Jackie Sadi

Adverse events associated with the use of cervical manipulation and mobilization for the treatment of neck pain in adults: A systematic review

Adverse events (AE) are a concern for practitioners utilizing cervical manipulation or mobilization. While efficacious, these techniques are associated with rare but serious adverse events. Five bibliographic databases (PubMed, CINAHL, PEDro, AMED, EMBASE) and the gray literature were searched from 1998 to 2009 for any AE associated with cervical manipulation or mobilization for neck pain. Randomized controlled trials (RCTs), prospective or cross-sectional observational studies were included. Two independent reviewers conducted study selection, method quality assessment and data abstraction. Pooled relative risks (RR) were calculated. Study quality was assessed using the Cochrane system, a modified Critical Appraisal Skills Program form and the McHarm scale to assess the reporting of harms. Seventeen of 76 identified citations resulted in no major AE. Two pooled estimates for minor AE found transient neurological symptoms [RR 1.96 (95% CI: 1.09-3.54) p < 0.05]; and increased neck pain [RR 1.23 (95% CI: 0.85-1.77) p > .05]. Forty-four studies (58%) were excluded for not reporting AE. No definitive conclusions can be made due to a small number of studies, weak association, moderate study quality, and notable ascertainment bias. Improved reporting of AE in manual therapy trials as recommended by the CONSORT statement extension on harms reporting is warranted.

Identifying SLAP lesions: A meta-analysis of clinical tests and exercise in clinical reasoning

OBJECTIVES To identify all published accounts of diagnostic accuracy for clinical tests of Superior Labral Antero-Posterior (SLAP) lesion of the shoulder, and provide an estimate of the pooled likelihood ratio for those tests that have been evaluated at least three times. A clinical reasoning exercise is presented to illustrate clinical useability of the findings. DESIGN Systematic review and meta-analysis. METHODS An extensive review of international electronic databases was performed to identify all published works of diagnostic accuracy of any test proposed to be diagnostic for SLAP lesions of the shoulder. Statistical pooling of likelihood ratios was performed using a random-effects model to provide an estimate of the pooled positive likelihood ratio (PLR) for each test with at least three data points available. RESULTS Twelve studies describing 14 tests were identified. Five tests had been evaluated at least 3 times in the published literature. Methodologic quality scoring was performed and data were extracted. The pooled PLR revealed that of the five tests studies, only Yergasons test demonstrates consistent evidence of significant diagnostic accuracy (PLR 2.29). Heterogeneity of effect sizes was present for the Crank test. The heterogeneity was substantially improved through removal of the effect from the study in which the test was initially described and validated. The fail-safe N statistic suggests that the findings for Yergasons test are robust to publication bias. None of the tests reviewed are very strong. CONCLUSIONS Among the clinical tests for SLAP lesions that have been published to date, Yergasons test is the only one that shows a significant ability to influence clinical decision making, based on the results of the current analysis. Methodologic inadequacies in the reporting of the publications are common, and caution must be exercised when drawing inferences from the results of these studies.

Evidence-based conservative rehabilitation for posterior glenohumeral instability: A systematic review☆

STUDY DESIGN Systematic review. OBJECTIVES To identify the best evidenced-based approach for the conservative rehabilitation of patients with posterior glenohumeral instability. BACKGROUND Posterior glenohumeral instability is more common than previously thought. Proper management is imperative to control symptoms and maximize function. METHODS We conducted an electronic search, up to November 2014, for English-language studies involving rehabilitation of posterior shoulder instability. A manual search of reference lists of included articles and previously published reviews was also performed. RESULTS Five studies met the review inclusion criteria. Most studies demonstrated that rotator cuff and posterior deltoid strengthening could reduce instability recurrence and pain, and increase function, mainly in those with atraumatic posterior instability without previous surgery. These studies were mainly case series or retrospective designs. CONCLUSIONS Rotator cuff and posterior deltoid strengthening may help with symptom-management and functioning in those with posterior glenohumeral instability. Further research is needed to detect statistically significant outcomes from conservative treatment. LEVEL OF EVIDENCE Therapy, Level 3.

