Eva-Maj Malmström

Postural and symptomatic improvement after physiotherapy in patients with dizziness of suspected cervical origin

OBJECTIVE To assess postural performance in patients with dizziness of suspected cervical origin in whom extracervical causes had been excluded, and to assess the effects of physiotherapy on postural performance and subjective complaints of neck pain and dizziness. DESIGN Prospective, randomized, controlled trial. SETTING Primary care centers and a tertiary referral center. PATIENTS AND SUBJECTS Of 65 referrals, 43 patients were excluded because extracervical etiology was suspected. Of the remaining 22 patients, 17 completed the study (15 women, 2 men, x age 37 yr, range 26-49). The controls were 17 healthy subjects (15 women, 2 men, x age 36 yr, range 25-55). INTERVENTION Physiotherapy based on analysis of symptoms and findings, and aimed to reduce cervical discomfort. Patients were randomized either to receive immediate physiotherapy (n = 9), or to wait 2 months, undergo repeat measurements, and then receive physiotherapy (n = 8). MAIN OUTCOME MEASURES Posturography, measuring velocity and variance of vibration-induced body sway and variance of galvanically induced body sway. Subjective intensity of neck pain (Visual Analog Scale ratings, 0-100), intensity and frequency of dizziness (subjective score 0-4). RESULTS The patients manifested significantly poorer postural performance than did healthy subjects (.05 > p > .0001). Physiotherapy significantly reduced neck pain and intensity and the frequency of dizziness (p < .01), and significantly improved postural performance (.05 > p > .0007). CONCLUSIONS Patients with dizziness of suspected cervical origin are characterized by impaired postural performance. Physiotherapy reduces neck pain and dizziness and improves postural performance. Neck disorders should be considered when assessing patients complaining of dizziness, but alternative diagnoses are common.

Zebris versus Myrin: a comparative study between a three-dimensional ultrasound movement analysis and an inclinometer/compass method: intradevice reliability, concurrent validity, intertester comparison, intratester reliability, and intraindividual variability.

Study Design. Experimental study. Objectives. To compare two devices for measuring cervical range of motion, a three-dimensional ultrasound motion device (Zebris) and a gravity-reference goniometer (Myrin). Summary of Background Data. Assessment of cervical range of motion is used to evaluate the effect of different treatments, determine impairment, and ascertain the relationship between neck disorders and cervical spine mobility. Methods. Sixty “neck-healthy” volunteers (25 men, 35 women; mean age 38 years, range 22–58 years) performed active maximal movements in flexion–extension, rotation, and lateral flexion. Maximal cervical range of motion was recorded simultaneously with the Zebris and Myrin devices. Intradevice reliability, concurrent validity, intertester comparison, intratester reliability, and intraindividual variability were computed. Results. Our study showed good agreement of full-cycle cervical range of motion measurement between devices, testers, and the test and retest (intraclass correlation [ICC] was >0.90 for intradevice reliability, >0.93 for concurrent validity, and >0.92 for intratester reliability). Method error, assessed with the within-subject coefficient of variation for 95% of the measurements, was 5.4% to 11.1% for intradevice reliability, 4.4% to 7.6% for concurrent validity, 3.6% to 7.6% for intratester reliability, and 5.3% to 9.9% for individual variability. Individual variability did not increase with an increased cervical range of motion. Conclusion. Both devices are reliable and showed good agreement. We conclude that the two techniques can be used interchangeably. Our study supports the continued use of the Myrin—a gravity-reference goniometer in routine clinical orthopedic work. The more sophisticated three-dimensional method adds information and allows evaluation of combined motion in two and three dimensions and is suitable for research.

Primary and coupled cervical movements: the effect of age, gender, and body mass index. A 3-dimensional movement analysis of a population without symptoms of neck disorders.

Study Design. Exploratory experimental design. Objectives. To examine primary and coupled cervical movements, and to study the effects of age, gender, and body mass index in a “neck-healthy” population. These data could serve as a basis for future interventions and to assess normal variations. Summary of Background Data. Cervical movements are biomechanically and neurophysiologically complex. Neck disorders and trauma most often influence cervical movements. With 3-dimensional recordings, it is possible to make precise, noninvasive evaluations of how the head moves on the stable trunk, and to analyze primary and coupled movements. Methods. A total of 120 subjects (60 men and 60 women, ages 20–79), were tested with Zebris (Zebris Medizintechnik GmbH, Isny, Germany), a 3-dimensional movement analyzer. Results. Age influences the majority of primary and coupled movements. With increasing age, primary movement size decreases in all cardinal planes. Age most strongly affects the coupled movements of primary rotation and lateral flexion. Gender and body mass index have only slight influences. Conclusions. Coupled movements are a natural part of cervical motion together with primary movements and follow specific patterns in subjects with no symptoms of neck disorders. Our study shows that cervical motion alters throughout life according to specific patterns but with individual variations.

