this population are highly variable (O’Sullivan et al., 1997; Hodges and Moseley, 2003; van Dieen et al., 2003). O’Sullivan reported that in general all disorders involving pain in the lumbar region are associated with movement or control impairment. The mere presence of these impairments does not imply that they represent the underlying basis for the disorder, or that correcting these impairments will result in resolving the disorder (O’Sullivan, 2004, 2005). O’Sullivan’s approach to classiﬁcation is based on a process of ‘diagnostics’ (Elvey and O’Sullivan, 2004) to make a clinical determination as to whether the patient

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presents with a classiﬁcation of motor control impairment (MCI) or whether the MCI is simply a secondary effect of another process. This process of diagnostics places a strong emphasis on the correlation between the subjective history, radiology, pain behaviour, physical examination ﬁndings and screens for serious pathology (‘red ﬂags’) and psycho-social factors (‘yellow ﬂags’). According to O’Sullivan motor responses present with LBP can be classiﬁed into three distinct broad groups (O’Sullivan, 2005). The first group consists of subjects whose motor response is secondary (and adaptive) to an underlying pathological process. The second group consists of subjects where the motor response is secondary to a dominance of psychological and/or social (non-organic) factors. O’Sullivan (2005) proposed that a third group exists where maladaptive motor responses result in chronic abnormal tissue loading leading to ongoing pain and distress. Five distinct (direction based) patterns of MCI have been previously described in detail (O’Sullivan, 2000, 2004). These sub-groups of MCI consist of the; ﬂexion pattern, active extension pattern, passive extension pattern, lateral shifting pattern and a multi-directional pattern (Table 1). Recently, Dankaerts et al. (2006a) showed that these sub-groups could be reliably identiﬁed by trained clinicians (physiotherapists and medical doctors). There is also growing support for the validity of these subgroups with recent studies revealing altered spinal repositioning sense (O’Sullivan et al., 2003), different spinal posture, kinematics and muscle activation patterns among sub-groups consistent with the CS (Burnett et al., 2004; Dankaerts et al., 2006b, c; O’Sullivan et al., 2006). Despite this growing evidence, there is a lack of longitudinal studies documenting outcome on these speciﬁc sub-groups following a targeted intervention. Synchronized recording of surface electromyography (sEMG) and spinal kinematics have been reported frequently in the literature as objective measurement methods in non-outcome LBP research (McGill et al., 1997; Callaghan et al., 1998; Peach et al., 1998; Callaghan and McGill, 2001; Green et al., 2002). This

methodological approach has been shown to be sensitive to quantify parameters of motor control and to subclassify NS-CLBP patients with MCI during sitting (Dankaerts et al., 2006b, c). An advantage of this form of measurement is that unlike simple range of motion (ROM), measures of sEMG and spinal kinematics have the capacity to quantify the quality and pattern of movement of the spinal-pelvic region through ROM. The aim of this case report is to investigate the use of O’Sullivan’s CS to evaluate and direct management of a patient with NS-CLBP and MCI. An objective laboratory-based assessment (using sEMG and spinal kinematics) was performed on a LBP patient and a matched pain-free control subject. The aim of the laboratory testing was to evaluate its capacity to lend support to the classiﬁcation of MCI and to quantify the clinical changes in motor control secondary to a speciﬁc motor learning intervention.

2. Subjective and physical examination A comprehensive subjective and physical examination was ﬁrst performed on the patient in order to classify her disorder. This information is summarized in Tables 2 and 3, respectively.

3. Classiﬁcation based on history and physical examination It is acknowledged that rather than relying on one test, classiﬁcation of a disorder should be based on information of the history taking examination and a ‘cluster of tests’ in combination with a reasoning process (Elvey and O’Sullivan, 2004). In this way, several key features of the physical examination ﬁndings (not one single test) consistent with the history, helped to formulate the hypothesis of a classiﬁcation of multidirectional pattern of MCI disorder (O’Sullivan, 2004). The critical factors of the classiﬁcation were that this patient had mechanically induced, localized pain that

Table 1 Deﬁnition of each pattern of motor control impairment (MCI) based on O’Sullivan (2000, 2004) Pattern of MCI

Deﬁnition

Flexion

Pain disorder resulting from a loss of motor control of the lumbar segment into ﬂexion (associated loss of segmental lordosis) Pain disorder resulting from a loss of motor control of the lumbar segment in the frontal plane (lateral shift pattern). This pattern is also associated with a loss of control into either ﬂexion or extension Pain disorder resulting from the lumbar segment being ‘actively’ held into extension (increased segmental lordosis) Pain disorder resulting from a loss of motor control of the lumbar segment into extension. This is associated with a tendency to passively over extend (hinging) at the symptomatic segment of the lumbar spine Pain disorder resulting from a multi-directional loss of control of a lumbar spinal segment (combinations of above)

Lateral shift (ﬂexion or extension) Active extension Passive extension Multi-directional

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Table 2 Subjective examination ﬁndings 37-year-old female; married; 2- and 4-year-old child Work: part-time (2/7) nurse; involved minimal lifting Home: household activities; picking up and carrying children History: gradual onset of LBP symptoms; starting during the pregnancy of the ﬁrst child (-4 years); post ﬁrst pregnancy pain free for 2 years; early in the second pregnancy (-2 years); progressively deteriorating LBP Pain: LBP only (occasionally left buttock region) Aggravating postures: sitting (4 in couch), lying on a hard mattress; sustained forward bending (e.g. doing dishes); sustained backwards bending (e.g. hanging cloths on the wash-line); standing (carrying children) Aggravating activities: walking (4 walking up hill), bending; lifting; previous treatment: ﬁt-ball (stabilizing) exercises, speciﬁc mobilising exercises (lying flat moving leg) Easing postures/activities: no symptom relief during weight bearing Pain-intensity (VAS): 4/10 (day intake examination); 4/10 (average pain week) Disability-score [Revised-Oswestry (Hudson-Cook et al., 1989)]: 34% Fear avoidance [Tampa Scale of Kinesiophobia(Kori et al., 1990)]: 34/68 Medical imaging (X-ray and CT): no abnormalities detected Psycho-social risk factors (‘yellow’ ﬂags): absent Serious pathology (‘red’ ﬂags’): absent Key features Localised LBP No signs of neural tissue involvement No reported impairment of movement Multi-directional pain pattern mechanical in nature Absence of radiological abnormality Absence of dominant non-organic features Absence of any signs suggesting serious underlying pathology

was multi-directional in nature. She had no impairment in range of spinal motion but presented rather with MCI resulting in repeated end range spinal strain and pain. Normalization of her altered motor control (control of the spinal neutral zone) reduced her pain.

4. Laboratory testing An objective laboratory-based assessment (surface EMG and spinal kinematics) was performed on the patient and a matched control subject. The method of this laboratory testing has been described in detail elsewhere (Dankaerts et al., 2006b, c). This case study reports on the lumbo-sacral kinematics and the sEMG activity of superﬁcial Lumbar Multiﬁdus (sLM) and transverse ﬁbres of Internal Oblique (trIO) during forward bending. This test was selected since it is frequently used in the LBP research to investigate the reduction in back muscle activity at full body ﬂexion (McGill and Kippers, 1994; Shirado et al., 1995; Kaigle et al., 1998; Gupta, 2001).

5. Intervention The patient’s management consisted of a motor learning intervention based on a cognitive behavioural model. It was progressed over a 14-week period (total of

8 visits, the ﬁrst 3 were spaced 1 week apart, with subsequent sessions once every 2–3 weeks) to address the impairments in motor control of this patient in a functionally speciﬁc manner. The choice of this treatment approach was based on the diagnosis and classiﬁcation assigned to this patient. Each session included re-evaluation and review of home exercises. The speciﬁc exercises and progression was linked with the examination ﬁndings and are described in detail by O’Sullivan (2004). Brieﬂy, this motor learning intervention was divided into stages, based on the model proposed by Fitts and Posner (1995). This approach to exercise training focuses on the quality of control of segmental spinal posture and movement. This approach operates within a cognitive behavioural framework where the mechanism of the ongoing pain sensitization is explained to the patient. The patient was educated on the mechanics of the spine, the nature of ongoing tissue sensitization with habitual adoption of end range postures and the importance of the muscle system of the lumbo-sacral region to control spinal motion segments and minimize strain. During this cognitive stage the patient was made aware that the postures and patterns of movements that she had adopted had in fact resulted in maintaining her pain. She was made aware she had no control, or sense of her neutral spine positions, nor an ability to isolate the activation of speciﬁc muscles (transverse abdominal wall, superﬁcial ﬁbres of lumbar multiﬁdus/sLM, pelvic

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Table 3 Physical examination ﬁndings Posture and movement analysis Standing: hyper-lordotic thoraco-lumbar posture; reduction in tone in the transverse abdominal wall and gluteal muscles Forward bending: splinting pattern (holding lumbar spine into extension); sudden drop into lumbar ﬂexion (curve reversal) at end range; full ROM (ﬁngers to ﬂoor) with associated pain Return from forward bending: initiated from the thoraco-lumbar spine by hyper-extending and associated with a lateral shifting pattern and a painful arc (‘catch of pain’); uses hands to return to neutral Backwards bending: provoked pain with a lateral shifting pattern present; full ROM Side bending (R/L): provoked pain with a lateral shifting pattern present; full ROM Single leg standing: prominent lateral shifting pattern (bilateral) Sitting posture: ﬂexed at the lower lumbar spine; extended at the thoraco-lumbar spine Sit to stand: difﬁculties of shifting load; tendency to hyper-extend and laterally shift the low back Speciﬁc movement tests (O’Sullivan, 2004) Inability to maintain neutral lordosis during trunk ﬂexion and load transfer in sitting and inability to achieve a neutral lordosis in standing Repositioning sense in sitting (O’Sullivan et al., 2003): inability to reposition the lumbar spine within a neutral lordosis; ‘over-shoot’ into either ﬂexion (kyphosis) or extension (lordosis) Speciﬁc muscle testing (O’Sullivan, 2004) Inability to activate the lower transverse abdominal wall (transverse ﬁbres of internal oblique and lower transversus abdominis) in side lying without breath holding Screening neurological examination (Hall and Elvey, 1999) Absence of neurological ﬁndings (provocation testing, reﬂexes, sensation and manual muscle testing) Passive physiological motion segment testing (Maitland, 1986) Absence of segmental movement restriction; increased segmental motion into both ﬂexion and extension at the two lower lumbar segments Passive accessory testing (Maitland, 1986) Posterior/Anterior pressure (PA) at L4/5 and L5/S1 levels highly symptomatic; reproductive of the patient’s symptoms Key features Full ROM with aberrant quality of motion Through range painful arc with hesitation and lateral movement at midrange of spinal motion No control of mid-position [‘neutral zone’] (Panjabi, 1992a,b) and rapidly moved from one end range spinal posture to the other Use of the hands to assist the return from forward bending Segmental hinging at end of range into extension Loss of neutral zone control of symptomatic spinal segments during loaded postures and spinal movements Increased passive segmental motion into both ﬂexion and extension at the two lower lumbar segments Absence of neurological ﬁndings Absence of a segmental movement impairment Provocation of pain linked to speciﬁc impairments of control Absence of dominant psycho-social ﬁndings (e.g. catastrophizing)

ﬂoor and gluteal muscles). She was ﬁrst instructed to control her lumbo-pelvic region through the mid-range independent from the thorax (in supine crook lying). At the same session she was instructed to co-activate the pelvic ﬂoor, transverse abdominal wall and sLM (Krause et al., 2000) in side lying. She was also instructed to change her sitting posture to maintain a neutral lordosis and relax the thoracolumbar region with co-contraction of the transverse abdominal (TrA/ trIO) wall. This was then progressed to standing. Once she had the ability to assume a neutral lordosis in weight bearing (sitting and standing) with cocontraction of the transverse abdominal wall this was incorporated into static holding tasks and dynamic tasks such as single leg stand, sit–stand, squat and lifting

(associative stage). As she was generally de-conditioned, she was encouraged to perform gentle aerobic activities (walking, exercise bike) with low level of co-contraction of her transverse abdominal wall while maintaining optimal postural alignment. At the 10-week point she was trained with loaded exercise (hand weights with squats and sit to stand) to increase her global strength and endurance whilst controlling her spinal midposition. The ﬁnal (autonomous) stage was reached when the patient reported that she could carry out functional movement tasks with a low degree of attention (Fitts and Posner, 1995). It should be noted that the patient had to achieve each stage of the program before it was progressed.

