Efficacy of manual therapy treatments for people with cervicogenic dizziness and pain : Protocol of a randomised controlled trial

BACKGROUND: Cervicogenic dizziness is a disabling condition characterised by postural unsteadiness that is aggravated by cervical spine movements and associated with a painful and/or stiff neck. Two manual therapy treatments (Mulligan’s Sustained Natural Apophyseal Glides (SNAGs) and Maitland’s passive joint mobilisations) are used by physiotherapists to treat this condition but there is little evidence from randomised controlled trials to support their use. The aim of this study is to conduct a randomised controlled trial to compare these two forms of manual therapy (Mulligan glides and Maitland mobilisations) to each other and to a placebo in reducing symptoms of cervicogenic dizziness in the longer term and to conduct an economic evaluation of the interventions. METHODS: Participants with symptoms of dizziness described as imbalance, together with a painful and/or stiff neck will be recruited via media releases, advertisements and mail-outs to medical practitioners in the Hunter region of NSW, Australia. Potential participants will be screened by a physiotherapist and a neurologist to rule out other causes of their dizziness. Once diagnosed with cervciogenic dizziness, 90 participants will be randomly allocated to one of three groups: Maitland mobilisations plus range-of-motion exercises, Mulligan SNAGs plus self-SNAG exercises or placebo. Participants will receive two to six treatments over six weeks. The trial will have unblinded treatment but blinded outcome assessments. Assessments will occur at baseline, post-treatment, six weeks, 12 weeks, six months and 12 months post treatment. The primary outcome will be intensity of dizziness. Other outcome measures will be frequency of dizziness, disability, intensity of cervical pain, cervical range of motion, balance, head repositioning, adverse effects and treatment satisfaction. Economic outcomes will also be collected. DISCUSSION: This paper describes the methods for a randomised controlled trial to evaluate the effectiveness of two manual therapy techniques in the treatment of people with cervicogenic dizziness for which there is limited established evidence-based treatment. TRIAL REGISTRATION: ACTRN1261100007390

The effect of end-range cervical rotation on vertebral and internal carotid arterial blood flow and cerebral inflow: a sub analysis of an MRI study

Introduction: Cervical spine manual therapy has been associated with a small risk of serious adverse neurovascular events, particularly to the vertebral arteries. Sustained end-range rotation is recommended clinically as a pre-manipulative screening tool; however ultrasound studies have yielded conflicting results about the effect of rotation on blood flow in the vertebral arteries. There has been little research on internal carotid arterial flow or utilising the reference standard of angiography. Objectives: To evaluate the mean effect of cervical rotation on blood flow in the craniocervical arteries and blood supply to the brain, as well as individual variation. Design: This was an observational study. Method: Magnetic resonance angiography was used to measure average blood flow volume in the vertebral arteries, internal carotid arteries, and total cerebral inflow, in three neck positions: neutral, end-range left rotation and end-range right rotation in healthy adults. Results: Twenty participants were evaluated. There was a decrease in average blood flow volume in the vertebral and internal carotid arteries on contralateral rotation, compared to neutral. This was statistically significant on left rotation only. Ipsilateral rotation had no effect on average blood flow volume in any artery. Total cerebral inflow was not significantly affected by rotation in either direction. Conclusions: It appears that in healthy adults the cerebral vasculature can compensate for decreased flow in one or more arteries by increasing flow in other arteries, to maintain cerebral perfusion. Sustained end-range rotation may therefore reflect the compensatory capacity of the system as a whole rather than isolated vertebrobasilar function

Clinical Educator and Student Perceptions of iPad™ Technology to Enhance Clinical Supervision: The Electronically-Facilitated Feedback Initiative (EFFI)

Purpose: Growing demands placed upon healthcare systems require more health professionals to be trained. Clinical placement education is an integral component of health professional training, however accommodating increasing numbers of student placements is a challenge for health services. Personal digital assistants such as iPads™ may assist in delivery of clinical education, by facilitating transfer of knowledge and skills from clinical educators to health professional students, however such an initiative has not been formally investigated. The present study sought to explore perceptions of clinical educators and allied health students regarding the impact of an iPad™-based feedback delivery system on student reflection and learning. Methods: A pilot study was performed using iPads™ with specialised software to deliver electronic formative feedback to physiotherapy, occupational therapy and speech pathology students during clinical placements. Students and clinical educators completed a questionnaire exploring advantages and disadvantages of the technology. Results: Nine clinical educators and 14 students participated and completed the survey. Clinical educators largely (n=7, 78%) reported the electronic feedback system was easy to use and 67% (n=6) reported it improved the quality of feedback provided to students. Five (56%) clinical educators thought electronic feedback improved student performance. Most students (n=10, 71%) reported electronic feedback facilitated reflection upon performance, and 64% (n=9) reported improved performance as a result. Disadvantages included poor wireless internet access and software inefficiencies (n=7 [78%] clinical educators, n=7 [50%] students), and difficulties using iPads™ in settings requiring infection control (n=2 [22%] clinical educators). Conclusions: Clinical educators and students perceived electronic feedback as a positive adjunct to student learning on clinical placement, however technological and software interface factors need to be considered for implementation in some settings

