Does inter-vertebral range of motion increase after spinal manipulation? A prospective cohort study
TL;DR: There was a modest dose-response relationship between the number of manipulations given and number of levels increasing IV-RoM - providing evidence that neck manipulation has a mechanical effect at segmental levels, however, patient-reported outcomes were not related to this.
Abstract: Background: Spinal manipulation for nonspecific neck pain is thought to work in part by improving inter-vertebral range of motion (IV-RoM), but it is difficult to measure this or determine whether it is related to clinical outcomes. Objectives: This study undertook to determine whether cervical spine flexion and extension IV-RoM increases after a course of spinal manipulation, to explore relationships between any IV-RoM increases and clinical outcomes and to compare palpation with objective measurement in the detection of hypo-mobile segments. Method: Thirty patients with nonspecific neck pain and 30 healthy controls matched for age and gender received quantitative fluoroscopy (QF) screenings to measure flexion and extension IV-RoM (C1-C6) at baseline and 4-week follow-up between September 2012-13. Patients received up to 12 neck manipulations and completed NRS, NDI and Euroqol 5D-5L at baseline, plus PGIC and satisfaction questionnaires at follow-up. IV-RoM accuracy, repeatability and hypo-mobility cut-offs were determined. Minimal detectable changes (MDC) over 4 weeks were calculated from controls. Patients and control IV-RoMs were compared at baseline as well as changes in patients over 4 weeks. Correlations between outcomes and the number of manipulations received and the agreement (Kappa) between palpated and QF-detected of hypo-mobile segments were calculated. Results: QF had high accuracy (worst RMS error 0.5o) and repeatability (highest SEM 1.1o, lowest ICC 0.90) for IV-RoM measurement. Hypo-mobility cut offs ranged from 0.8o to 3.5o. No outcome was significantly correlated with increased IV-RoM above MDC and there was no significant difference between the number of hypo-mobile segments in patients and controls at baseline or significant increases in IV-RoMs in patients. However, there was a modest and significant correlation between the number of manipulations received and the number of levels and directions whose IV-RoM increased beyond MDC (Rho=0.39, p=0.043). There was also no agreement between palpation and QF in identifying hypo-mobile segments (Kappa 0.04-0.06). Conclusions: This study found no differences in cervical sagittal IV-RoM between patients with non-specific neck pain and matched controls. There was a modest dose-response relationship between the number of manipulations given and number of levels increasing IV-RoM - providing evidence that neck manipulation has a mechanical effect at segmental levels. However, patient-reported outcomes were not related to this.
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TL;DR: Some types of mobilizations probably produce an immediate and short-term, statistically significant increase in skin sympathetic nerve activity when compared to a sham procedure, whereas spinal SNAGs and spinal HVLA techniques may have no acute effect on the studied markers of ANS activity.
Abstract: The autonomic nervous system (ANS) interests many chiropractors and manual therapists, because joint manipulative techniques (JMT), e.g. high velocity low amplitude (HVLA) manipulations and mobilizations, appear to produce acute changes in ANS mediated physiology. The complexity of this issue justifies a systematic critical literature review. To review the literature comparing the acute changes in markers of ANS activity between JMT applied on spinal or peripheral joints and a sham procedure in healthy or symptomatic subjects. We searched PsycINFO, PEDro, PubMed, Cochrane library, EMBASE, and Medline up to December 2017. We updated the search with PubMed, Cochrane library, EMBASE, and Medline including July 2018. Inclusion criteria were: randomized sham-controlled trials assessing the effect of JMT on markers of ANS activity; manually applied JMT, regardless of technique, applied on either healthy or symptomatic humans; outcome measurements recorded at baseline and repeated during and/or after interventions. Selection of articles and data extraction were performed independently by two reviewers. The quality of studies was assessed using the Cochrane ‘risk of bias’ tool and a technical check-list. Results were reported narratively with some meta-analyses. The Cochrane GRADE approach was used to assess the certainty of evidence. Twenty-nine of 2267 studies were included in the synthesis. Mobilizations (oscillatory technique) probably produce an immediate and short-term, bilateral increase in skin sympathetic nerve activity (reflected by an increase in skin conductance) regardless of the area treated (moderate-certainty evidence). It is uncertain whether the sympathetic arousal also explains an increase in respiratory rate (very low-certainty evidence). Our evaluation of the literature suggests that spinal sustained apophyseal glides (SNAGs) mobilization and HVLA manipulation of the spine may have no acute effect on the studied markers of ANS activity (very low- to low-certainty evidence). Some types of mobilizations probably produce an immediate and short-term, statistically significant increase in skin sympathetic nerve activity when compared to a sham procedure, whereas spinal SNAGs and spinal HVLA techniques may have no acute effect on the studied markers of ANS activity. No region-specific results were noted. The literature suffers from several shortcomings, for which reason we strongly suggest further research.
26 citations
TL;DR: This study found no difference in cervical lordosis (sagittal alignment) between patients with mild non-specific neck pain and matched healthy volunteers and there was no significant change in lordosis in patients after 4 weeks of cervical spinal manipulation.