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At the end of the 14-week intervention (8 sessions) she was asked to be aware of her spinal posture, and maintain her ﬁtness level by means of regular cardiovascular exercise (alternating between walking and exercise biking).

6. Clinical outcome The patient progressed well during the intervention with a gradual decrease in pain and an increase in functional ability. At 14 weeks (end of intervention) she reported to be pain-free with an ability to perform work and household-related tasks. This was associated with a normalization of her movement patterns and absence of pain, improved spinal proprioception, adoption of neutral zone postures and reduced tissue sensitivity. The Revised-Oswestry Disability Questionnaire (Hudson-Cook et al., 1989) was used to document functional progress and disability. The patient’s Revised-Oswestry score (0–100%) decreased across the study period from 34% (pre-intervention) to 14% post-intervention. In the three months following discharge, the patient experienced no exacerbation of LBP-related symptoms and continued to improve functionally (2% at 6-month follow-up). This status was maintained at 1-year followup (0%). The pain intensity score (average over a week; 0–10) decreased from 4/10 pre-intervention, to 2/10 post-intervention, to 0/10 at 6-month follow-up. This pain free status was maintained at 12-month follow-up. The score for fear avoidance (measured by the Tampa Scale of Kinesophobia) decreased from 34/68 to 17 (the minimum score that can be recorded) at 6-month follow-up and was maintained at 12-month follow-up. These scores reﬂect an absence of pain, transition in function from moderate disability (o40) to no disability and an absence of fear avoidance following the intervention.

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represent a lordotic posture. Fig. 1a represents a matched (age and parity) healthy control subject. A pattern of gradual change of L C (from being extended to being ﬂexed) is observed. Fig. 1b represents the case study patient preintervention. Lumbar spine hyperextension was maintained as she progressed into the forward bending range with a curve reversal at the end (3rd to 4th quartile). At the 6-month follow-up (Fig. 1c) curve reversal was observed more central in range (2nd to 3rd quartile) and this was similar to the control case data (Fig. 1a). 7.3. Forward bending: surface EMG findings 7.3.1. Superficial lumbar multifidus (sLM) Fig. 2a shows the raw sEMG activation of the sLM during forward bending and return from forward bending of the matched control subject. A burst of EMG activity, as the subject starts the movement, is observed followed by a pattern of muscle relaxation at

7. Laboratory testing outcome 7.1. Forward bending: range of motion The patient’s lumbar spine ROM into forward bending was 481 at the intake examination and 471 at 6-month follow-up. This conﬁrms the clinically observed absence of any movement impairment into forward bending being related to her LBP. This is consistent with the CS. 7.2. Forward bending: kinematic pattern Fig. 1 shows the lumbar curvature (L C) in degrees as measured by the FastrakTM in standing and per quartile as the subject bends forward. Negative values

Fig. 1a–c. Forward bending kinematics; lumbar curvature in degrees (negative values indicate lordosis) as measured by the FastrakTM per quartile (Q) of full movement (time normalised) for (a) control subject; (b) case subject pre-intervention and (c) case subject at 6-month follow-up.

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the end of the forward bending phase and the return is then associated with a burst in the sLM. This pattern of onset–offset during forward bending is commonly referred to as the ﬂexion relaxation phenomena (FRP). Watson et al. (1997) indicated that this type of dynamic sEMG activity of the paraspinal muscles can be reliably measured and is useful in differentiating CLBP patients from normal controls. Prior to the intervention, the patient displayed increased muscle activity with no FRP during forward bending (Fig. 2b). At the 6-month follow-up, a more normal sEMG pattern, with an FRP was observed (Fig. 2c). 7.3.2. Lower transverse fibres of the internal oblique (trIO) Surface EMG proﬁle of the control subject (Fig. 3a) during forward bending and return from forward bending shows a clear pattern of onset–offset–onset for trIO similar to that observed in the sLM at the end of ROM. In contrast the patient pre-intervention

(Fig. 3b) showed no clear onset–offset–onset pattern with a deﬁcit in motor activity. At the six month followup an onset–offset–onset pattern (similar to the control subject) was observed (Fig. 3c).

8. Discussion The patient described in this case report would be ‘classically’ diagnosed as having NS-CLBP based on the absence of any abnormal radiological ﬁndings linked to the clinical presentation (Waddell, 1987, 2004; Dillingham, 1995). Based on the CS (O’Sullivan, 2004) this patient was classiﬁed as having a multi-directional pattern of MCI. The use of a CS to guide management of patients with LBP and MCI has been reported previously (Maluf et al., 2000; Van Dillen et al., 2003). There are several main differences with the classiﬁcation approach suggested by O’Sullivan (and applied on this case subject). Rather than relying only on signs and symptoms

Fig. 2a–c. Raw surface electromyographic activity of the superﬁcial lumbar multiﬁdus during standing, forward bending and return from forward bending for (a) control subject; (b) case subject pre-intervention and (c) case subject at 6-month follow-up.

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Fig. 3a–c. Raw surface electromyographic activity of lower transverse ﬁbres of internal oblique during standing, forward bending and return, for (a) control subject; (b) case subject pre-intervention and (c) case subject at 6-month follow-up.

(Van Dillen et al., 1998, 2003a,b), the proposed CS is based on a process of ‘diagnostics’ (Elvey and O’Sullivan, 2004) to make a clinical determination as to whether the patient presented with a classiﬁcation of MCI rather than the altered motor response being a secondary effect of another process. The patient described in this case report presented with full ROM (no movement impairment) in forward and backward bending supporting the classiﬁcation of MCI. In research and clinical practice, ROM measurements are routinely used to assess patients with LBP. However, these tests do not quantify control parameters during the movement itself. Although excellent convergent validity (Saur et al., 1996; Perret et al., 2001) has been reported for forward bending ROM measurements (compared to dynamic radiographs), of most clinical

importance is the lack of discriminative validity highlighted by the weak to non-existing relationship between lumbar ROM measures and functional ability (Parks et al., 2003; Zuberbier et al., 2001). Based on clinical observations it is very unlikely that for patients with MCI, the lumbar ROM test into forward bending will have any validity as a sensitive outcome measurement. Its hypothesized that impaired spinal mobility may be reﬂective of a different sub-group of patients with a classiﬁcation of movement impairment (O’Sullivan, 2005). A novel aspect of this case report is the addition of laboratory-based support to the clinical examination ﬁndings of MCI associated with sagittal spinal movement. Despite having full ROM into forward bending, the case subject presented clinically with symptoms

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through ROM, suggesting a lack of motor control during this movement. The kinematic quantitative assessment was capable of identifying patterns of MCI. Fig. 1b shows that as the patient progressed into forward bending a substantial lordosis (hyper-extension) was maintained, with the curve reversal at the end range (3rd to 4th quartile). This is consistent with O’Sullivan (O’Sullivan, 2000, 2004) who postulated that patients with a multi-directional pattern of MCI have a lack of ability to control a neutral spine posture during functional movements and have a less gradual transition from one end range position to the other. At the 6month follow-up, laboratory testing showed the curve reversal appearing earlier in the range (2nd to 3rd quartile) (Fig. 1c). This is similar to the control case data shown in Fig. 1a. This is an important ﬁnding in the search for quantiﬁable outcome measurements for this sub-group of CLBP patients. This demonstrates that the kinematic analyses were sensitive in detecting changes in motor control following a speciﬁc intervention. Further research is warranted to evaluate these parameters in a larger population. For this case report EMG data were also recorded during the laboratory-based testing. Raw EMG is frequently used for pattern recognition and onset–offset EMG detection (Shirado, et al., 1995; Hodges and Richardson, 1997). Marked reduction in back muscle activity at full body ﬂexion, known as FRP, has been investigated in numerous studies (McGill and Kippers, 1994; Shirado et al., 1995; Kaigle et al., 1998; Gupta, 2001). Most studies support that the phenomenon occurs in healthy subjects before reaching the maximum ﬂexed position. In contrast, patients with CLBP don’t typically demonstrate FRP (e.g. Shirado et al., 1995; Kippers and Parker, 1984). These ﬁndings are consistent with the pattern observed in the case subject prior to the intervention period, a lack of reduction in electrical activity in sLM (Fig. 2b) during forward bending and the absence of an onset/offset pattern of EMG activity in trIO (Fig. 3b). Several mechanisms have been suggested in the literature that may be responsible for the absence of an FRP in the presence of LBP (Ahern et al., 1990; McGill and Kippers, 1994; Shirado et al., 1995; Kaigle et al., 1998; Gupta, 2001). Ahern et al., 1990 proposed that the absence of FRP seen in LBP patients is associated with guarded movements in response to pain. Although pain might be a possible mechanism for the absence of FRP in this case, it is interesting that the muscle activity near end range did not restrict her movement (she achieved full range spinal ﬂexion). Watson et al. (1997) suggested that the assessment of change in FRP could be used in evaluating treatment interventions. EMG data at 6-month follow-up clearly detected a change in motor control pattern during

forward bending with a clear FRP present in the sLM (Fig. 2c), which was also associated with a similar pattern in trIO (Fig. 3c). The sEMG ﬁndings from trIO during forward bending and return highlight a lack of co-contraction between trIO and sLM prior to the intervention (Fig. 3b). The CLBP literature contains numerous reports on co-activity and synergistic behaviour of muscle groups during trunk ﬂexion-extension and it is well accepted that the trIO muscle increase intraabdominal pressure (Cresswell et al., 1992; Cholewicki et al., 1999), and act in co-contraction with trA, pelvic ﬂoor muscles and back extensors to stabilize the lumbar spine (Panjabi, 1992a,b). Loss of co-contraction between trunk muscles has been previously reported in LBP populations (Hodges and Richardson, 1996; O’Sullivan et al., 1997; Hodges and Richardson, 1999). The absence of co-contraction in combination with the kinematic data, in this case, lends support to the classiﬁcation of MCI. From a review of the literature it seems that the exact mechanism affecting trunk muscle recruitment in the presence of LBP is not completely understood with several mechanisms hypothesized in the literature (see Hodges and Moseley, 2003 for review). Farfan (1973), Panjabi (1992a,b) and Richardson et al. (1999) amongst others, have presented models that suggest that deﬁcits in motor control lead to poor control of joint movement, repeated microtrauma and pain. However, the opposite (pain leads to changes in motor control) may also be true. Recent data (e.g. Hodges et al., 2003) has shown that experimentally induced LBP produced changes in the motor control of the trunk muscles similar to that identiﬁed in people with LBP. While this does not exclude the possibility that changes in control of the trunk muscles may lead to pain, it does argue that, at least in some cases, pain may cause the changes in control. Hodges et al. (2003) suggested that it is unlikely that the simple inhibitory pathways can mediate the complex changes in motor control of the trunk muscles. The most likely causes are changes in motor planning via a direct inﬂuence of pain on the motor centres, factors associated with the attention demand, stressful and fearful aspects of pain, or due to changes in the sensory system (Hodges et al., 2003). For this case subject it is not known whether pain caused the changes in motor control or whether motor control changes lead to pain, or both. However, we hypothesize that the improvement in pain intensity and disability was primarily due to the improvement in her spine motor control, which in turn reduced the peripheral nociceptive drive of pain. It is also acknowledged that cognitive factors such as enhanced patient awareness, improved coping strategies and increased functional capacity (which are all powerful cognitive factors associated with the intervention), are likely to

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reduce the central drive of pain. The capacity of this form of intervention to impact on the physical and cognitive aspects of the pain disorder is highlighted by the documented reductions in fear avoidance behaviour at 6- and 12-month follow-up. Due to the limitations associated with a case report, the results do not imply a deﬁnite answer to the cause–effect question, nor can the patient’s outcomes be generalized across a larger sample. However, the classiﬁcation of MCI is strengthened by the laboratory-observed changes indicating more normal spinal kinematics and muscle co-activation patterns at 6-month follow-up.