Cervicogenic dizziness - musculoskeletal findings before and after treatment and long-term outcome.

Purpose. To explore musculoskeletal findings in patients with cervicogenic dizziness and how these findings relate to pain and dizziness. To study treatment effects and long-term symptom progress. Method. Twenty-two patients (20 women, 2 men; mean age 37 years) with suspected cervicogenic dizziness underwent a structured physical examination before and after physiotherapy guided by the musculoskeletal findings. Questionnaires were sent to the patients six months and two years after treatment. Results. Dorsal neck muscle tenderness and tightness was found in a majority of the patients. Zygapophyseal joint tenderness was found at all cervical levels. Cervical range of motion was equal to or larger than expected age and gender matched values. The cervico-thoracic region was often hypomobile. Most patients had postural imbalance. Dynamic stabilization capacity was reduced. Suboccipital muscles tightness correlated with posture imbalance and poor neck stability. The treatment resulted in reduced tenderness in levator scapula, high and middle paraspinal and temporalis muscles and zygapophyseal joints at C4-C7 and increased cervico-thoracic mobility. Reduction of middle paraspinal muscle tenderness correlated with neck pain relief. Postural alignment improved, as did dynamic stabilization in trunk, neck and shoulders. After 6 months, 13 of the 17 patients had still no or less neck pain and 14 had no or less dizziness. After 2 years, 7 patients had no or less neck pain and 11 no or less dizziness. Conclusion. Patients with suspected cervicogenic dizziness have some musculoskeletal findings in common. Treatment based on these findings reduces neck pain as well as dizziness long-term but some patients might need a maintenance strategy.

Improved Balance Confidence and Stability for Elderly After 6 Weeks of a Multimodal Self-Administered Balance-Enhancing Exercise Program A Randomized Single Arm Crossover Study

Objective: To develop and assess the efficacy of a multimodal balance-enhancing exercise program (BEEP) designed to be regularly self-administered by community-dwelling elderly. The program aims to promote sensory reweighting, facilitate motor control, improve gaze stabilization, and stimulate continuous improvement by being constantly challenging. Method: Forty participants aged 60 to 80 years performed 6 weeks of BEEP training, on average for 16 min four times weekly, in a randomized one-arm crossover design. Results: One-leg standing time improved 32% with eyes open (EO), 206% with eyes closed (EC) on solid surface, and 54% EO on compliant surface (p < .001). Posturography confirmed balance improvements when perturbed on solid and compliant surfaces with EO and EC (p ≤ .033). Walking, step stool, and Timed Up and Go speeds increased (p ≤ .001), as did scores in Berg Balance and balance confidence scales (p ≤ .018). Discussion: Multimodal balance exercises offer an efficient, cost-effective way to improve balance control and confidence in elderly.

Change of Body Movement Coordination during Cervical Proprioceptive Disturbances with Increased Age.

Background: To date, there are very few studies on postural stability in older adults using body movement recordings to capture the postural movement pattern. Moreover, the importance of proprioception at key areas such as the calf or neck on the postural movement pattern in older adults has rarely been investigated. Objective: To investigate whether the body movement coordination strategy to calf or neck vibration was affected by aging. Methods: Body movement measurements were taken at five locations (ankle, knee, hip, shoulder and head) from 18 younger (mean age 29.1 years) and 16 older (mean age 71.5 years) adult subjects using a 3D movement measuring system while subjected to 50 s of pseudo-random calf or neck vibratory stimulation pulses with eyes open or closed. The positions from the knee, hip, shoulder and head markers were correlated against one another to give an indication of the body coordination. Results: During quiet standing, older adults had greater correlation between the head and trunk than the young. There was an age effect in the body movement coordination strategy. Older adults had a different movement pattern with neck vibration involving mainly more independent knee movements, indicating balance difficulty. Conclusions: Neck vibration affects the movement pattern in older adults more compared with younger adults and calf vibration, suggesting that, the regulation of body orientation in older adults is more difficult, especially during cervical proprioceptive disturbances.

