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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01 Dec 2003
TL;DR: Head rotation, defined in this paper as the rotation angle around the instantaneous helical axis (IHA), is used for extracting a number of variables (e.g., angular velocity and range, symmetry of motion).
Abstract: This paper presents an assessment tool for objective neck movement analysis of subjects suffering from chronic whiplash-associated disorders (WAD). Three-dimensional (3-D) motion data is collected by a commercially available motion analysis system. Head rotation, defined in this paper as the rotation angle around the instantaneous helical axis (IHA), is used for extracting a number of variables (e.g., angular velocity and range, symmetry of motion). Statistically significant differences were found between controls and subjects with chronic WAD in a number of variables.
50 citations
TL;DR: The EDI-320 is shown to be a moderately reliable instrument for quantifying cervical flexion and extension range of motion and the presence of systematic error in the study highlights the importance of following standardized procedures and suggests that the EDi-320 could be more reliable than reported in this study.
48 citations
"Does inter-vertebral range of motio..." refers methods in this paper
...Participants completed a warm-up of 5 flexion-extension repetitions to reduce range variability [31] followed by recording of their maximum comfortable flexion and extension ranges using the CROM instrument (Performance Attainment Associates Inc....
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TL;DR: A significantly reduced ROM was found in all movements in WH subjects compared with an age-matched population, and the computerized study of neck ROM may constitute a useful tool in the evaluation of WH at baseline and follow-up.
Abstract: In recent decades whiplash injuries, being a major reason for compensation claims, have become increasingly important in forensic medicine. In view of this, a reliable diagnostic method of assessing cervical range of motion (ROM) is needed. The aim of the present study was to evaluate neck function with a 3D kinematic method compared with clinical evaluation in whiplash injury. Seventy consecutive patients (M/F = 18/52) with a history of whiplash injury (WH) and 46 healthy volunteers (M/F = 24/22), mean age, respectively 33 +/- 9 and 28 +/- 6 years (mean+/-SD) entered the study. Patients suffered from neck pain and/or unilateral headache. A computerized kinematic analysis of the ROM (Elite system) using passive markers and two infrared TV cameras was used. Clinical evaluation of active ROM was also performed both in patients and in 61 controls (M/F = 23/38; mean age 47 +/- 18 years). Thirty out of 70 patients were tested at the time of their first consultation (T0) and 6 months later (T6), and 12 were also followed up after a year (T12). All neck movements, except extension, were significantly reduced in WH subjects compared with controls, in particular lateral bending. Comparing ROM at T0, T6 and T12, no significant differences were found. A global index of motion (GIM), obtained by calculating the sum of ROM in absolute value for all the movements acquired, was significantly reduced in WH compared with control subjects. The interobserver reliability of the clinical evaluation was globally acceptable. On the basis of the clinical evaluation, a significantly reduced ROM was found in all movements in WH subjects compared with an age-matched population. Computing the number of impaired cervical movements (ICMs), a significantly higher number was observed in WH patients than in controls, showing a decreasing trend at T6 and T12, with a significant improvement at T6 vs. T0. The computerized study of neck ROM may constitute a useful tool in the evaluation of WH at baseline and follow-up.
47 citations
TL;DR: The Forum recommended that images should be acquired during regular trunk motion that is controlled for velocity and range, in order to minimise externally imposed variability as well as to correlate intervertebral motion with trunk motion.
Abstract: Quantitative fluoroscopy (QF) is an emerging technology for measuring intervertebral motion patterns to investigate problem back pain and degenerative disc disease. This International Forum was a networking event of three research groups (UK, US, Hong Kong), over three days in San Francisco in August 2009. Its aim was to reach a consensus on how best to record, analyse, and communicate QF information for research and clinical purposes. The Forum recommended that images should be acquired during regular trunk motion that is controlled for velocity and range, in order to minimise externally imposed variability as well as to correlate intervertebral motion with trunk motion. This should be done in both the recumbent passive and weight bearing active patient configurations. The main recommended outputs from QF were the true ranges of intervertebral rotation and translation, neutral zone laxity and the consistency of shape of the motion patterns. The main clinical research priority should initially be to investigate the possibility of mechanical subgroups of patients with chronic, nonspecific low back pain by comparing their intervertebral motion patterns with those of matched healthy controls.
45 citations
"Does inter-vertebral range of motio..." refers background or methods in this paper
...This generated positional information for each vertebra and automatically calculated inter-vertebral rotations using a method similar to that used in the lumbar spine [18]....
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...However, during the last decade considerable progress has been made with detailed measurement of inter-vertebral motion using quantitative fluoroscopy (QF) [18]....
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Journal Article•
39 citations
"Does inter-vertebral range of motio..." refers background or methods in this paper
...Furthermore, spinal manipulation targets specific levels, often to improve inter-vertebral range of motion (IV-RoM) [15], but it is not known if this actually happens, or if reduced IV-RoM is even detectable by clinical examination (palpation)....
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...These consisted of high velocity, low amplitude (HVLA) manipulation of the cervical spine using diversified techniques [15]....
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