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Technical and measurement report

Evaluation of repeatability of pressure algometry on the neck muscles for clinical use Jari Ylinena,, Matti Nyka¨nenb, Hannu Kautiainenc, Arja Ha¨kkinena a

Department of Physical and Rehabilitation Medicine, Jyva¨skyla¨ Central Hospital, Keskussairaalantie 19, 40620 Jyva¨skyla¨, Finland b Punkaharju Rehabilitation Centre, Vaahersalontie 44, 58450 Punkaharju, Finland c Rheumatism Foundation Hospital, 18120 Heinola, Finland Received 30 April 2004; received in revised form 10 February 2006; accepted 1 June 2006

Abstract Neck and shoulder pain is a common disorder which is often associated with a low-pressure pain threshold (PPT) of muscle tissues as manifested by hyperalgesia on palpation or the use of a pressure algometer. The objective of the present study was to evaluate the intratester repeatability of pressure algometer (Force-Fives) on the neck and shoulder area in women with neck pain. The study was cross-sectional with single-group repeated measurements. PPT measurements in 20 women with chronic non-speciﬁc neck pain were measured on consecutive days at the levator scapulae, at two points on the trapezius muscles on each side and at the sternum as the only non-muscular site. The intratester repeatability of the PPT measurements was satisfactory or good (Intraclass correlation coefﬁcient (ICC 0.78–0.93). The coefﬁcient of repeatability ranged from 16.8 to 24.4 N/cm2 and the coefﬁcient of variation ranged from 10% to 22%, depending on the site tested. Considerable individual variation was observed when consecutive measures were analysed against their mean. On the group level the repeatability of the measurements allows the pressure algometer to be used for research purposes. However, on the individual level, due to the considerable variation found in the PPT results, caution is advised when interpreting the results in clinical practice. r 2006 Elsevier Ltd. All rights reserved. Keywords: Pain threshold; Muscle hyperalgesia; Cervical pain; Algometer; Nociception

1. Introduction Chronic neck pain is one of the most common musculoskeletal disorders (Coˆte´ et al., 2000; Aromaa and Koskinen, 2002). It is often associated with hyperalgesia of muscle tissues. In clinical practice, among both doctors and physiotherapists, palpation is still a common way of locating areas affected with hyperalgesia. It is also important to ﬁnd the primary areas causing the pain, as pain is often felt in referred areas. This means performing a thorough manual examination. Modern technology has not yet replaced Corresponding author. Tel. +358 40 5229230; fax: +358 14 254544. E-mail address: jari.ylinen@ksshp.ﬁ (J. Ylinen).

1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.06.010

manual examination in the clinic, as US, X-ray, CT, MRI and other imaging techniques are seldom able to reveal the source of pain. Palpation by an experienced practitioner may be a sufﬁciently reliable method for screening painful areas and may reveal the site of the pain (Jacobs et al., 1995; Andersen et al., 2002). However, a quantitative indicator of the degree of hyperalgesia would enhance clinical assessment. Andersen et al. (2002) found that a low-pressure pain threshold (PPT) was an individual risk factor for neck and shoulder pain with pressure hyperalgesia among industrial workers. The repeatability of PPT measurements has been widely studied in both healthy people and people with different medical conditions (Mikkelsson et al., 1992; Delaney and McKee, 1993; Antonaci et al., 1998;

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Nussbaum and Downes, 1998; Sterling et al., 2002). The main statistical method used in such studies has been correlation analysis. However, this method is liable to systematic error and does not reveal clearly the variation between each pair of repeated measures. The aim of this study was to evaluate the repeatability of pressure algometry on the neck muscles in women with chronic neck pain with a view to determining the usefulness of the method for clinical purposes. In previous research, PPT measurements have been conducted with up to ﬁve repetitions in order to control for between-repetition variability. However, this number of repetitions is not feasible in clinical practice if several sites are to be checked. This study, therefore, investigates normal variability so as to provide clinicians who only test PPTs with one repetition with knowledge of the amount of variability needed to establish cases outside of the norm.

2. Methods 2.1. Participants The subjects were 20 middle-aged women with nonspeciﬁc neck pain of at least 6 months duration (Table 1). The women were recruited through their respective occupational health care systems, where they had been referred for rehabilitation as their neck pain was causing them difﬁculties in coping at work. Thus, the primary inclusion criterion for the study was non-speciﬁc, frequent or continuous neck pain of over 6 months duration and causing impairment of working capacity. The other inclusion criteria were age 25–53 years, female gender, clerical employee and possession of a permanent full-time job. Exclusion criteria were speciﬁc disorders, such as cervical disc prolapse, spinal stenosis, post-operative conditions, trauma, instability, spasmodic torticollis, frequent migraine, nerve entrapment, ﬁbromyalgia, shoulder diseases, inﬂammatory rheumatic diseases and severe psychiatric illness. These states were assessed by

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reference to the subjects’ medical histories and a clinical examination prior to their entering the study. 2.2. Outcomes Subjectively perceived neck pain was assessed by the visual analogue scale (Dixon and Bird, 1981) and disability by the modiﬁed Neck and Shoulder Pain and Disability Index (Viikari-Juntura et al., 1988) and Vernon Neck Disability Index (Vernon and Mior, 1991). On each scale the theoretical range is from 0 to 100. A hand-held digital pressure algometer (Force ﬁveTM, Wagner Instruments, Box 1217, Greenwich, CT 06836) was used to measure the PPT on the cervical muscles. The speed of the device is 100 samples per second and accuracy 70.75 N. Compression pressure at the round tip of 1 cm2 was gradually increased perpendicularly at the rate of 10 N/s on the muscle tissue (Fig. 1). The patient was told to state immediately when the pressure sensation turned into a pain sensation, at which point compression was stopped. After a rest of about 30 s the next measurement was taken. We used no marking on the skin to help in the location of the test sites, as patients tend to reject this procedure in clinical followup studies. PPT was assessed, ﬁrst, at the reference site, which was located 2 cm below the upper border of the sternum in the midline while the patient was lying supine on the examination table. Thereafter PPT measurements were performed at the suboccipital sites near the upper

Table 1 Demographic and clinical characteristics in women with chronic neck pain (n ¼ 20)

Age (years) Weight (kg) Height (m) Body mass index (kg/m2) Neck pain in VASa (mm) Duration of neck pain (years) Neck and shoulder pain and disability index Vernon neck disability index a

Visual analogue scale.

Mean

SD

47 69 1.63 26 69 9 41

5 13 0.05 5 20 6 14

24

12 Fig. 1. Pressure pain threshold measurements on the neck while the patient was lying prone.

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18 17.8 (13.6 to 25.7) b

a

Effect size, conﬁdence interval obtained by bias corrected bootstrapping (2000 replications). Intraclass correlation coefﬁcient. c Value below which 95% of the differences between two replicated measurements should lie. d Within-subjects coefﬁcient of variation.

0.80 (0.57 to 0.92) 0.79 (0.36 to 1.26) 5.3 (2.2 to 8.5) 35.3 (16.2) Sternum (N/cm2)

30.0 (13.3)

11 10 19.8 (15.1 to 28.6) 17.7 (13.6 to 25.6) 0.78 (0.53 to 0.91) 0.91 (0.79 to 0.96) 0.36 (0.04 to 0.72) 0.21 (0.26 to 0.93) 3.3 (1.0 to 7.6) 1.8 (2.2 to 5.7) 60.2 (23.3) 60.7 (22.2) Levator scapulae (N/cm2) Right Left

56.8 (20.9) 59.0 (22.2)

18 22 20.2 (15.4 to 29.2) 24.4 (18.7 to 35.2) 0.86 (0.70 to 0.94) 0.85 (0.67 to 0.94) 0.35 (0.11 to 0.81) 0.25 (0.19 to 0.54) 3.3 (1.1 to 7.7) 2.9 (2.5 to 8.4) 37.0 (16.6) 35.4 (15.8)

16.8 (12.8 to 24.2) 22.5 (17.2 to 32.5) 0.93 (0.83 to 0.97) 0.84 (0.64 to 0.93) 0.15 (0.28 to 0.57) 0.13 (0.34 to 0.60) 1.2 (2.6 to 5.0) 1.4 (3.7 to 6.5) 38.4 (12.3) 37.4 (16.4)

Difference mean (95% CI) Second day mean (SD) First day mean (SD)

40.3 (19.0) 38.3 (19.3)

The PPTs for each site measured on the two test occasions conducted on successive days and the differences found between them are shown in Table 2.

Trapezius (N/cm2) Right Left

3. Results

Measurements

The results are expressed as means with standard deviations (SD) and with 95% conﬁdence intervals (CIs). The normality of the variables was evaluated by the Shapiro–Wilk test. Intraclass correlation coefﬁcients (ICC) were calculated with the one-way random effects model. Coefﬁcients of repeatability with 95% CI were calculated for each measurement site. A within-subjects coefﬁcient of variation ((SD/mean) 100) was calculated for all measurement sites (Bland, 2000). An analysis described by Bland and Altman (1986) was performed in which differences between two consecutive PPT measurements were plotted against the corresponding mean for each site to show the variability of the results at the individual level. The a-level was set at 0.05 for all tests. The effect size was calculated by the mean change divided by the SD and CIs were obtained by bias corrected bootstrapping with 2000 multiplications (Cohen, 1988).

Site of measurements

2.4. Statistics

Table 2 Repeatability of pressure pain thresholds on neck muscles in women with chronic neck pain

The ethics committee of the Punkaharju Rehabilitation Center, Punkaharju, Finland, approved the study design and the participants gave their informed written consent prior to inclusion in the study.

39.6 (15.9) 38.9 (17.9)

ES (95% CI)a

2.3. Ethics

Splenius capitis (N/cm2) Right Left

ICCb (95% CI)

Repeatability

Coefﬁcient of variationd (%)

insertion of the trapezius muscle 2 cm lateral to the spinous processus of the axis and on the levator scapulae muscle 2 cm above the lower insertion located in the upper medial border of the scapulae while patients were lying prone. Finally, measurements were taken on the upper border of the trapezius muscle half-away between the midline and lateral border of the acromion. These testing sites were chosen as they are known, through clinical experience, to be sensitive in patients with chronic non-speciﬁc neck pain. They were also used in all trials, as intratester repeatability in reassessing pain sites qualitatively has been shown to be fair only (Ohrbach and Gale, 1989). The PPT measurements were repeated in the same order at the same time on the following day by the same tester to evaluate the repeatability of the method. All measurements were performed by the same physiotherapist, who had several years experience in testing. The algometer maintains the maximum applied pressure until tared. Thus, the measurements were performed blinded, as the display was not in view of the tester and the peak output was read only after each measurement.

