Does inter-vertebral range of motion increase after spinal manipulation? A prospective cohort study.

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

Proportional lumbar spine inter-vertebral motion patterns: a comparison of patients with chronic, non-specific low back pain and healthy controls

Introduction: Identifying biomechanical subgroups in chronic, non-specific low back pain (CNSLBP) populations from inter-vertebral displacements has proven elusive. Quantitative fluoroscopy (QF) has excellent repeatability and provides continuous standardised inter-vertebral kinematic data from fluoroscopic sequences allowing assessment of mid-range motion. The aim of this study was to determine whether proportional continuous IV rotational patterns were different in patients and controls. A secondary aim was to update the repeatability of QF measurement of range of motion (RoM) for inter-vertebral (IV) rotation

Sagittal jaw position in relation to body posture in adult humans – a rasterstereographic study

BACKGROUND: The correlations between the sagittal jaw position and the cranio – cervical inclination are described in literature. Only few studies focus on the sagittal jaw position and the body posture using valid and objective orthopaedic examination methods. The aim of this study was to test the hypothesis that patients with malocclusions reveal significant differences in body posture compared to those without (upper thoracic inclination, kyphotic angle, lordotic angle and lower lumbar inclination). METHODS: Eighty-four healthy adult patients (with a mean age = 25.6 years and ranging from 16.1 to 55.8 years) were examined with informed consent. The orthodontic examination horizontal overjet (distance between upper and lower incisors) was determined by using an orthodontic digital sliding calliper. The subjects were subdivided in respect of the overjet with the following results: 18 revealed a normal overjet (Class I), 38 had an increased overjet (Class II) and 28 had an reversed overjet (Class III). Rasterstereography was used to carry out a three – dimensional back shape analysis. This method is based on photogrammetry. A three-dimensional shape was produced by analysing the distortion of parallel horizontal white light lines projected on the patient's back, followed by mathematical modelling. On the basis of the sagittal profile the upper thoracic inclination, the thoracic angle, the lordotic angle and the pelvic inclination were determined with a reported accuracy of 2.8° and the correlations to the sagittal jaw position were calculated by means of ANOVA, Scheffé and Kruskal-Wallis procedures. RESULTS: Between the different overjet groups, no statistically significant differences or correlations regarding the analysed back shape parameters could be obtained. However, comparing males and females there were statistically significant differences in view of the parameters 'lordotic angle' and 'pelvic inclination'. CONCLUSION: No correlations between overjet and variables of the thoracic, lordotic or the pelvic inclination could be observed

Lumbar segmental mobility disorders: comparison of two methods of defining abnormal displacement kinematics in a cohort of patients with non-specific mechanical low back pain

BACKGROUND: Lumbar segmental rigidity (LSR) and lumbar segmental instability (LSI) are believed to be associated with low back pain (LBP), and identification of these disorders is believed to be useful for directing intervention choices. Previous studies have focussed on lumbar segmental rotation and translation, but have used widely varying methodologies. Cut-off points for the diagnosis of LSR & LSI are largely arbitrary. Prevalence of these lumbar segmental mobility disorders (LSMDs) in a non-surgical, primary care LBP population has not been established. METHODS: A cohort of 138 consecutive patients with recurrent or chronic low back pain (RCLBP) were recruited in this prospective, pragmatic, multi-centre study. Consenting patients completed pain and disability rating instruments, and were referred for flexion-extension radiographs. Sagittal angular rotation and sagittal translation of each lumbar spinal motion segment was measured from the radiographs, and compared to a reference range derived from a study of 30 asymptomatic volunteers. In order to define reference intervals for normal motion, and define LSR and LSI, we approached the kinematic data using two different models. The first model used a conventional Gaussian definition, with motion beyond two standard deviations (2sd) from the reference mean at each segment considered diagnostic of rotational LSMD and translational LSMD. The second model used a novel normalised within-subjects approach, based on mean normalised contribution-to-total-lumbar-motion. An LSMD was then defined as present in any segment that contributed motion beyond 2sd from the reference mean contribution-to-normalised-total-lumbar-motion. We described reference intervals for normal segmental mobility, prevalence of LSMDs under each model, and the association of LSMDs with pain and disability. RESULTS: With the exception of the conventional Gaussian definition of rotational LSI, LSMDs were found in statistically significant prevalences in patients with RCLBP. Prevalences at both the segmental and patient level were generally higher using the normalised within-subjects model (2.8 to 16.8% of segments; 23.3 to 35.5% of individuals) compared to the conventional Gaussian model (0 to 15.8%; 4.7 to 19.6%). LSMDs are associated with presence of LBP, however LSMDs do not appear to be strongly associated with higher levels of pain or disability compared to other forms of non-specific LBP. CONCLUSION: LSMDs are a valid means of defining sub-groups within non-specific LBP, in a conservative care population of patients with RCLBP. Prevalence was higher using the normalised within-subjects contribution-to-total-lumbar-motion approach