Rehabilitation of symptomatic atraumatic degenerative rotator cuff tears: A clinical commentary on assessment and management

Study Design: Clinical Commentary. Introduction: Atraumatic rotator cuff (RC) disease, is one of the most common cause of shoulder pain, which encompasses a continuum from tendinopathy to full thickness cuff tears. Extrinsic, intrinsic and environmental factors have been implicated in the pathophysiology of this disorder, affecting the clinical presentation of symptoms including pain and irritability. Successful rehabilitation of symptomatic atraumatic degenerative rotator cuff (SADRC) tears must address the underlying mechanisms causing dysfunction and correct modifiable factors. Purpose of the Study: The purpose of this paper is to review the shoulder complex anatomy, introduce atraumatic degenerative RC pathology, differentiate between symptomatic and asymptomatic degenerative RC tears, propose an assessment and introduce the Rotator Cuff Protocol 1 (RCP1) designed by the clinical reasoning of one of the lead authors (LW) as a rehabilitation management approach for those clients who present with SADRC tears. Methods/Results/Discussion: N/A for clinical commentary. Conclusions: The ability to identify SADRC tears should consider shoulder anatomy, extrinsic, intrinsic and environmental factors, and the consideration for the natural history of atraumatic partial and full thickness tears in the general population. A thorough clinical history and examination, which includes shoulder symptom modification tests, allows the examiner to determine at what phase the patient may start their exercise program. The RCP1 is a program that has been used clinically by many therapists and clients over the years and research is underway to test this protocol in atraumatic rotator cuff disease including SADRC tears. Level of Evidence: 5.

What is the reliability of clinical measurement tests for humeral head position? A systematic review

STUDY DESIGN Systematic review. INTRODUCTION Physiotherapists routinely assess the position of the humeral head (HH) in patients with shoulder pain. PURPOSE OF THE STUDY To conduct a systematic review to determine the quality and content of studies that evaluated the reliability of clinical measurement methods for assessing the HH position. METHODS Five databases and gray literature were searched for studies fitting the eligibility criteria. After abstract and full-text review, the included studies were appraised using the Quality Appraisal of Reliability Studies checklist. Articles were considered of high quality if 8 was achieved on the checklist, and the overall quality of evidence was classified using prespecified criteria. Multiple raters extracted and performed quality ratings; a consensus process was used to finalize the reliability data that were synthesized and presented in a narrative synthesis. Reliability was classified as excellent if the intracorrelation coefficients or intercorrelation coefficients (ICCs) reported exceeded 0.75. RESULTS Fifteen studies on the reliability of ultrasound (US) and 3 studies on palpation were included. The methodologic quality was moderate in 17 of 18 studies. The intrarater reliability for all studies was excellent (ICC, 0.76-0.99) with the exception of the 90° abduction in internal rotation position (ICC, 0.48) for palpation. The inter-rater reliability tended to be lower (ICC, 0.48-0.68) for palpation and higher (ICC, 0.66-0.99) for US. Physiotherapists demonstrated excellent intrarater reliability across different levels of training in ultrasonography. DISCUSSION Our study found a moderate overall level of evidence to support the use of US for assessing HH position in symptomatic or asymptomatic subjects. CONCLUSION A moderate overall level of evidence exists for the use of US to reliably assess the HH position. Limited research supports the methods used for palpation within a clinical setting. LEVEL OF EVIDENCE 2a.

Evidence-Based Review of Clinical Diagnostic Tests and Predictive Clinical Tests That Evaluate Response to Conservative Rehabilitation for Posterior Glenohumeral Instability: A Systematic Review

Context: Posterior glenohumeral instability is poorly understood and can be challenging to recognize and evaluate. Using evidence-based clinical and predictive tests can assist clinicians in appropriate assessment and management. Objective: To review evidence-based clinical diagnostic tests for posterior glenohumeral instability and predictive tests that identify responders to conservative management. Data Sources: A comprehensive electronic bibliographic search was conducted using Embase, Ovid MEDLINE, PEDro, and CINAHL databases from their date of inception to February 2017. Study Selection: Studies were included for further review if they (1) reported on clinical diagnostic tests for posterior or posteroinferior instability of the glenohumeral joint, (2) assessed predictive clinical tests for posterior instability of the glenohumeral joint, and (3) were in English. Study Design: Systematic review. Level of Evidence: Level 4. Data Extraction: Data were extracted from the studies by 2 independent reviewers and included patient demographics and characteristics, index/reference test details (name and description of test), findings, and data available to calculate psychometric properties. Results: Five diagnostic and 2 predictive studies were selected for review. There was weak evidence for the use of the jerk test, Kim test, posterior impingement sign, and O’Brien test as stand-alone clinical tests for identifying posterior instability. Additionally, there was weak evidence to support the use of the painless jerk test and the hand squeeze sign as predictive tests for responders to conservative management. These findings are attributed to study design limitations, including small and/or nonrepresentative samples. Conclusion: Clustering of thorough history and physical examination findings, including the aforementioned tests, may identify those with posterior glenohumeral instability and assist in developing management strategies.