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Coefﬁcient of repeatabilityc (95% CI)

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As the SDs show, there was wide inter-individual variation in the PPTs at all the sites measured. The mean of the second test was uniformly lower than that of the ﬁrst test at every site measured, the average difference between means being 7%. The power of the PPT measurements on the muscles varied from 13% to 46%. Intratester repeatability was shown to be moderate or good at the sites tested, according to the ICCs, which varied from 0.78 to 0.93 (95% CI from 0.53 to 0.97) (Table 2.). The coefﬁcient of repeatability ranged from 16.8 to 24.4 N/cm2 and the mean coefﬁcient of variation was 16%. The wide intra-individual variation between the ﬁrst and second measurements at the different sites is shown in Figs. (2a)–(d). The intratester measurement error between trials within the 95% limit of agreement ranged from 15 to +17 and 20 to +23 N/cm2 for the right and left upper trapezius, 15 to +22 and 20 to +26 N/ cm2 for the right and left mid trapezius, 16 to +21 and 15 to +18 N/cm2 for the right and left levator scapulae.

4. Discussion The results were well reproducible at all the sites measured, according to the ICCs. ICCs have been used in several studies to evaluate intratester repeatability in different muscles in both healthy volunteers and patients. Slightly better correlations, ranging from 0.69 to 0.92 have been found for healthy subjects compared to correlations ranging from 0.43 to 0.94 for patient populations (Mikkelsson et al., 1992; Delaney and McKee, 1993; Sand et al., 1997; Antonaci et al., 1998; Sterling et al., 2002). However, the ICC lacks sensitivity to systematic changes in results, such as incremental improvements, or deterioration due to repeated testing. Complementary statistical methods should thus be used in evaluating the repeatability of PPT measurements. In earlier studies, repeatability of the PPT has been evaluated by using Pearson’s correlation coefﬁcient, which has commonly resulted in high correlations with intratester repeatability ranging from 0.71 to 0.96 (Ohrbach and Gale, 1989; Hogeweg et al., 1992). However, this method only compares the means of repeated measurements on separate test occasions and does not show the true variation between inter-individual measurements. In the present study, the coefﬁcient of repeatability demonstrated the existence of rather wide variation between repeated measurements. This result was in accordance with previous ﬁndings (Sand et al., 1997; Antonaci et al., 1998). The coefﬁcient of variation was on the same level as previously reported for healthy subjects (Brennum et al., 1989; Antonaci et al., 1998). Levoska et al. (1993) found intraobserver repeatability coefﬁcients for PPT measurements to vary from 0.65 to 0.78 in the trapezius and levator region in subjects with neck pain and from 0.54 to 0.85 in healthy controls.

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The ICC does not provide information about the magnitude of the ﬂuctuation over paired measures, which are commonly used in clinical practice to monitor possible change over time. Hence we used the analysis in which the differences between the repeated measurements were plotted against their mean. Previously this analysis has been used by Nussbaum and Downes (1998), who evaluated the PPT of biceps muscles on consecutive days in healthy subjects using a Fisher algometer. They also noted considerable variation, as the intratester measurement error between trials within the 95% limit of agreement ranged from 9 to 8 N/cm2. The error increased almost two-fold when the tester was changed, ranging from 14 to 18 N/cm2. Smidt et al. (2002) assessed intertester reproducibility in measurements of the PPT on the lateral epicondyle in patients with lateral epicondylitis and found a range of error from 28 to 15 N/cm2, which was on the same level as in the present study. Hence to ﬁnd a real difference between measurements with 95% CI, the nominal difference would need to be more than 20 N/cm2. These results support Fischer (1988), who suggested that a compression force equivalent to more than 20 N between a painful site and a corresponding normal site is clinically signiﬁcant and indicates pathology on the hyperalgesic site, while smaller differences may be due to biologic or measurement variation. Taking several PPT measurements at each site may decrease possible error due to variation in individual measurements and increase repeatability. This method has been used by some researchers in repeatability studies (Delaney and McKee, 1993; Kosek et al., 1993). However, even multiple measurements may not be sufﬁcient to estimate a patient’s PPT in the clinic. Moreover, to double or triple the number of measurements at each site is time consuming, especially when several sites are tested, and is poorly suited to clinical practice. Thus, in the present study each site was measured once on each test occasion. Measurements were performed at the same time on consecutive days to avoid possible effects of the menstrual cycle, which may inﬂuence results when the interval between measurement runs over several days (Cimino et al., 2000; Isselee et al., 2001). There are several PPT measurement devices on the market. Technically, they can be divided into strain gauges, pressure gauges and simple spring mechanisms. To date no comparative studies of different devices have been done, and hence the results of this study cannot automatically be generalized to devices other than the one used here.

5. Conclusions The intratester ICCs showed correlations varying from moderate to good at different sites. PPT measurements

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Fig. 2. (a–d) The difference in pressure pain threshold between the ﬁrst and the second measurements plotted against their mean for each patient. Dotted lines show 95% limits of agreement.

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can be used to monitor changes in groups and thus may be suitable for clinical studies. However, when repeated measurements of the PPT were compared against their means, the variation in patients with chronic neck pain was two-fold compared to that found previously in symptom-free subjects. To be diagnosed as meaningful, the difference between PPT measurements at hyperalgesic and reference sites should be at least 20 N. Despite the fact that several researchers have recommended PPT measurements for clinical purposes on the grounds of good repeatability, caution should be exercised when interpreting such results on the individual level.

Acknowledgements The authors thank the Social Insurance Institution Finland for funding the study and physiotherapist Leena Nyrhinen for administering the PPT measurements. References Andersen JH, Kaergaard A, Frost P, Thomsen JF, Bonde JP, Fallentin N, et al. Physical, psychosocial, and individual risk factors for neck/shoulder pain with pressure tenderness in the muscles among workers performing monotonous, repetitive work. Spine 2002;27:660–7. Antonaci F, Sand T, Lucas GA. Pressure algometry in healthy subjects: inter-examiner variability. Scandinavian Journal of Rehabilitation Medicine 1998;30:3–8. Aromaa A, Koskinen S., editor. Health and functional capacity in Finland. Baseline results of the Health 2000 health examination survey. Helsinki: Publications of the National Public Health Institute B3; 2002. Bland M. An introduction to medical statistics. 3rd ed. Oxford Medical Publications; 2000. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurements. Lancet 1986;1:307–10. Brennum J, Kjeldsen M, Jensen K, Jensen TS. Measurements of human pressure-pain thresholds on ﬁngers and toes. Pain 1989;38: 211–7. Cimino R, Farella M, Michelotti A, Pugliese R, Martina R. Does the ovarian cycle inﬂuence the pressure pain threshold of the masticatory muscles in symptom-free women? Journal of Orofacial Pain 2000;14:105–11. Cohen J. Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Lawrence Erlbaum Associates Publishers; 1988. Coˆte´ P, Cassidy JD, Carroll L. The factors associated with neck pain and its related disability in the Saskatchewan population. Spine 2000;25:1109–17.

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Delaney GA, McKee AC. Inter- and intra-rater repeatability of the pressure threshold meter in measurement of myofascial trigger point sensitivity. American Journal of Physical Medicine & Rehabilitation 1993;72:136–9. Dixon JS, Bird HA. Reproducibility along a 10-cm vertical visual analogue scale. Annals of the Rheumatic Diseases 1981;40:87–9. Fischer AA. Documentation of myofascial trigger points. Archives of Physical Medicine and Rehabilitation 1988;69:286–91. Hogeweg JA, Langereis MJ, Bernards AT, Faber JA, Helders PJ. Algometry. Measuring pain threshold, method and characteristics in healthy subjects. Scandinavian Journal of Rehabilitation Medicine 1992;24:99–103. Isselee H, De Laat A, Bogaerts K, Lysens R. Long-term ﬂuctuations of pressure pain thresholds in healthy men, normally menstruating women and oral contraceptive users. European Journal of Pain 2001;5:27–37. Jacobs JW, Geenen R, van der Heide A, Rasker JJ, Bijlsma JW. Are tender point scores assessed by manual palpation in ﬁbromyalgia reliable? An investigation into the variance of tender point scores. Scandinavian Journal of Rheumatology 1995;24:243–7. Kosek E, Ekholm J, Nordemar R. A comparison of pressure pain thresholds in different tissues and body regions. Long-term reliability of pressure algometry in healthy volunteers. Scandinavian Journal of Rehabilitation Medicine 1993;25:117–224. Levoska S, Keinanen-Kiukaanniemi S, Bloigu R. Repeatability of measurement of tenderness in the neck–shoulder region by a dolorimeter and manual palpation. Clinical Journal of Pain 1993;9:229–35. Mikkelsson M, Latikka P, Kautiainen H, Isomeri R, Isomaki H. Muscle and bone pressure pain threshold and pain tolerance in ﬁbromyalgia patients and controls. Archives of Physical Medicine and Rehabilitation 1992;73:814–8. Nussbaum EL, Downes L. Reliability of clinical pressure-pain algometric measurements obtained on consecutive days. Physical Therapy 1998;78:160–9. Ohrbach R, Gale EN. Pressure pain thresholds, clinical assessment, and differential diagnosis: reliability and validity in patients with myogenic pain. Pain 1989;39:157–69. Sand T, Zwart JA, Helde G, Bovim G. The reproducibility of cephalic pain pressure thresholds in control subjects and headache patients. Cephalalgia 1997;17:748–55. Smidt N, van der Windt DA, Assendelft WJ, Mourits AJ, Deville WL, de Winter AF, et al. Interobserver reproducibility of the assessment of severity of complaints, grip strength, and pressure pain threshold in patients with lateral epicondylitis. Archives of Physical Medicine and Rehabilitation 2002;83:1145–50. Sterling M, Jull G, Carlsson Y, Crommert L. Are cervical physical outcome measures inﬂuenced by the presence of symptomatology? Physiotherapy Research International 2002;7:113–21. Vernon H, Mior S. The neck disability index: a study of reliability and validity. Journal of Manipulative and Physiological Therapeutics 1991;14:409–15. Viikari-Juntura E, Takala E-P, Alaranta H. Neck and shoulder pain and disability. Scandinavian Journal of Rehabilitation Medicine 1988;20:167–73.

Manual Therapy (2007) 12(2), 198

Diary of events

First international Fascia Research Congress Basic Science and Implication for Conventional and Complementary Health Care 4–5 October 2007 The Conference Center, Harvard Medical School Boston MA http://www.fascia2007.com

10th International Conference in Mechanical Diagnosis and Therapy — The Evidence Mounts 23–25 March 2007 Queenstown, New Zealand Honorary Chairman: Robin McKenzie Presented by: The McKenzie Institute International For more information visit: www.mckenziemdt.org

5th International Course on the Hand October 21–25, 2007 Target audience: colleagues of the following disciplines; physical medicine and rehabilitation, plastic- and hand surgery, physical- and occupational therapy and other health care professionals, interested in the topic of the hand Lectures include: Prof. Dr. S.E.R Hovius, Ton A.R. Schreuders PT, PhD and G. Van Strein MSc Accreditation applied for at the EACCME (Accreditation Council) of the European Union of Medical Specialists (UEMS) More information and registration: website: www.vitalmedbodrum.com E-mail: [email protected]

4th Low Back Pain Symposium April 30–May 3, 2007 Target audience: colleagues of the following disciplines; physical medicine and rehabilitation, orthopaedic surgery, neurosurgery, physical-, occupational-, manual- and Mensendieck therapy. Moreover, company doctors, medical advisors of insurance companies and other health care professionals interested in the topic of low back pain. Chairmen: Prof. Dr. Henk J. Stam, Prof. David Niv M.D. FIPP, Prof. Dr. Mehmet Zileli Accreditation applied for at the EACCME (Accreditation Council) of the European Union of Medical Specialists (UEMS) More information and registration: website: www.vitalmedbodrum.com E-mail: [email protected]

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

6–10 July 2007, Singapore Changing Pain and Movement Behaviour – A Classiﬁcation Based Approach to the Management of Chronic Low Back Pain Disorder by A/P Peter O’Sullivan for information on the workshop, please e-mail [email protected]

If you wish to advertise a course/conference, please contact: Karen Beeton, Associate Head of School (Professional Development), School of Health and Emergency Professions, University of Hertfordshire, College Lane, Hatﬁeld, Herts AL10 9AB, UK. There is no charge for this service.

