Manual examination of accessory movements--seeking R1

Reliability and Validity of the Variability Model Testing Procedure for Somatic Dysfunction Assessment: A Comparison with Gait Analysis Parameters in Healthy Subjects

Somatic dysfunction (SD) is an altered body function involving the musculoskeletal system. However, its clinical signs-tissue texture abnormalities, positional asymmetry, restricted range of motion, and tissue tenderness-did not achieve satisfactory results for reliability. A recent theoretical model proposed a revision assessing the movement variability around the joint rest position. The asymmetry and restriction of motion may characterize functional assessment in osteopathic clinical practice, demonstrating the reliability required. Hence, this study investigated the reliability of the new variability model (VM) with gait analysis (GA). Three blind examiners tested 27 young healthy subjects for asymmetry of motion around rest position and the SD grade on six body regions. The results were compared to the VICON procedure for 3D-GA. The inter-rater agreement for the detection of reduced movement variability ranged from 0.78 to 0.54, whereas for SD, grade ranged from 0.64 to 0.47. VM had a sensitivity and specificity of 0.62 and 0.53, respectively, in SD detection compared to step length normality. Global severity grade of SD demonstrated moderate to good correlation with spatial-temporal parameters. The VM showed palpatory reliability and validity with spatial-temporal parameters in GA. Those findings contribute to the innovation for SD examination with implications for the clinical practice.

Correlation between diminished vagal tone and somatic dysfunction severity in very and extremely low birth weight preterm infants assessed with frequency spectrum heart rate variability and salivary cortisol

Osteopathic manipulative treatment (OMT) is evolving in the neonatal intensive care unit (NICU) setting. Studies showed its efficacy in length of stay and hospitalization costs reduction. Moreover, it was suggested that OMT has a modulatory effect on the preterm infants' autonomic nervous system (ANS), influencing saturation and heart rate. Even if OMT is based on the palpatory examination of the somatic dysfunctions (SD), there are controversies about its identification and clinical relevance. The objective of this study was to evaluate the inter-rater reliability, clinical characteristics, and functional correlation of the SD Grade score with the heart rate variability (HRV) and the salivary cortisol (sCor) using a multivariate linear model approach. To evaluate those features, we implemented an ad hoc SD examination for preterm infants that was performed by 2 trained osteopaths. It was based on the new variability model of SD that includes an SD Grade assessment procedure. The ANS features were assessed by frequency parameters of HRV studying high frequency (HF), low frequency (LF), and HF/LF, whereas sCor was tested with a radioimmunoassay. The ANS assessment was standardized and performed before SD testing. Sixty-nine premature infants were eligible. SD Grade showed excellent concordance between the blinded raters. Using SD Grade as a grouping variable, the infants presented differences in GA, Apgar, pathological findings, length of stay, and ventilatory assistance. In our multivariate model, HF, LF, and LF/HF resulted linearly correlated with SD Grade. Instead, sCor presented a linear correlation with 5' Apgar and respiratory distress syndrome but not with SD Grade. SD Grade was in line with the natural history of the underdevelopment due to prematurity. Our models indicate that the cardiac vagal tone is linearly related with SD Grade. This finding may improve the multidisciplinary decision making inside NICU and the management of modifiable factors, like SD, for cardiac vagal tone regulation.

Acute Effects of Increased Joint Mobilization Treatment Duration on Ankle Function and Dynamic Postural Control in Female Athletes With Chronic Ankle Instability

Background:

Chronic ankle instability (CAI) is linked to mechanical and functional insufficiencies. Joint mobilization is purported to be effective at treating these deficits.

Purpose:

To examine the effect of different treatment durations of a grade IV anterior-to-posterior ankle joint mobilization on weightbearing dorsiflexion range of motion (WB-DFROM), posterior talar glide (PG), and dynamic postural control in individuals with CAI.

Study Design:

Controlled laboratory study.