Abstract: The association between cervical lordosis (sagittal alignment) and neck pain is controversial. Further, it is unclear whether spinal manipulative therapy can change cervical lordosis. This study aimed to determine whether cervical lordosis changes after a course of spinal manipulation for non-specific neck pain. Posterior tangents of C2 and C6 were drawn on the lateral cervical fluoroscopic images of 29 patients with subacute/chronic non-specific neck pain and 30 healthy volunteers matched for age and gender, recruited August 2011 to April 2013. The resultant angle was measured using ‘Image J’ digital geometric software. The intra-observer repeatability (measurement error and reliability) and intra-subject repeatability (minimum detectable change (MDC) over 4 weeks) were determined in healthy volunteers. A comparison of cervical lordosis was made between patients and healthy volunteers at baseline. Change in lordosis between baseline and 4-week follow-up was determined in patients receiving spinal manipulation. Intra-observer measurement error for cervical lordosis was acceptable (SEM 3.6°) and reliability was substantial ICC 0.98, 95 % CI 0.962–0991). The intra-subject MDC however, was large (13.5°). There was no significant difference between lordotic angles in patients and healthy volunteers (p = 0.16). The mean cervical lordotic increase over 4 weeks in patients was 2.1° (9.2) which was not significant (p = 0.12). This study found no difference in cervical lordosis (sagittal alignment) between patients with mild non-specific neck pain and matched healthy volunteers. Furthermore, there was no significant change in cervical lordosis in patients after 4 weeks of cervical spinal manipulation.
18 citations
Cites background from "Does inter-vertebral range of motio..."
...Seven patients reported using hot or cold packs during the study period, and 18 used over the counter pain-relieving medication [22]....
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...spective cohort study [22] (the ‘parent study’) investigating the effect of spinal manipulation on inter-vertebral...
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TL;DR: The results suggest that a single SM of the thoracic spine has no specific effect on cardiovascular autonomic activity and the relationship between autonomic outcomes and pressure pain threshold after the SM is found.
Abstract: The autonomic nervous system interacts with the pain system. Knowledge on the effects of high velocity low amplitude spinal manipulations (SM) on autonomic activity and experimentally induced pain is limited. In particular, the effects of SM on autonomic activity and pain beyond the immediate post intervention period as well as the relationship between these two outcomes are understudied. Thus, new research is needed to provide further insight on this issue. The aim was to assess the effect of a single SM (i.e. SM vs. sham) on cardiovascular autonomic activity. Also, we assessed the relationship between cardiovascular autonomic activity and level of pain threshold after the interventions. We conducted a randomized, cross-over, sham-controlled trial on healthy first-year chiropractic students comprising two experimental sessions separated by 48 h. During each session, subjects received, in a random order, either a thoracic SM or a sham manipulation. Cardiovascular autonomic activity was assessed using heart rate and systolic blood pressure variabilities. Pain sensitivity was assessed using pressure pain threshold. Measurements were performed at baseline and repeated three times (every 12 min) during the post intervention period. Participants and outcome assessors were blinded. The effect of the SM was tested with linear mixed models. The relationship between autonomic outcomes and pressure pain threshold was tested with bivariate correlations. Fifty-one participants were included, forty-one were finally analyzed. We found no statistically significant difference between SM and sham in cardiovascular autonomic activity post intervention. Similarly, we found no post-intervention relationship between cardiovascular autonomic activity and pressure pain threshold. Our results suggest that a single SM of the thoracic spine has no specific effect on cardiovascular autonomic activity. Also, we found no relationship between cardiovascular autonomic activity and pressure pain threshold after the SM. Further experimental research should consider the use of several markers of autonomic activity and a more comprehensive pain assessment. N° NCT03273868. Registered September 6, 2017.
15 citations
Cites background from "Does inter-vertebral range of motio..."
...For instance, the effects of spinal manipulative techniques have been explored using biomechanical [5, 6] and neurophysiological outcomes, in the latter case studying e....
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TL;DR: Quantitative fluoroscopy was found to have a high level of accuracy and with a few exceptions, moderate to substantial repeatability for the measurement of translation and FCR from fluoroscopic motion sequences.
13 citations
TL;DR: This is the first report of quantified anti-directional cervical flexion and extension motion and it document that large proportions of anti- Directional cervical Flexion and Extension motions were normal.
13 citations
Cites background from "Does inter-vertebral range of motio..."
...Comparing ratios of anti-directional joint motion of joints between flexion and extension showed there was a significant interaction between movement and joints (Mixed ANOVA: F [6, 119] = 8....
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...Video-fluoroscopy has previously been reported reliable for in vivo investigation of spine kinematics [4,6,24]....
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...Cervical anti-directional motion Anti-directional joint motions have previous been reported for cervical joints; however the reports have not given quantified descriptions [6,10,12]....
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...anti- and pro-directional motions (ANOVA: F [6, 119] = 10....
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...The upper cervical joints (C0/C1, C1/C2, C2/C3) showed higher ratios of antidirectional motions compared with lower cervical joints (C4/C5, C5/C6, and C6/C7) (ANOVA: F [6, 119] = 14....