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Masterclass

Diagnosis and classiﬁcation of pelvic girdle pain disorders, Part 2: Illustration of the utility of a classiﬁcation system via case studies Peter B. O’Sullivan, Darren J. Beales Curtin University of Technology, School of Physiotherapy, GPO Box U1987, Perth, WA 6845, Australia

Abstract Pelvic girdle pain (PGP) disorders are complex and multi-factorial and are likely to be represented by a series of sub-groups with different underlying pain drivers. Both the central and peripheral nervous systems have the potential to mediate PGP disorders. Even in the case of a peripheral pain disorder, the central nervous system can modulate (to promote or diminish) the pain via the forebrain (cognitive factors). It is hypothesised that the motor control system can become dysfunctional in different ways. A change in motor control may simply be a response to a pain disorder (adaptive), or it may in itself promote abnormal tissue strain and therefore be ‘mal-adaptive’ or provocative of a pain disorder. Where a deﬁcit in motor control is ‘mal-adaptive’ it is proposed that it could result in reduced force closure (deﬁcit in motor control) or excessive force closure (increased motor activation) resulting in a mechanism for ongoing peripheral pain sensitisation. Three cases are presented which highlight the multi-dimensional nature of PGP. These cases studies outline the practical clinical application of a classiﬁcation model for PGP and the underlying clinical reasoning processes inherent to the application of this model. The case studies demonstrate the importance of appropriate classiﬁcation of PGP disorders in determining targeted intervention directed at the underlying pain mechanism of the disorder. r 2007 Published by Elsevier Ltd. Keywords: Pelvic girdle pain; Sacroiliac joint; Classiﬁcation; Pain mechanisms; Motor control; Case studies

1. Introduction Pelvic girdle pain (PGP) of musculoskeletal origin has become recognised as a clinical entity distinct from that of low back pain. Not unlike low back pain though, clarity in the classiﬁcation of PGP disorders is regularly lacking in both research and clinical settings. Failure to effectively classify these disorders in a meaningful manner has resulted in confusion about PGP disorders in the same way that a lack of classiﬁcation of back pain has contributed to the problems surrounding the diagnostic label of ‘non-speciﬁc’ low back pain. The failure to meaningfully classify PGP disorders based on their underlying pain mechanism ultimately leads to difﬁculties in providing appropriate care for the patient, Corresponding author. Tel.: +61 8 9266 3629; fax: +61 8 9266 3699. E-mail address: [email protected] (P.B. O’Sullivan).

1356-689X/$ - see front matter r 2007 Published by Elsevier Ltd. doi:10.1016/j.math.2007.03.003

as the treatment may not be directed at the mechanism/s that drive the pain disorder. In the accompanying article to this paper, a nonexclusive classiﬁcation system based on a biopsychosocial approach has been presented (O’Sullivan and Beales, 2007a). The underlying basis of this model is one of understanding the mechanism/s involved in the development and maintenance of PGP disorders. It recognises the multi-faceted nature and complex interaction of these mechanisms. This mechanism-based approach directly leads to and facilitates the uptake of appropriate management strategies. To demonstrate the utility of this classiﬁcation system three case studies are presented. Note: Where not else stated, subjective data presented in the case studies (fear, beliefs, anxiety, depression scales, etc.) represent a 10-point numerical rating score from data collected from the Orebro Musculoskeletal Pain Questionnaire (Linton, 2005).

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2. Case studies 2.1. Case 1: Centrally mediated PGP 2.1.1. Subjective examination findings 39-year-old female; married; two children Work: home duties History: 5 year history of chronic PGP that began during her second pregnancy and did not resolve. She reported that after the birth of her second child she became disabled and sought various treatments to manage her disorder. These interventions included manipulation, stabilisation exercises and a pelvic belt. She reported little beneﬁt from these treatments over a period of 2 years. Over this time she had become inactive and very disabled. She was then referred to a clinic that specialised in PGP disorders. As she had great difﬁculty performing the active straight leg raise (ASLR) test, and pelvic compression did not reduce the pain and heaviness, she was advised that her pelvis was ‘very unstable’ and that she required surgical fusion. Initially she underwent fusion of the symphysis pubis and when this was not successful, she also underwent fusion of both sacroiliac joints (SIJs) (Fig. 1). When this did not beneﬁt her she was referred to a multi-disciplinary pain management clinic for psychological, medical and physical management. She was still disabled with PGP and was attending active rehabilitation sessions three times per week. Family history: nil Pain: constant pain over the posterior pelvis as well as pubic area (left side bias) Aggravating postures: all postures—sitting, standing, lying Aggravating activities: all activities—walking, lifting, bending, activities of daily living Easing postures/activities: no symptom relief during weight bearing or non-weight bearing Activity levels: low

Coping strategies: rest, spends much of the day lying down Beliefs: 1. Back pain likely to become persistent 10/10 2. Activity aggravates back pain 10/10 3. Activities that aggravate back pain are likely to be damaging 10/10 4. Work likely to aggravate back pain 10/10 5. Basis of the pain—not known Pain-intensity (VAS): 8/10 (day intake examination); 8/10 (average pain week); 8/10 pain (average over 3 months) Disability scale score: revised-Oswestry (Fairbank et al., 1980): 50% Fear avoidance: high levels of fear avoidance behaviour Psycho-social risk factors (‘yellow’ flags): 1. Stress levels (7/10) 2. Depression (7/10) Medical imaging: X-rays—successful fusion of the pelvis Medication: Strong analgesics, pain modulation medication 2.1.2. Key subjective features

Widespread symptoms Constant pain Pain is of a high level and non-mechanical in nature High levels of disability High levels of stress and anxiety High levels of fear avoidance behaviour Belief that something is damaged and disorder is unlikely to resolve Fused pelvis

2.1.3. Plan for physical examination

Examine for the presence of consistent clinical patterns—organic vs non-organic signs Investigate relationship between movement behaviour and pain behaviours

2.1.4. Physical examination findings Posture and movement analysis

Fig. 1. X-ray of subject in Case 1 depicting surgical fusion of both sacroiliac joints and the symphysis pubis.

Standing: patient constantly moved—shifting weight from side to side. There was no consistency with this behaviour. She presented with poor control of standing balance. Forward bending and return: full range of motion (ROM)

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Backwards bending: full ROM Single leg standing: gross generalised shaking and loss of control on left leg Gait: inconsistent gait pattern—ataxic in nature Squat: unable to perform a squat due to loss of control of left leg Sitting posture: during interview and examination the patient constantly moved, changing position, bracing and unloading spine with arms. There was no consistent pattern with this behaviour. Sit to stand: use of hands and breath holding

2.1.6. Diagnosis

Specific movement tests (O’Sullivan, 2005)

Unable to normalise movement behaviours in sitting, standing, single leg standing, squat No change in pain with attempts to change movement behaviours No clear relationship between pain and movement behaviours

Weakness in her left leg—strength was inconsistent depending on position tested ASLR—prone/supine (Mens et al., 1999)

Gross weakness and loss of control, not inﬂuenced by pelvic compression

Generalised gross motor disruptions of left leg Inconsistent motor performance No clear relationship between abnormal pain and movement behaviours—pain was not altered with attempts to normalise movement behaviours Widespread pain and hypersensitivity No clear consistent pain pattern to suggest an organic basis to disorder

Non-speciﬁc PGP

2.1.7. Classification

Specific muscle testing (O’Sullivan, 2005)

Central nervous system driven pain disorder with central pain sensitisation and abnormal pain and movement behaviours (Fig. 2). Presence of abnormal pain behaviours without a clear, consistent clinical pattern to them Psycho-social pain drivers: J High levels of disability, functional impairment and inability to work J Passive coping strategies for pain management— abnormal illness behaviour, relief with rest, avoidance of provoking activities, medication J High levels of stress and depression

Neurological screening examination (Hall and Elvey, 1999)

Case 1: Centrally mediated pelvic girdle pain

• • • • • • • • •

Absence of neurological ﬁndings (normal neural provocation testing, reﬂexes, sensation and manual muscle tests)

Passive physiological (Maitland, 1986)

motion

segment

testing

No spinal movement impairment SIJ provocation tests (Laslett et al., 2003)

All highly pain sensitive Lumbar spine palpation (Maitland, 1986)

Hyperalgesia across lumbosacral, sacroiliac, buttock and pubic symphysis regions (left bias)

2.1.5. Key features of physical examination findings

Presence of abnormal pain behaviours without a clear, consistent clinical pattern to them

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Nature of the disorder : Widespread pain +/- referral Pain constant, severe and debilitating All activity and movement provoke pain Absence of consistent mechanical pattern of provocation Minimal relieving factors (medication only) Pain at rest Disrupted sleep +ve sacroiliac joint pain provocation tests Active straight leg raise test – inability to lift leg but not relieved with pelvic compression • Widespread changes in motor system • High levels of disability • Widespread allodynia Result : Centrally mediated pelvic girdle pain

Management : • Medical : Central nervous system modulation • Psychological : Pain management coping strategies • Physical : Maintain functional capacity

Fig. 2. The nature and management of centrally mediated pelvic girdle pain.

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2.1.8. Stage

her with active coping strategies that enabled her to reduce her disability levels, change her beliefs and maintain moderate levels of functional capacity.

Chronic, stable.

2.1.9. Management The classiﬁcation of this disorder is based on the high levels of widespread constant pain, generalised hyperalgesia, the non-mechanical nature of the disorder, the absence of a clear organic basis to pain, widespread disruption to the motor system and abnormal pain behaviours, the lack of a clear relationship between the abnormal movement behaviour and pain and resistance to conservative treatments. All these factors support that the pain is centrally mediated (Fig. 2). These disorders are very complex and highly resistant to change. The management approach for this disorder must be multidisciplinary (Fig. 2):

Cognitive (psychologist intervention) A focus on normalising beliefs and cognitive functioning Educate regarding vicious pain cycle (Fig. 3) Developing active coping strategies Pacing strategies Medical pain management: central nervous system inhibitory medication Rehabilitation: normalising movement behaviours and restoration of function, no pain focus, graduated functional whole body exercise programs, group exercise

2.1.10. Outcome In spite of ongoing multi-disciplinary management, 5 years later this patient lives with ongoing chronic PGP. The cognitive components to the intervention provided

CENTRALLY MEDIATED PELVIC GIRDLE PAIN

2.1.11. Commentary This case highlights the danger of considering PGP disorders purely from a biomechanical perspective. This patient did not respond to the multiple conservative and invasive interventions directed at her pelvis, based on the premise that her pelvis was ‘unstable’. This in turn promoted fear, passive dependence on health care, passive coping strategies, disability, reinforcing abnormal pain behaviours and providing fuel for a centrally mediated pain disorder to develop (Fig. 3). This patient has all the hall-marks of centrally mediated pain— widespread, severe, constant pain, allodynia, gross and widespread motor disturbances, high levels of disability with peripherally directed interventions exacerbating the disorder. This case highlights the importance of the early classiﬁcation of PGP disorders and directing management at the mechanism/s that underlie the pain disorder. It highlights the danger of focussing on the signs and symptoms of a disorder (i.e. ASLR test) without consideration for the complex central mechanisms that can drive pain. A one-dimensional view for the classiﬁcation and management of PGP disorders (in this case assuming the pelvis was ‘unstable’) may in fact amplify pain. 2.2. Case 2: Reduced force closure 2.2.1. Subjective examination findings 36-year-old female; married; two children (2 and 4 years old)

Pain aggravated with movement

Avoidance behaviour, altered loading and movement patterns

Belief that pelvis is ‘unstable’

‘Wind-up’ of central nervous system

Amplification of pain, deconditioning, disability, no work

Interventions to ‘stabilise’ the pelvis

Increased fear, anxiety, lack of awareness, loss of control, passive coping

Failure of interventions Fig. 3. The vicious cycle of pain for centrally mediated pelvic girdle pain.