Methods:

A total of 48 female athletes (mean age, 22.8 ± 4.8 years) with unilateral CAI participated in this study. Participants were randomly assigned to 1 of 3 treatment conditions: 30 seconds, 60 seconds, and 120 seconds. Treatment was provided to the injured limb on 3 separate occasions 48 hours apart and consisted of a Maitland grade IV anterior-to-posterior talar joint mobilization based on the participant’s initial group assignment. WB-DFROM; PG; and the anterior (ANT), posteromedial (PM), and posterolateral (PL) reach directions of the Star Excursion Balance Test were measured bilaterally before and after each treatment. The uninjured limb acted as a control. Data were analyzed using 2-way mixed-model analyses of variance, and effect sizes were calculated through use of Hedges g.

Results:

Significant differences were detected after all treatment sessions for all outcome measures (P ≤ .001) and between treatment groups after sessions 1, 2, and 3 for all outcome measures (P ≤ .001). Effect sizes were very large or huge for all treatment groups for WB-DFROM, PG, and ANT reach direction. Substantial variation was found in effect sizes for PM and PL measures.

Conclusion:

Accessory mobilization is an effective treatment to induce acute changes in ankle motion and dynamic postural control in patients with CAI, with longer treatment durations conferring greater improvements.

Clinical Relevance:

This study adds clarity to the use of joint mobilization treatments and will add to the current clinical practice strategy for patients with CAI.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The intra-rater reliability of a revised 3-point grading system for accessory joint mobilizations

OBJECTIVES

Joint mobilizations are often quantified using a 4-point grading system based on the physiotherapist's detection of resistance. It is suggested that the initial resistance to joint mobilizations is imperceptible to physiotherapists, but that at some point through range becomes perceptible, a point termed R1. Grades of mobilization traditionally hinge around this concept and are performed either before or after R1. Physiotherapists, however, show poor reliability in applying grades of mobilization. The definition of R1 is ambiguous and dependent on the skills of the individual physiotherapist. The aim of this study is to test a revised grading system where R1 is considered at the beginning of range, and the entire range, as perceived by the physiotherapists maximum force application, is divided into three, creating 3 grades of mobilization.

METHOD

Thirty-two post-registration physiotherapists and nineteen pre-registration students assessed end of range (point R2) and then applied 3 grades of AP mobilizations, over the talus, in an asymptomatic models ankle. Vertical forces were recorded through a force platform. Intra-class Correlation Coefficients, Standard Error of Measurement, and Minimal Detectable Change were calculated to explore intra-rater reliability on intra-day and inter-day testing. T-tests determined group differences.

RESULTS

Intra-rater reliability was excellent for intra-day testing (ICC 0.96-0.97), and inter-day testing (ICC 0.85-0.93). No statistical difference was found between pre- and post-registration groups.

DISCUSSION

Standardizing the definition of grades of mobilization, by moving R1 to the beginning of range and separating grades into thirds, results in excellent intra-rater reliability on intra-day and inter-day tests.

LEVEL OF EVIDENCE

3b.

Study protocol for patient response to spinal manipulation - a prospective observational clinical trial on physiological and patient-centered outcomes in patients with chronic low back pain

Background

Low back pain (LBP) is a major health issue due to its high prevalence rate and socioeconomic cost. While spinal manipulation (SM) is recommended for LBP treatment by recently published clinical guidelines, the underlying therapeutic mechanisms remain unclear. Spinal stiffness is routinely examined and used in clinical decisions for SM delivery. It has also been explored as a predictor for clinical improvement. Flexion-relaxation phenomenon has been demonstrated to distinguish between LBP and healthy populations. The primary objective of the current study is to collect preliminary estimates of variability and effect size for the associations of these two physiological measures with patient-centered outcomes in chronic LBP patients. Additionally biomechanical characteristics of SM delivery are collected with the intention to explore the potential dose–response relationship between SM and LBP improvement.

Methods/Design

This is a prospective, observational study applying side-lying, high velocity, low amplitude SM as treatment for patients with LBP over a course of 6 weeks. Approximately 80 participants will be enrolled if they present with chronic LBP of 1, 2 or 3 in Quebec Task Force Classification for spinal disorders, a Roland-Morris Disability Questionnaire (RMDQ) score ≥ 6, and persistent LBP ≥ 2 with a maximum ≥ 4 using numerical rating scale. Patient-centered outcomes include LBP using visual analog scale, RMDQ, and PROMIS-29. Lumbar spine stiffness is assessed using palpation, a hand-held instrumented device, and an automated device. Flexion-relaxation is assessed using surface electromyography at the third level of the lumbar spine. Biomechanical characteristics of SM are assessed using a self-reported, itemized description system, as well as advanced kinetic measures that will be applied to estimate forces and moments at the lumbar segment level targeted by SM.