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References
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TL;DR: The prevalence and incidence of work absenteeism involving neck pain in a cohort of claimants to the Ontario Workplace Safety & Insurance Board in 1998 is measured and the importance of properly capturing all neck pain cases is highlighted.
Abstract: Study design Cohort study. Objective To measure the prevalence and incidence of work absenteeism involving neck pain in a cohort of claimants to the Ontario Workplace Safety & Insurance Board (WSIB). Summary of background data According to workers' compensation statistics, neck pain accounts for a small proportion of lost-time claims. However, these statistics may be biased by an underenumeration of claimants with neck disorders. Methods We studied all lost-time claimants to the Ontario WSIB in 1998 and used 2 methods to enumerate neck pain cases. We report the prevalence and incidence of neck pain using 2 denominators: (1) annual number of lost-time claimants and (2) an estimate of the Ontario working population covered by the WSIB. Results The estimated percentage of lost-time claimants with neck pain ranged from 2.8% (95% CI 2.5-3.3) using only codes specific for neck pain to 11.3% (95% CI 9.5-13.1) using a weighted estimate of codes capturing neck pain cases. The health care sector had the highest percentage of claims with neck pain. The annual incidence of neck pain among the Ontario working population ranged from 6 per 10,000 full-time equivalents (FTE) (95% CI 5-6) to 23 per 10,000 FTE (95% CI 20-27) depending on the codes used to capture neck pain. Male workers between the ages of 20 and 39 years were the most likely to experience an episode of work absenteeism involving neck pain. Conclusion Neck pain is a common and burdensome problem for Ontario workers. Our study highlights the importance of properly capturing all neck pain cases when describing its prevalence and incidence.
126 citations
"Does inter-vertebral range of motio..." refers background in this paper
...The condition can also be a significant cause of work absence [2,3], decreased productivity [4] and increased healthcare costs [5]....
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TL;DR: The best available evidence suggests initial assessment for neck pain should focus on triage into 4 grades, and those with common neck pain might be offered the listed noninvasive treatments if short-term relief is desired.
106 citations
"Does inter-vertebral range of motio..." refers background in this paper
...Spinal manipulation, mobilisation, exercise, analgesics, acupuncture and low level laser therapy have all been shown to provide at least some degree of short-term relief of neck pain in the absence of trauma [6]....
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TL;DR: Age was associated with declining ROM independent of degeneration, amounting to a 5° decrease in subaxial cervical ROM every 10 years and gender had a significant association with ROM only at C2–C3.
Abstract: Study design Retrospective review and multivariate analysis. Objective Assess cervical spine segmental range of motion (ROM) with flexion/extension (F/E) radiographs and determine the relation to clinical variables. Summary of background data Previous studies investigated the roles of age and degeneration on cervical ROM with univariate analyses. Multivariate analyses are required to account for multiple factors that may affect ROM and quantify their relative effects. Methods Radiographs of 195 patients were analyzed, including 133 females and 62 males with ages ranging from 15 to 93 years. Segmental ROM and Kellgren score (KS) of degeneration were assessed for C2-C7. Patient's age and gender were documented. Multivariate analyses were performed for each level. Independent variables evaluated were: (1) KS at the level of interest, (2) KS at the level above, (3) KS at the level below, (4) age, and (5) gender. Significance was defined as P Results Interobserver reliabilities for assessing KS (intraclass correlation coefficient 0.81) and segmental ROM (intraclass correlation coefficient 0.72) were good to excellent. Age had a significant negative association with ROM at C2-C3, C3-C4, C4-C5, and C5-C6. KS at the level of interest had a significant negative association with ROM at C2-C3, C3-C4, C4-C5, C5-C6, and C6-C7. KS at the inferior segment had a significant positive association with ROM at C2-C3, C3-C4, and C4-C5. Gender had a significant association with ROM only at C2-C3. Conclusion Age was associated with declining ROM independent of degeneration, amounting to a 5 degrees decrease in subaxial cervical ROM every 10 years. Degeneration was also associated with ROM. For every point increase in KS at a given level, there was an associated 1.2 degrees decrease in ROM at that level, and a 0.8 degrees increase in ROM at the level above. These results provide a framework with which to counsel patients about cervical ROM and a benchmark from which procedure specific changes can be compared.
93 citations
TL;DR: The present findings will assist in the choice of outcome measures in trials on neck pain and illustrate a methodologic framework for interpreting change scores in terms of clinical improvement, facilitating the process of making sense of research data in the clinical setting.
Abstract: Study Design.Prospective, single-cohort study.Objective.To determine the relative sensitivity of a range of outcome measures used in evaluating treatment interventions in patients with neck pain and the magnitude of change scores on the neck Bournemouth Questionnaire and the cutoff score on the Pati
88 citations
"Does inter-vertebral range of motio..." refers methods in this paper
...These, plus the Patient Global Impression of Change (PGiC) [28,29] were completed again at 4 weeks along with a single satisfaction question [30]....
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TL;DR: Some conservative interventions for neck pain are effective in the short term, and few interventions that have been investigated have shown longer term effects that are better than placebo or minimal intervention.
83 citations