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Work: physiotherapist (unable to work because of pain) Home: household activities; picking up and carrying 2-year-old child History: gradual onset of PGP during second pregnancy. Pain increased following child birth and had not abated. Pain remained at a high level and disabling, and attempts to rehabilitate had failed. Multiple interventions and advice left her confused and disabled. Initial treatment after her child was born was pelvic manipulation which aggravated her pain. The second physiotherapist she saw advised that her pelvis was unstable and that she needed to dynamically stabilise it. She was instructed to perform transverse abdominal wall exercises and was given a series of exercise progressions that involved graduated limb loading in supine. She reported no relief from this treatment. She was then referred to a PGP clinic where she was instructed that she had a hypertonic pelvic ﬂoor and she needed to learn to relax it. She was instructed to do relaxation and breathing exercises and gradually increased her cardiovascular ﬁtness. However this resulted in a signiﬁcant increase in her pain. She took analgesic medication and non-steroidal anti-inﬂammatories regularly. She reported that she had developed stress incontinence after training her pelvic ﬂoor to relax. Family history: nil Pain: localised SIJ pain on the right with some gluteal referral. Pain was intermittent in nature. Aggravating postures: sitting, standing (loading right leg) Aggravating activities: walking (410 min), lifting and carrying child; previous treatment stabilising exercises: ﬁt-ball, limb loading, stretching exercises for the hip Easing postures/activities: relief during unloading of right leg and non-weight bearing, rest eases pain Coping strategies: rest, avoiding provoking activities Beliefs: 1. Back pain likely to become persistent (5/10) 2. Activity aggravates back pain (10/10) 3. Activities that aggravate back pain are likely to be damaging (7/10) 4. No idea as to the basis of the pain or what is required to manage it Pain-intensity (VAS): 6/10 (day intake examination); 5/10 (average pain week); 5/10 pain (average for 3 months) Disability scale score: Revised-Oswestry (Fairbank et al., 1980): 38% Fear avoidance: Tampa Scale of Kinesiophobia (French et al., 2007): 38/68 Psycho-social risk factors (‘yellow’ flags): 1. Stress levels (4/10)—pain and disability results in stress

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2. Depression (7/10)—gets down because of pain disorder Medical imaging: X-rays and CT-imaging—no abnormalities detected Blood tests: ve 2.2.2. Key subjective features

Localised SIJ pain Loading pain disorder No awareness of pain disorder—conﬂicting advice regarding management and underlying pain mechanism Passive coping strategies High levels of pain, disability and movementbased fear Absence of pathoanatomical disorder on radiology

2.2.3. Plan for physical examination

Identify symptomatic structure Investigate provoking postures and activities to determine whether control or movement impairments are linked to pain disorder Investigate motor control of lumbar spine and pelvis—especially regarding right limb loading Investigate whether enhancing control over painful structure/s reduces pain in provocative postures and activities Determine if beliefs regarding movement-based fear are real or perceived Physical examination findings

2.2.4. Posture and movement analysis

Standing: sway posture standing (Fig. 4a) (pelvis anterior to thorax) with avoidance of loading right leg. Reduction in tone in the transverse abdominal wall, lumbar multiﬁdus and right gluteal muscles Forward bending: full ROM (no pain) Return from forward bending: poor control of posterior pelvic rotation via hips Backwards bending: full ROM (no pain) Side bending (R/L): full ROM Single leg standing: right—increased sway of pelvis anterior to thorax and trendelenberg pattern of right hip (with pain) Sitting posture: slumped sitting with weight shift to left buttock Sit to stand: tendency to laterally shift load to left leg Single leg sit to stand on right leg: inability to transfer load on right leg

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Specific muscle testing (O’Sullivan, 2005)

Attempts to elevate pelvic ﬂoor were associated with bracing of the abdominal wall, breath holding and depression of the pelvic ﬂoor Attempts to activate the lower transverse abdominal wall (transverse ﬁbres of internal oblique and lower transversus abdominis) in side lying and supine were associated with bracing and breath holding Inability to initiate isometric contraction of right gluteal muscles Marked weakness of right gluteal muscle on testing ASLR—prone/supine (Mens et al., 1999)

Marked ‘heaviness’ when elevating right leg with breath holding and bracing of the abdominal wall Manual pelvic compression across ilium normalised the test

Neurological screening examination (Hall and Elvey, 1999)

Fig. 4. (a) Subject in Case 2 with a classiﬁcation of reduced force closure exhibits a passive sway standing posture as her normal standing posture. This posture is associated with inhibition of the local force closure muscles (transverse abdominal wall, lumbar multiﬁdus, gluteal muscles, pelvic ﬂoor). (b) Corrected standing posture facilitates automatic postural activation of local force closure muscles. Assumption of this posture immediately reduced her SIJ pain.

Lifting: avoidance of loading right leg/ﬂexed lumbar spine Gait: trendelenberg pattern on right

Absence of neurological ﬁndings (normal neural provocation testing, reﬂexes, sensation and manual muscle tests) SIJ provocation tests (Laslett et al., 2003)

All tests positive—except she experienced relief with ilium compression

Passive physiological (Maitland, 1986)

motion

segment

testing

No spinal movement impairment Lumbar spine palpation (Maitland, 1986)

Specific movement tests (O’Sullivan, 2005)

Correcting sway standing posture (Fig. 4b): neutral lumbar lordosis, aligned relaxed thorax over pelvis (no sway) with equal loading reduced sacroiliac pain. Standing on right leg with the same postural correction as standing resulted in gluteal activation and reduced pain—the addition of manual compression to ilium further reduced pain—rapid fatigue of the right leg muscles was reported. Sitting with lumbopelvic posture with equal loading on buttocks reduced pain—the addition of manual ilium compression further reduced pain Poor capacity to isolate anterior pelvic rotation independent of thorax

Tenderness inferior sulcus of SIJ Trigger points and tenderness over gluteal and piriformis muscles

2.2.5. Key features of physical examination findings

Full ROM of lumbar spine (active and passive) Avoidance of loading right lower limb Loading pain when weight bearing on right side and was associated with a lack of activation of postural stabilising muscles (right gluteal, transverse abdominal wall, lumbar multiﬁdus, left quadratus lumborum) Facilitating optimal loading reduced pelvic pain +ve ASLR—normalised with compression Inability to isolate activation of local pelvic muscles

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Provocation of pain linked to deﬁcits of control of the pelvic stabilising muscles High levels of disability Loss of conditioning

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Cognitive drivers: lack of awareness of pain disorder, anxiety, depression, passive coping, inability to function, hyper-vigilance

2.2.8. Stage 2.2.6. Diagnosis

Chronic, stable. Other important factors contributing to disorder

2.2.7. Classification: mal-adaptive movement disorder

Passive coping strategies for pain management—relief with rest, avoidance of provoking activities, medication Lack of awareness of the basis (i.e. mechanism) of the pain disorder

Non-speciﬁc PGP (post partum PGP)

Peripheral driver: reduced force closure of right SIJ and associated structures (Fig. 5)

Case 2: Reduced force closure Nature of the disorder: • Localised pain +/- referral • Pain provoked by sustained or repeated loading sitting / standing / walking • No spinal movement impairment or pain • Pain provoked by long lever exercises, stretching +/- manipulation • Pain relieved by increased pelvic compression / sacroiliac belt / local muscle activation / optimizing alignment • +ve sacroiliac joint provocation tests • +ve ASLR test (supine +/- prone) normalized by pelvic compression • Passive postures with poor lumbopelvic position sense • Inability to isolate local pelvic muscle synergies (pelvic floor, lower internal oblique, transverses abdominis, +/- lumbar multifidus, psoas major, gluteal muscles)

Case 3: Excessive force closure Nature of the disorder: • Localised pain +/- referral • Pain provoked by sustained or repeated loading sitting / standing/ walking • No spinal movement impairment or pain • Pain provoked by increased pelvic compression / sacroiliac belt / muscle activation • Pain relieved with relaxation / stretching / massage • +ve sacroiliac joint provocation tests • -ve ASLR test • Erect active postures

• Avoidance of painful activity • Disability

• High levels of muscle tone and tension of pelvic floor, abdominal wall, adductors, gluteal muscles • Muscle guarding and tension (↑intraabdominal pressure) with inability to relax pelvic muscles • Disability

Result: Peripheral pain sensitization due to a loss of local compression within pelvic joints resulting in repeated strain in sacroiliac joints and surrounding structures

Result: Peripheral pain sensitization due to excessive and sustained compression of sacroiliac joints and surrounding pain sensitive structures (increased pelvic compression)

Reduced force closure classification • • • •

Cognitive drivers: Anxiety related to chronic disabling pain Fear of activity (non-pathological) Lack of control and awareness of disorder Belief that activity is provocative (nonpathological) Result: Central amplification of pain due to cognitive components of disorder

Excessive force closure classification Cognitive drivers: • Associated underlying anxiety • Active coping, poor pacing, • Hyper-vigilence

Result: Central amplification of pain due to cognitive components of disorder

Management: Management: Enhancing local force closure via motor learning in Reducing excessive motor activity and facilitating conjunction with appropriate cognitive intervention relaxation using both motor learning and appropriate cognitive intervention leads to resolution /control leads to resolution/control of the disorder of the disorder

Fig. 5. The nature and management associated with mal-adaptive motor control disorders of the pelvis with; Case 2: Reduced force closure classiﬁcation and Case 3: Excessive force closure classiﬁcation. Normal text represent common features of the disorders while italics text highlights differences between the disorders (ASLR ¼ active straight leg raise).