Discussion

Beside alterations in material properties of the passive components of the spine, increased neuromuscular activity may also contribute to a stiffened spine. Examining changes in both spinal stiffness and flexion-relaxation along the course of the treatment provides an opportunity to understand if the therapeutic effect of SM is associated with its action on active and/or passive components of the spine.

Trial registration

NCT01670292 on clinicaltrials.gov.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Performance and reliability of a variable rate, force/displacement application system

OBJECTIVE

Spinal manipulation therapy (SMT), an intervention used to treat low back pain, has been demonstrated to affect the stiffness of the spine. To adequately quantify the effects of SMT on stiffness, a device capable of applying specific parameters of manipulation in addition to measuring force-displacement values has been developed previously. Previously developed indentation techniques that quantify stiffness have been modified for novel use in evaluating SMT parameters. The reliability of stiffness measurements performed by the newly adapted device was assessed in this study.

METHODS

Seven springs of varying stiffness were each indented 10 times by a variable rate force/displacement (VRFD) device. Indentations were performed at a rate of 0.5 mm/s to a maximal displacement of 4 mm. The stiffness coefficients for a middle portion of the resulting force-displacement graph and the terminal instantaneous stiffness (stiffness at end displacement) were calculated. The intraclass correlation and confidence interval were calculated for these stiffness measurements to assess device reliability.

RESULTS

Repeated spring stiffness measures yielded an intraclass correlation coefficient value of 1.0. The mean stiffness values had narrow 95% confidence intervals ranging from 0.01 N/mm to 0.06 N/mm and small coefficients of variation.

CONCLUSION

This VRFD device provides highly reliable stiffness measurements in controlled conditions. Although in vivo reliability remains to be established, the results of this study support the use of the VRFD device in future trials investigating the impact of various SMT parameters on spinal stiffness.

Relation between changes in posteroanterior stiffness and active range of movement of the cervical spine following manual therapy treatment

STUDY DESIGN

Repeated measures study of active and passive movements in patients with neck pain.

OBJECTIVES

To determine if, following manual therapy: (1) changes occur in active range of movement (AROM) and stiffness of posteroanterior (PA) movements, (2) such changes are dependent on the location treated, and (3) there is a relation between changes in PA stiffness and AROM.

SUMMARY OF BACKGROUND DATA

PA movements are frequently used to assess patients with neck pain but little is known about how these movements are related to patient symptoms.

METHODS

One location deemed symptomatic and hypomobile and 1 asymptomatic location were selected in 20 patients with neck pain for more than 2 weeks. PA stiffness at each location and AROM were measured before and after each of 4 manual therapy interventions: PA movements to each location, a general treatment, and a control intervention.

RESULTS

The general intervention had a greater increase in each axis of AROM than the other interventions (F = 2.814 to 7.929, DF = 3) but there were no differences in PA stiffness across interventions (F = 0.945, DF = 3). Differences in PA stiffness was divided into regions by applied force. After treatment to the symptomatic location, regions of stiffness at forces above 8 N demonstrated significant correlations with total AROM (R = -0.466 to -0.628).

CONCLUSION

After manual therapy, increased AROM is related to decreased PA stiffness in patients with neck pain, but only for the treated location and only when that location had been identified previously as symptomatic and hypomobile.

Force-displacement relationship during anteroposterior mobilization of the ankle joint

OBJECTIVE

The purpose of this study was to determinate the correlation between force and displacement during passive anteroposterior mobilization of the talus and the effect of this treatment technique on ankle dorsiflexion range of motion (ROM).