Clinimetric evaluation of active range of motion measures in patients with non-specific neck pain: a systematic review

The study is to provide a critical analysis of the research literature on clinimetric properties of instruments that can be used in daily practice to measure active cervical range of motion (ACROM) in patients with non-specific neck pain. A computerized literature search was performed in Medline, Cinahl and Embase from 1982 to January 2007. Two reviewers independently assessed the clinimetric properties of identified instruments using a criteria list. The search identified a total of 33 studies, investigating three different types of measurement instruments to determine ACROM. These instruments were: (1) different types of goniometers/inclinometers, (2) visual estimation, and (3) tape measurements. Intra- and inter-observer reliability was demonstrated for the cervical range of motion instrument (CROM), Cybex electronic digital instrument (EDI-320) and a single inclinometer. The presence of agreement was assessed for the EDI-320 and a single inclinometer. The CROM received a positive rating for construct validity. When clinical acceptability is taken into account both the CROM and the single inclinometer can be considered appropriate instruments for measuring the active range of motion in patients with non-specific neck pain in daily practice. Reliability is the aspect most frequently evaluated. Agreement, validity and responsiveness are documented less frequently

An in-vivo study exploring correlations between early-to-moderate disc degeneration and flexion mobility in the lumbar spine

Purpose: Early disc degeneration (DD) has been thought to be associated with loss of spine 6 stability. However, before this can be understood in relation to back pain, it is necessary to 7 know the relationship between DD and intervertebral motion in people without pain. This 8 study aimed to find out if early to moderate DD is associated with intervertebral motion in 9 people without back pain. 10 Methods: Ten pain free adults, aged 51-71 received recumbent and weight bearing MRI 11 scans and quantitative fluoroscopy (QF) screenings during recumbent and upright lumbar 12 flexion. Forty individual level and 10 composite (L2-S1) radiographic and MRI DD gradings 13 were recorded and correlated with intervertebral flexion ROM, translation, laxity, and 14 motion sharing inequality and variability for both positions. 15 Results: Kinematic values were similar to previous control studies. DD was evidenced up to 16 moderate levels by both radiographic and MRI grading. Disc height loss correlated slightly, 17 but negatively with flexion during weight bearing flexion (R=-0.356, p=0.0.025). Composite 18 MRI DD and T2 signal loss evidenced similar relationships (R= -0.305, R= -0.267) but did not 19 reach statistical significance (p=0.056, p=0.096). No significant relationships between any 20 other kinematic variables and DD were found. 21 Conclusion: This study found only small, indefinite associations between early-to-moderate 22 DD and intervertebral motion in healthy controls. Motion sharing in the absence of pain 23 was also not related to early DD, consistent with previous control studies. Further research 24 is needed to investigate these relationships in patients. 25 Key words: back pain, disc degeneration, instability, imagin

Intra-subject repeatability of in vivo intervertebral motion parameters using quantitative fluoroscopy.

Purpose: In vivo quantification of intervertebral motion through imaging has progressed to a point where biomarkers for low back pain are emerging. This makes possible deeper study of the condition’s biometrics. However, the measurement of change over time involves error. The purpose of this prospective investigation is to determine the intra-subject repeatability of six in vivo intervertebral motion parameters using quantitative fluoroscopy. Methods: Intra-subject reliability (ICC) and minimal detectable change (MDC) of baseline to 6-week follow-up measurements were calculated for 6 lumbar spine intervertebral motion parameters in 109 healthy volunteers. A standardised quantitative fluoroscopy (QF) protocol was used to provide measurements in the coronal and sagittal planes using both passive recumbent and active weight bearing motion. Parameters were: intervertebral range of motion (IV-RoM), laxity, motion sharing inequality (MSI), motion sharing variability (MSV), flexion translation, and anterior disc height change during flexion. Results: The best overall intra subject reliability (ICC) and agreement (MDT) were for disc height (ICC 0.89, MDC 43%) and IV-RoM (ICC 0.96, MDC 60%) and the worst for MSV (ICC 0.04, MCD 408%). Laxity, MSI and translation had acceptable reliability (most ICCs >0.60), but not agreement (MDC >85%). Conclusion: Disc height and IV-RoM measurement using QF could be considered for randomised trials while laxity, MSI and translation could be considered for moderators, correlates or mediators of patient reported outcomes. MSV had both poor reliability and agreement over 6 weeks