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Belief that activity is provocative (correct)—reinforcing disability Avoidance behaviours relating to right leg loading Deconditioning, high disability levels

2.2.9. Management: cognitive

Provide an awareness of pain mechanism—educate regarding vicious cycle (Fig. 6) Make patient aware of loss of pelvic motor control and how her postural control and avoidance behaviours have reinforced her pain disorder Enhance functional capacity in order to develop active coping strategies with pain control

2.2.10. Management: motor learning

Train ability to elevate pelvic ﬂoor muscles and isolate activation of transverse abdominal wall without global abdominal wall activation and breath holding (O’Sullivan and Beales, 2007b) Train control of pelvis independent to the thorax (in supine, sitting, and standing) Train lumbopelvic sitting and aligned standing postures with equal limb loading (O’Sullivan et al., 2002) Train loading of right leg with optimal alignment of the thorax relative to the pelvis and pain control Train lifting techniques with equal weight bearing and lumbopelvic control Graduated cardiovascular ﬁtness program—progress from exercise bike to walking Increase conditioning of lumbopelvic region with whole body exercise and right leg loading exercises— lunges, squats and hand weights

Pelvic girdle pain aggravated with movement

Amplification of pain, deconditioning, disability, no work

Lack of awareness, loss of control, passive coping

Avoidance of provoking activities

Graduated functional restoration with movement and pain control—speciﬁc to patient’s provocative activities Graduated return to work

2.2.2. Outcome Twelve months later this patient had returned to work as a physiotherapist with very little pain and had returned to playing handball and other sporting activities. Her bladder control also normalised. 2.2.3. Commentary These examination ﬁndings support the presence of a loading pain disorder of the right SIJ and surrounding structures, associated with a loss of local motor control resulting in a loss of adequate force closure (impaired load transfer) of the SIJ complex. This results in excessive strain being placed through the pain sensitive supporting ligamentous structures of the SIJ, with resultant maintenance of pain during loading (Fig. 6). This loss of control is reinforced by the faulty postural and movement behaviours she had developed. Her avoidance behaviours have developed from an inability to optimally load the right leg without pain. Management logically focuses on a cognitive based motor control intervention directed at the functional activation of the key force closure muscles of the SIJ to enhance the dynamic stability to the joint. Achieving pain control during loading allows for the restoration of normal movement and coping behaviours, reduced avoidance behaviours, conditioning and the resumption of work and sporting activities. This in turn promotes the resolution of the disorder.

Avoidance behaviour, altered loading and movement patterns, adoption of passive postures

Deficit in local pelvic muscles, activation of thoraco-pelvic muscles

REDUCED FORCE CLOSURE

Increased tissue strain linked to reduced force closure

Fig. 6. The vicious cycle of pain for pelvic girdle pain with a classiﬁcation of reduced force closure.

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2.9. Case 3: Excessive force closure 2.9.1. Subjective examination findings 38-year-old female; single Work: Pilates instructor full time (12 hours per day— 6 days per week) History: Onset of PGP 2 years earlier following heavy Pilates session which focussed on pelvic stabilisation exercises and hip stretching. The disorder progressively deteriorated over time in spite of various treatments. These treatments involved—stabilising exercise training (focussed on the pelvic ﬂoor, transverse abdominal wall, lumbar multiﬁdus and gluteal muscles, stretching, muscle energy techniques for the SIJs, trigger point work and massage to the piriformis and quadratus lumborum). In spite of signiﬁcant treatment the disorder worsened. She had been advised by a physiotherapist and chiropractor that her SIJs were ‘unstable’ and regularly become ‘displaced’, and as the stabilising exercise program has not worked, she required prolotherapy (sclerosing injections to the SIJ ligaments). However following the sclerosing injections, there was no change in her pain. She was ﬁnding it increasingly difﬁcult to work and was highly anxious regarding her ‘unstable pelvis’, had high levels of pain, and was disabled. She wore a SIJ belt even though it was provocative. Following advice she was considering SIJ fusion surgery. She also reported developing bladder control problems. Family history: Nil Pain: localised to SIJs with spread to buttocks (right4left), also internal pelvic pain across perineum Aggravating postures: sitting, standing Aggravating activities: walking, bending, lifting, working, pain worse at end of working day and after exercise (power walking and swimming) and Pilates classes, no symptom relief during weight bearing Easing postures/activities: rest and relaxation, heat, massage, non-steroidal anti-inﬂammatories Coping strategies: Pelvic stabilisation—isometric muscle contractions of the pelvic ﬂoor, transverse abdominal wall, lumbar multiﬁdus and gluteal muscles, although these strategies did not reduce the pain. She was reliant on passive treatments 2–3 times per week involving massage of the pelvic muscles. On questioning she very rarely rested and relaxed. After work (12 hours without a break) she would go power walking or swimming where she would focus on gluteal and pelvic ﬂoor contractions. She reported that she was constantly focussed on her pain and contracting her pelvic muscles. Beliefs: 1. Her pelvis was unstable and weak and regularly ‘goes out’ 2. The more stable her pelvis is the better she should be

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3. The more exercise she does the better she should be 4. Holding erect postures and contracting pelvic muscles is beneﬁcial 5. PGP likely to become persistent (10/10) Pain-intensity (VAS): 6/10 (day intake examination); 6/10 (average pain week); 6/10 pain (average for 3 months) Disability scale score: revised-Oswestry (Fairbank et al., 1980): 32% Fear avoidance: low score Psycho-social risk factors (‘yellow’ flags): 1. Stress levels (8/10)—highly stressed and anxious person 2. Depression (5/10)—gets down because of pain disorder Medical imaging: X-rays and CT-imaging—no abnormalities detected; bone scan—mild signs of inﬂammation of the SIJs (right4left) Blood tests: ve 2.9.2. Key subjective features

Pain localised to SIJs Loading provokes pain Unloading and relaxation relieves pain Belief that pelvis is ‘unstable’ reinforced by treatment providers Patient constantly activates pelvic stabilising muscles although this does not relieve pain Coping strategies—exercise, muscle contraction, passive treatments (with resultant poor control over pain disorder) Lack of pacing, long work hours, lack of relaxation and rest Signs of inﬂammation of SIJ on bone scan (right4 left) High levels of stress and anxiety and focus on pain Absence of any signs suggesting serious underlying pathology

2.9.3. Plan for physical examination

Identify painful structure/s Investigate patient’s movement behaviours Investigate provoking postures and activities to determine whether impairments of motor control or excessive motor activity are linked to the pain disorder Investigate whether enhancing control over pelvis reduces or increases pain in provocative postures and activities Determine whether her current coping strategies are beneﬁcial

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Specific muscle testing (O’Sullivan, 2005)

Determine if beliefs regarding ‘unstable pelvis’ and ‘weakness’ are valid

2.9.4. Physical examination findings Posture and movement analysis

Ability to co-activate the pelvic ﬂoor, lower transverse abdominal wall (transverse ﬁbres of internal oblique and lower transversus abdominis) and lumbar multiﬁdus at L5/S1 in side lying and supine without breath holding High levels of strength of hip ﬂexors and extensors Difﬁculty relaxing gluteals, lumbar multiﬁdus and lower abdominal wall Rapid, apical breathing in all postures including supine Difﬁculty belly breathing in supine High levels of ﬂexibility of trunk and hip muscles Internal pelvic ﬂoor examination (by womens health physiotherapist) conﬁrmed the ability to contract and elevate the pelvic ﬂoor, but difﬁculty relaxing it. Strength grade 5+ Oxford scale, very strong contraction on Peritron.

Standing: erect thoracolumbar posture; high tone in the abdominal wall, back and gluteal muscles, apical breathing pattern Forward bending: hands ﬂat on the ﬂoor with no increase in pain Backwards bending: hyperextension of the spine without pain Side bending (R/L): full ROM Single leg standing: erect standing with gluteal activation Sitting posture: erect active sitting (Fig. 7a) with forward incline, extended thoracolumbar spine, apical breathing pattern Sit to stand: initiated with hip ﬂexion and thoracolumbar spine maintained in extension Squat: full movement with ease Gait: rigid erect thoracolumbar spine (minimal rotation) with accentuated hip extension

Specific movement tests (O’Sullivan, 2005)

Neurological screening examination (Hall and Elvey, 1999)

Relaxation of sitting posture via thorax (Fig. 7b) and abdominal wall reduced pelvic pain Relaxation of gluteal, back and abdominal wall muscles with reduced lumbar lordosis and increased thoracic ﬂexion in standing reduced pelvic pain

ASLR—prone/supine (Mens et al., 1999)

ve Ability to lift leg with ease Increase in pain with addition of manual pelvic compression and local stabilising muscle activation

Absence of neurological ﬁndings (normal neural provocation testing, reﬂexes, sensation and manual muscle tests) SIJ provocation tests (Laslett et al., 2003)

All tests positive—except she experienced relief with lateral distraction of the ilium

Passive physiological (Maitland, 1986)

motion

segment

testing

Normal for spine and pelvis Lumbar spine palpation (Maitland, 1986)

Tenderness of right inferior sulcus of SIJ Trigger points and tenderness over gluteal and piriformis muscles

2.9.5. Key features of physical examination findings Fig. 7. (a) Subject in Case 3 adopts an erect active sitting posture with high levels of activation in the superﬁcial abdominal wall and the thoracolumbar erector spinae, as well as an apical breathing pattern. (b) Relaxed sitting results in relaxation of the abdominal wall, back and pelvic ﬂoor muscles with an associated reduction in pelvic girdle pain.

Full ROM spinal mobility (active and passive) High tone in pelvic stabilising muscles with erect rigid spinal postures with pain Relaxation of spino-pelvic postures and local pelvic muscles reduced pain

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Ability to activate local stabilising muscles but difﬁculty relaxing them +ve SIJ provocation tests ve ASLR in prone and supine with increased pain on addition of manual compression and local muscle activation Abnormal movement behaviours—erect and rigid movement Current beliefs that pelvis is ‘unstable’ were not conﬁrmed by examination Current coping strategies were provocative of pain High levels of anxiety

Non-speciﬁc PGP

2.9.7. Classification: mal-adaptive movement disorder

Peripheral drivers: excessive force closure of SIJ and associated myofascial pain (Fig. 5) Cognitive drivers: faulty beliefs, anxiety, lack of pacing, inability to relax, hyper-vigilance

2.9.8. Stage

Lack of pacing, rest, relaxation and unloading of pelvic structures Ironically, treatments that gave relief were those that induce relaxation of pelvic muscles—massage, trigger point work and heat (in contrast to her beliefs) Management: cognitive

2.9.6. Diagnosis

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Educate regarding vicious cycle (Fig. 8) Provide an awareness of pain mechanism—the fact that increasing pelvic compression increases pain and reducing it decreases pain. Change beliefs—pelvis is stable, muscles are strong and the inability to relax the pelvic muscles abnormally loads the pelvic structures which increases pain Importance of pacing, learning to relax postures, not consciously activating the pelvic and trunk muscles, use breathing control to relax and reduce anxiety levels—in order to reduce peripheral and central pain drive Seek psychological/medical help with regards to reducing anxiety levels Implement strategies to reduce work hours/introduce breaks into working day/reduce manual ‘demonstrations’ in Pilates classes and focus more on instruction Importance of relaxing during exercise

Chronic/stable Management: motor learning Other important factors contributing to disorder

Belief that pelvis is unstable and that more muscle activity is better Lack of accurate awareness of basis (i.e. mechanism) of the pain disorder Coping strategy (increasing muscle activation) is provocative

Pelvic girdle pain aggravated with movement

Teach relaxation strategies—breathing control, relaxation Instruct on relaxation of spinal postures in sitting and standing Teach strategies to relax and move normally with movement—such as rolling, sit to stand, bending, walking

Muscle guarding, fear and anxiety

Amplification of pain, distress and disability

Active postures, no rest, high levels of muscle tone, poor pacing

Fear, anxiety, lack of pain coping, hyper-vigilance, more exercise and increased muscle guarding

EXCESSIVE FORCE CLOSURE

Belief that pelvis is ‘unstable’

Increased tissue load linked to excessive force closure

Fig. 8. The vicious pain cycle of pelvic girdle pain with a classiﬁcation of excessive force closure.