METHODS

This is an exploratory, methodological study. Maitland grades III and IV mobilization were applied on the right ankle of 25 healthy subjects (mean age +/- standard deviation, 25.08 +/- 3.01 years) by 2 randomized raters (A and B). Applied forces were measured using a small force plate and displayed for the rater on a computer monitor. Linear displacement of the ankle joint was quantified by a motion analysis system. Synchronization of these 2 systems was obtained by software. Dorsiflexion active ROM, before and after mobilization, was assessed using a biplane goniometer. Statistical analysis was performed using the Pearson correlation coefficient for force and displacement variables and the paired t test to compare dorsiflexion ROM mean values.

RESULTS

A fair positive correlation was found between force range and displacement (r = 0.370; P = .049, 1-tailed), and a fair negative correlation was found between minimum forces and displacement (r = 0.404; P = .035, 1-tailed), only for rater A data. Significant increase in dorsiflexion was found in the right ankle (P = .035), comparing ROM before and after mobilization, which did not occur in the left ankle.

CONCLUSIONS

These data do not support a linear force-displacement relationship during Maitland grades III and IV passive joint mobilization, although they confirmed an increase in ankle dorsiflexion ROM immediately after joint mobilization. The use of visual feedback may increase interrater reliability of forces applied during ankle joint mobilization.

Intertester reliability and validity of motion assessments during lumbar spine accessory motion testing

BACKGROUND AND PURPOSE

Posterior-anterior (PA) assessment of the lumbar spine correlates with radiographic signs of instability and can guide treatment choices, yet studies of the validity of lumbar PA assessments have not been conducted in vivo. The purposes of this study were to determine the intertester reliability of the PA examination in assessing intersegmental lumbar spine motion and to evaluate the validity of this procedure in vivo with dynamic magnetic resonance imaging (MRI).

SUBJECTS

Twenty-nine subjects with central lumbar pain participated in this study.

METHODS

Two physical therapists independently identified each subject's most and least mobile lumbar segments using the PA procedure. Midsagittal lumbar images were obtained simultaneously during one examiner's assessment. Lumbar segmental mobility was quantified from magnetic resonance images as the change in the intervertebral angle between the resting position and the end range of the PA force application. For each vertebral level tested, maximal sagittal-plane segmental motion was determined.

RESULTS

The intertester reliability for identifying the least mobile segment was good (agreement=82.8%, kappa=.71, 95% confidence interval [CI]=.48 to .94), but it was poor for identifying the most mobile segment (kappa=.29, 95% CI=-.13 to .71), despite good agreement (79.3%). The level of agreement between the PA assessments and intervertebral motion measured by MRI was poor (kappa=.04, 95% CI=-.16 to .24, and kappa=.00, 95% CI=-.09 to .08, for the least and most mobile segments, respectively).

DISCUSSION AND CONCLUSION

Despite good intertester reliability for identifying the least mobile segment, PA assessments of lumbar segmental mobility did not agree with sagittal-plane motion measured by dynamic MRI. This finding calls into question the validity of the PA procedure for assessing intervertebral lumbar spine motion.

Study of the force applied during anteroposterior articular mobilization of the talus and its effect on the dorsiflexion range of motion

OBJECTIVE

The aim of this study was to investigate the behavior of the force applied during the Maitland grade III anteroposterior joint mobilization of the talus and its effect on dorsiflexion range of motion (ROM).

METHODS

Two examiners performed measurements of dorsiflexion ROM on both ankles of healthy volunteers using a universal goniometer. The anteroposterior talus mobilization was first applied by examiner A for 30 seconds. Examiner B then repeated the same procedure. A platform was placed under the volunteer's leg to register the forces obtained during mobilization. After the procedure, examiner A assessed the ankle dorsiflexion.

RESULTS

The results showed consistency regarding maximal forces applied throughout the 30 seconds of mobilization as well as low consistency upon the minimal forces. A significant increase in dorsiflexion ROM of the ankle was found immediately after joint mobilization.

CONCLUSIONS

The results of the present study have shown consistent maximal forces applied by one examiner and inconsistent minimal forces during an ankle mobilization in healthy volunteers when the same examiner was compared. Moreover, the applied force was able to increase dorsiflexion ROM after the Maitland grade III anteroposterior mobilization of the talus.