Confirmation and Characterization of the Eccentric, Warm Jupiter TIC 393818343 b with a Network of Citizen Scientists

NASA’s Transiting Exoplanet Survey Satellite (TESS) has identified over 7000 candidate exoplanets via the transit method, with gas giants among the most readily detected due to their large radii. Even so, long intervals between TESS observations for much of the sky lead to candidates for which only a single transit is detected in one TESS sector, leaving those candidate exoplanets with unconstrained orbital periods. Here, we confirm the planetary nature of TIC 393818343 b, originally identified via a single TESS transit, using radial velocity data and ground-based photometric observations from citizen scientists with the Unistellar Network and Exoplanet Watch. We determine a period of P = 16.24921 −0.00011+0.00010 days, a mass M P = 4.34 ± 0.15 M J, and semimajor axis a = 0.1291 −0.0022+0.0021 au, placing TIC 393818343 b in the “warm Jupiter” population of exoplanets. With an eccentricity e = 0.6058 ± 0.0023, TIC 393818343 b is the most eccentric warm Jupiter to be discovered by TESS orbiting less than 0.15 au from its host star and therefore an excellent candidate for follow-up, as it may inform our future understanding of how hot and warm Jupiter populations are linked

Light Curves and Colors of the Ejecta from Dimorphos after the DART Impact

On 26 September 2022 the Double Asteroid Redirection Test (DART) spacecraft impacted Dimorphos, a satellite of the asteroid 65803 Didymos. Because it is a binary system, it is possible to determine how much the orbit of the satellite changed, as part of a test of what is necessary to deflect an asteroid that might threaten Earth with an impact. In nominal cases, pre-impact predictions of the orbital period reduction ranged from ~8.8 - 17.2 minutes. Here we report optical observations of Dimorphos before, during and after the impact, from a network of citizen science telescopes across the world. We find a maximum brightening of 2.29 $\pm$ 0.14 mag upon impact. Didymos fades back to its pre-impact brightness over the course of 23.7 $\pm$ 0.7 days. We estimate lower limits on the mass contained in the ejecta, which was 0.3 - 0.5% Dimorphos' mass depending on the dust size. We also observe a reddening of the ejecta upon impact.Comment: Accepted by Natur

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

A valid pre-manipulative screening tool is needed

The Australian Physiotherapy Association's Clinical Guidelines for Pre-Manipulative Procedures for the Cervical Spine represent a positive step towards the goal of reducing the incidence of vertebrobasilar strokes following neck manipulation. Nevertheless, the predictive value of the guidelines is largely contingent upon the validity of the physical screening tests, particularly sustained end–range cervical rotation. The primary issue is the sensitivity of the tests for detecting patients with vertebral artery occlusion and vertebrobasilar insufficiency, and who are at high risk of experiencing significant forces during manipulation which could result in intimal dissection

Letter to editor response (letter)

I would like to thank Dr. Kerry and Mr. Taylor for raising some important issues related to cervical spine pre-manipulative screening in response to my recent editorial (Rivett, 2006).Of course, an editorial is by nature brief and cannot fully cover all matters pertaining to this issue. It is also by definition an opinion or view, albeit an informed one

A diagnostic dilemma of dizziness

If the cause of a patient's dizziness is cervicogenic dizziness then clinical experience and empirical research both indicate there will be a prompt favourable response to manual therapy such as SNAGs applied to the upper cervical spine.A failure to respond after three to four such treatments suggests there is probably another cause for the dizziness. Howard had a marked reduction in his pain and dizziness after the first SNAG treatment. Because Howard had an immediate decrease in his dizziness after manual therapy treatment to the upper cervical spine, it can be inferred that mechanical dysfunction in the upper cervical spine was the likely source of the problem and that the hypothesis of cervicogenic dizziness was probably correct. It also suggests that the SNAG treatment positively addressed this dysfunction