Quantifying performance metrics of cervical spine mobilization for improved education and clinical outcomes: Early experience with a novel wearable device

Introduction Evaluation of manual skills training for spinal rehabilitation has been stagnant for 40 years. Observation and mimicry are coupled with feedback from “expert” observers to train and evaluate learners, relying on rater experience to discern speed and force. Spinal manipulation is a controlled act under the Regulated Health Professions Act (1991) as it is not without risk. The discordance between current methods for evaluating proficiency and the potential risks of inadequate application is a critical gap. Methods This work reports a novel wearable device that measures finger forces via microstrain bending of the physiotherapist’s nail. The device leaves the tactile finger pad unobstructed and does not interfere with treatment application. Five expert-level physiotherapists performed a standard postero-anteriorly directed spinal segmental mobilization treatment for 1 min at 1–1.5 Hz rhythm. Results The device successfully measured all treatment forces (0.2–27.3 N). Physiotherapists applied a maximum force rate of 0.03 ± 0.01 N/s with a rhythm of 1.76 ± 0.38 Hz. In 15 trials, there were no device failures. The device was easily applied and removed, and physiotherapists were able to walk about and interact normally with patients. Conclusions These results indicate that this technology can be integrated into a skills training program to provide quantitative feedback for objective assessments.

Clinical Diagnostic Tests versus Medial Branch Blocks for Adults with Persisting Cervical Zygapophyseal Joint Pain: A Systematic Review and Meta-Analysis

Purpose: A systematic review and meta-analysis were performed to identify clinical tests for diagnosing cervical zygapophyseal joint pain (CZP) and to determine their diagnostic accuracy. Method: A search strategy was carried out to find relevant evidence published in CINAHL, Embase, MEDLINE, and PEDro from 1980 to January 1, 2015, pertaining to the clinical diagnosis of CZP. Quality assessment was completed using the Quality Assessment of Diagnostic Accuracy Studies-2. Results were analyzed to pool sensitivity and specificity and clarify diagnostic value. Results: Seven articles (n=463) were included for data synthesis and review. Intersegmental mobility tests were found to have the highest diagnostic accuracy, with pooled sensitivity of 0.91 (95% CI: 0.85, 0.94) and specificity of 0.74 (95% CI: 0.65, 0.81). The pooled sensitivity for mechanical sensitivity (palpation) was 0.88 (95% CI: 0.78, 0.95), and specificity was 0.61 (95% CI: 0.50, 0.71). Conclusion: Limited studies are available that discuss the clinical diagnosis of CZP, and significant heterogeneity is present in the available data. In this review, intersegmental mobility tests were found to be the most accurate. Clustering of tests, agreement on a reference standard, and further exploration of CZP referral patterns are recommended.

Feasibility of an at Home, Online, Yoga-Based and Standard Exercise Intervention for Rotator Cuff Injuries

Exercise has been shown to benefit RC patients in terms of reducing pain, improving strength, ROM and function.3 However, clinical studies have primarily examined the role of traditional exercise for RC rehabilitation. The effects of yoga as exercise through an online home based setting have been scarcely investigated. This chapter will discuss the feasibility of a 6-week long exercise intervention. The purposes of this feasibility study were to:

Rotator cuff tendon surgery and postoperative therapy

Rotator cuff tear is a prevalent problem in the aging population and is the most common tendon injury in the adult population.1 Tears can be categorized based on their size (in the anteroposterior plane), the amount of retraction (in the mediolateral plane), their chronicity (acute or chronic), and their thickness (partial or full thickness).2 A partial thickness rotator cuff tear will involve fraying of the bursal side of the tendon or more commonly the articular side of the tendon, while preserving continuity in the lateral attachment on the greater tuberosity. It has been shown that the size of a full thickness tear can influence the loss of strength of the patient.3 Many full thickness tears will increase in size if not repaired, but the clinical implications of this remain unclear.4 In our experience, the chronicity of the tear and the amount of retraction might render the surgical repair impossible or overtensioned. Massive rotator cuff tears have had many definitions over the years, but the 2 most frequently cited are tears over 5 cm and tears involving more than 1 tendon.5-7 Pathology of the rotator cuff can be a consequence of tendon degeneration resulting from microtrauma (repetitive motion and/ or overload) or acute injury such as a fall.8-10 Extrinsic compression of the rotator cuff by the acromion has been the most widely accepted cause of rotator cuff disease, but this is now being disputed since most degenerative cuff disease is observed on the articular rather than the bursal tendon surface.11,12 Acute injury to the rotator cuff tendons occursmore commonly in younger patients and results from a fall on the outstretched hand with the shoulder in external rotation and abduction.13 The presence of a rotator cuff tear does not always warrant treatment. In fact, the prevalence of rotator cuff tears in asymptomatic populations ranges from 10% to 39% 14-25 and increases with advancing age.26 When individuals develop symptomatic rotator cuff disease, rehabilitation interventions have been shown to be effective for a spectrum of rotator cuff pathologies, including full