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Maintain cardiovascular ﬁtness but with relaxed spinal postures and increased trunk rotation Reduce exercise levels to four times per week Prescribed rest each day Cease stabilising exercises Relaxation yoga

2.9.9. Outcome Twelve months later this patient had changed jobs, reduced her activity levels to a normal level, stopped contracting her pelvic muscles, normalised her movement behaviours and had very little pain or disability. Her bladder control had also normalised. 2.9.10. Commentary This disorder was driven by the belief that the pelvis was ‘unstable’ reinforced by her physiotherapists and her own belief system. The management and coping strategies that the patient has been taught to develop (conscious activation of pelvic stabilising muscles) and the belief that her pelvis is unstable are highly provocative for these disorders, reinforcing hypervigilance and abnormally high levels of dynamic compression across her sensitised pelvic joints (Fig. 8). Her long work hours, the active nature of her work, the lack of rest, high levels of exercise, high levels of anxiety and focus on pain further increase the muscle tone resulting in increased central and peripheral drive of pain. All these factors contributed to maintaining a vicious pain cycle (Fig. 8). Management must address both cognitive and motor control factors that drive pain. Providing a new belief system and different coping strategies is critical for this patient. Learning to relax, move normally, cease stabilisation exercises and passive treatments, change the focus away from pain towards relaxation and appropriate pacing is critical. This highlights how faulty belief systems and abnormal motor control strategies reinforced by physiotherapists and adopted by patient’s can be potentially detrimental to a patients disorder.

3. Summary These three distinct cases act as clinical examples highlighting the importance of classiﬁcation and speciﬁcally directed management of PGP disorders. Working within a biopsychosocial framework is critical for the management of these disorders. Management strategies that target both the physical and cognitive impairments associated with these disorders has the potential to positively impact on long-term PGP disorders. References Fairbank JC, Couper J, Davies JB, O’Brien JP. The Oswestry low back pain disability questionnaire. Physiotherapy 1980;66(8):271–3. French DJ, France CR, Vigneau F, French JA, Evans RT. Fear of movement/(re)injury in chronic pain: a psychometric assessment of the original English version of the Tampa scale for kinesiophobia (TSK). Pain 2007;127(1–2):42–51. Hall TM, Elvey RL. Nerve trunk pain: physical diagnosis and treatment. Manual Therapy 1999;4(2):63–73. Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provocation tests. Australian Journal of Physiotherapy 2003;49(2):89–97. Linton S. Understanding pain for better clinical perspective: a psychological perspective. Edinburgh: Elsevier; 2005. Maitland GD. Vertebral manipulation. London: Butterworth Heinemann; 1986. Mens JM, Vleeming A, Snijders CJ, Stam HJ, Ginai AZ. The active straight leg raising test and mobility of the pelvic joints. European Spine Journal 1999;8(6):468–74. O’Sullivan PB. ‘Clinical Instability’ of the lumbar spine: its pathological basis, diagnosis and conservative management. In: Jull GA, Boyling JD, editors. Grieve’s modern manual therapy. 3rd ed. Edinburgh: Churchill Livingstone; 2005. p. 311–31 [Chapter 22]. O’Sullivan PB, Beales DJ. Diagnosis and classiﬁcation of pelvic girdle pain disorders, Part 1: a mechanism based approach within a biopsychosocial framework. Manual Therapy 2007a;12(2):86–97. O’Sullivan PB, Beales DJ. Changes in pelvic ﬂoor and diaphragm kinematics and respiratory patterns in subjects with sacroiliac joint pain following a motor learning intervention: a case series. Manual Therapy, 2007b in press, doi:10.1016/j.math.2006.06.006 O’Sullivan PB, Grahamslaw KM, Kendell M, Lapenskie SC, Moller NE, Richards KV. The effect of different standing and sitting postures on trunk muscle activity in a pain-free population. Spine 2002;27(11):1238–44.

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Book Review Psychology in the Physical and Manual Therapies, G.S. Kolt, M.B. Andersen. Elsevier, Churchill Livingstone (2004). 369pp., Price £29.99, ISBN: 044307352X. The aim of this book is to provide physical and manual therapists with ideas and practices to care for their clients more effectively. The notion behind this is that it is not sufﬁcient to treat the physical injury or illness that the patient suffers from. In clientcentred healthcare, as is expected nowadays, the person as a whole needs to be treated. This book provides insight into the psychological aspects of a client’s health and into techniques for managing these aspects. This book consists of three sections. The ﬁrst section discusses extensively of psychological models of health and healthy behaviour, and their relevance for daily practice in physical and manual therapy. The second section focuses on speciﬁc practices (e.g., (counter)transference, cognitive and behavioural interventions, and relaxation) that can be used to address and manage psychological aspects of health. Their use in building and terminating the therapeutic relationship is also

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elaborated on. The third section is dedicated to the speciﬁc client populations with traumatic brain injury and stroke, spinal cord injuries, cardiovascular and respiratory conditions, injury from sports, exercise and physical activity, arthritis, functional somatic syndromes, personality disorders and terminal illness. The editors and authors of this book have succeeded in providing a very extensive review of relevant psychological aspects of physical and manual therapy, and do so in a very clear and concise manner. Perhaps the only drawback of this book, should you want to use it as a reference book, is its comprehensiveness, which can make it difﬁcult to ﬁnd exactly that piece of information that is required. Does it help the clinician to understand the psychological aspects of their clients’ health better and aid the clinician to caring for them more effectively? Yes, without a doubt. Ruud Houben Department of Medical, Clinical and Experimental Psychology, Maastricht University, Maastricht, The Netherlands

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Book review Cranial Manipulation, Theory and Practice, L. Chaitow. Elselvier-Churchill, Livingstone (2005). 421pp., price £36,99, ISBN: 0443074496. This book aims to give an overview of different cranial manual therapy concepts. As the author suggests in his preface, ‘‘explanations for different philosophies and methods of cranial manual therapy are needed to unite apparently disparate ideas and methods. This becomes particularly important because of a paradigm shift in manual therapy professions from a more authority-based approach towards more evidence based practice.’’ In my opinion, the author’s statement is meeting these demands by this book. The text initially introduces the different cranial manual therapy approaches (osteopathic, chiropractic, dental and physical therapeutic) from a historical perspective followed by techniques from the various approaches and concludes with their speciﬁc clinical applications. Wherever possible, short research summarizes are mentioned, including helpful graphics in a way that is easy to

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understand. A strong aspect of the book is the link between the theory and the practical problems of the clinician on the background of evidence-based practice. It includes palpation and technique exercises supported by small short video clips on a CD-ROM. A minor aspect is, that different themes are not clearly separated but directly follow each other, which may be confusing for the reader. In summary it is a book, which can be described as an overview book with much theoretical and practical material for clinicians who are interested in cranial facial manual therapy. It facilitates new hypothesis of undeﬁned clinical patterns in the head-face and neck region that manual therapist see. It also provides a fundamental source of ideas for students who are engaged in cranial manual therapy research for instance at Masters level.

Harry J.M. von Piekartz Department of Physical Therapy, Ootmarsum, The Netherlands

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Book review Manipulation of the Spine, Thorax and Pelvis: An Osteopathic Perspective. 2nd ed. Gibbons P, Tehan P. Elsevier-Churchill Livingstone, Kidlington, UK (2006) (269pp. (+CD-ROM), price £47.99, ISBN 044310039X). This is an excellent book; written with insight, experience and wisdom. It is a rare example of a rational, logical and academically sound osteopathic textbook. The authors should be regarded as among the top thinkers for the future of the osteopathic profession. The ﬁrst section of the book explores and outlines osteopathic theory. The theory is not just historical rhetoric, but builds on up-to-date research evidence to support osteopathic musculoskeletal assessment, diagnosis and management. Narrative is clear, uses simple (not a derogatory term here) language, good diagrams and photographs. It is probably true to say that other texts will go into greater depth for each of the topics concerned, e.g. spinal biomechanics, but, if all practicing osteopaths knew and understood this text, the profession would be formidable. The next four sections provide detailed explanation of manipulative techniques for the cervical spine, thoracic spine, lumbar spine and pelvis. The explanations are excellent, clear and unambiguous. Photographs are given for all techniques, again clear and self-explanatory. An included CD-ROM is great to learn from also. A fairly detailed discussion on complications of spinal manipulation is given, with particular emphasis on cervical HVLA manipulation. This again uses recent

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research evidence as a basis for discussion. The guidance given here is sound, honest and will help osteopaths make informed decisions, and enhance patient safety. The only negative view I would express concerns the last two chapters on sacro-iliac and coccyx manipulation. Sacro-iliac dysfunction is a controversial topic, with strong opinions given by many osteopaths on prevalence and signiﬁcance. The scientiﬁc evidence supporting SI dysfunction is weak, and a section exploring this area would have been nice to see, particularly from Gibbons and Tehan’s scientiﬁc but osteopathic perspective. I also have concerns about coccyx manipulation as an evidenced based approach. The only other postscript would be that the psychological and social inﬂuences on musculoskeletal pain and disability have not been explored with much depth. At present, research health professionals perhaps deal with these two topics more competently; no one profession can claim the higher ground yet. It will be interesting to see how the musculoskeletal professions (chiropractic, osteopathy, physiotherapy) go forward with their concepts and models of care in the coming years. I cannot see how greater integration will not take place. Conclusion: excellent, all students and osteopaths should have a copy as a core reference.

Tim McClune Spinal Research Unit, University of Huddersfield, UK E-mail address: [email protected]

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Book review A Manual Therapist’s Guide to Movement: Teaching Motor Skills to the Orthopaedic Patient. Browne, G. Elsevier, Churchill Livingstone, New York (2006) (p. 389, £39.99, ISBN: 0443102163). When initially asked to review this text I admittedly put it to the side thinking not another ‘‘how to’’ book. I have also been a little cynical lately of the predominantly positivist viewpoint of much of the literature in manual therapy, so it was such a delight to read even the preface of this book to ﬁnd a challenge to this paradigm. Hence I read avidly on. The language in this text is refreshing and I could hear the author, which makes a change from the dry technical description that is often found in the recipe of physiotherapy manuals. The author uses analogies to ‘‘Goldilocks’’, ‘‘The Worm’’ and ‘‘Tyrannosaurus Rex’’ which add creativity to the techniques and ideas. There is an introductory section, which focuses on motor learning and inﬂuencing motor behaviour, which is referenced and mostly up-to-date and incorporates the science, physiotherapy and other philosophies such as Feldenkrais method. The other sections are very practical and not only provide novel ideas to consider when working with patients (or students as Gordon prefers) but also provided ideas for my own exercise regime. Luckily, I was at home when I read this book as I am sure I would have received some strange looks from my ofﬁce colleagues. While I enjoyed reading this book, there are some criticisms. The initial focus was on motor learning; however, there was little attention to neuroplasticity except for a small section, which appeared in the last chapter, which makes it seem as an afterthought. Also I think the author should have continued with the focus on the neurophysiological approach rather than attempt to provide often shaky and dated evidence for the

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biomechanical basis for movement dysfunction and disease. For example in discussion on the intradiscal radiographic changes, the author draws on dated evidence (Fahrni and Trueman, 1965) to imply that primitive populations had more healthy backs. There is growing evidence (Jensen et al., 1994; Boos et al., 2000) to disprove any links between radiological evidence of degeneration and reports of pain and dysfunction. Therefore the reader should read with caution where there is speculation of what happens to tissues, based on a biomechanical model. Overall I found this an entirely readable book and would recommend this to my colleagues and anyone who is looking for ideas to adopt a more person-centred approach to manual therapy. I would also recommend this as additional reading for students in undergraduate courses. References Boos N, Semmer N, Elfering A, Schade V, Gal I, Zanetti M, et al. Natural history of individuals with asymptomatic disc abnormalities in magnetic resonance imaging. Spine 2000;12: 1484–92. Farhni WH, Trueman GE. Comparative radiological study of the spines of a primitive population with North Americans and North Europeans. Journal of Bone and Joint Surgery 1965;47B: 1105–27. Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic resonance imaging of the lumbar spine in people without back pain. The New England Journal of Medicine 1994;331(2):69–73.

John Hammond Faculty of Health and Social Care Sciences, St. George’s University of London, Kingston University, London, UK