Influence of prolonged unilateral cervical muscle contraction on head repositioning – Decreased overshoot after a 5-min static muscle contraction task

The ability to reproduce a specified head-on-trunk position can be an indirect test of cervical proprioception. This ability is affected in subjects with neck pain, but it is unclear whether and how much pain or continuous muscle contraction factors contribute to this effect. We studied the influence of a static unilateral neck muscle contraction task (5 min of lateral flexion at 30% of maximal voluntary contraction) on head repositioning ability in 20 subjects (10 women, 10 men; mean age 37 years) with healthy necks. Head repositioning ability was tested in the horizontal plane with 30 degrees target and neutral head position tests; head position was recorded by Zebris((R)), an ultrasound-based motion analyser. Head repositioning ability was analysed for accuracy (mean of signed differences between introduced and reproduced positions) and precision (standard deviation of the differences). Accuracy of head repositioning ability increased significantly after the muscle contraction task, as the normal overshoot was reduced. An average overshoot of 7.1 degrees decreased to 4.6 degrees after the muscle contraction task for the 30 degrees target and from 2.2 degrees to 1.4 degrees for neutral head position. The increased accuracy was most pronounced for movements directed towards the activated side. Hence, prolonged unilateral neck muscle contraction may increase the sensitivity of cervical proprioceptors.

Healthcare consultation and sick leave before and after neck injury: a cohort study with matched population-based references.

Objectives Recent studies based on self-assessed data on exposure and outcome suggest a negative association between poor health before neck injury and recovery. Our aim was to study actual healthcare consultation and work disability before and after neck injury (whiplash). Design Cohort study with matched references studied prospectively and retrospectively via regional and national held registers. Setting Population-based study in Region Skåne, Sweden (population=1.21 million) including all levels of healthcare. Participants 1443 participants aged ≥18 (54% women) with acute neck injury, Whiplash, (International Classification of Diseases-10-SE code S13.4*) in 2007 or 2008 and no such diagnosis since 1998. Each patient with a neck injury was assigned four randomly selected population references matched for age, sex and area of residence (97% of the patients and 94% of the references were followed during the whole study period). Primary and secondary outcome measures We studied changes in healthcare consultations 3 years before to 3 years after diagnosis as well as sick leave episodes. Analyses were also stratified by preinjury frequency of consultation. Results Before the injury, the mean number of total consultations over 36 months among the neck injured (n=1443) and references (n=5772) was 9.3 vs 7.2 (p<0.0001) and postneck injury 12.7 vs 7.8 (p<0.0001). In the group of high-frequent consulters, there were more women compared with frequent and low-frequent consulters (70.6% vs 32.8%; p<0.0001). Among low-frequent and frequent consulters preinjury (n=967, 67% of the cohort), 16% became high-frequent consulters attributable to the injury. The number of days of sick leave preinjury was correlated with the number of preinjury and postinjury consultations (r=0.47 (99% CI 0.38 to 0.49), r=0.32 (99% CI 0.25 to 0.37)). Conclusions People with a neck injury constitute a heterogeneous group. The preinjury level of healthcare consultation is associated with the postinjury level of consultation.

QUANTITATIVE SENSORY TESTING OF TEMPERATURE THRESHOLDS: POSSIBLE BIOMARKERS FOR PERSISTENT PAIN?

OBJECTIVE To investigate the reproducibility of thermal thresholds, as measured by repeated quantitative sensory testing (QST) in healthy controls, and to asses if temperature sensitivity differs between healthy controls and a cohort of patients with persistent pain. SUBJECTS A total of 54 healthy controls were compared with 25 consecutive patients selected for pain rehabilitation by multidisciplinary assessment teams. METHODS Heat and cold detection and pain thresholds in the forearm and neck were determined by QST. Reproducibility was evaluated by 2 consecutive tests 6-9 months apart. RESULTS Thermal detection and pain thresholds were reproducible in a subgroup of 20 healthy controls. The patients had slightly increased heat and cold detection thresholds, but significantly lower thresholds for cold and heat pain. The most clear-cut differences between patients and healthy controls were observed for cold pain thresholds. Calculation of the differences between thermal detection and pain thresholds (delta values) further strengthened the differences between patients and healthy controls. CONCLUSION Thermal detection and pain thresholds are reproducible over time, allowing longitudinal assessment of sensory function using QST. Although increased sensitivity to cold pain was the most prominent finding in this cohort of patients with persistent pain, calculation of the differences between thermal detection and pain thresholds may prove superior in detecting sensory alterations.

The whiplash enigma: Still searching for answers

Department of Neurology and Rehabilitation Medicine, Section for Specialized Pain Rehabilitation and Centre for Research and Development, kane University Hospital, Lund, Sweden Department of Health Sciences, Lund University, Sweden Oregon Health and Science University School of Medicine, Public Health and Preventive Medicine, Portland, USA Section of Forensic Medicine, Umea University, Sweden and Department of Forensic Medicine, Aarhus University, Denmark Department of Clinical Sciences, Lund University, Sweden