Neil Alan Tuttle

Do changes within a manual therapy treatment session predict between-session changes for patients with cervical spine pain?

Physiotherapists often use within-session changes to provide a guide for refining treatment application. This study tested the validity of within-session changes as predictors of between-session changes for patients with neck pain receiving manual therapy treatment. A total of 70 pairs of treatments from 29 patients with sub-acute non-specific neck pain receiving manual therapy were assessed to determine the relationship between within-session and between-session changes in range of motion (ROM), pain intensity, and centralisation. Measurements were taken of ROM of the more limited direction on each axis of flexion, extension, lateral-flexion and rotation, and pain (intensity and location) before and after treatment. The same measurements were repeated before the following treatment. Regression analysis demonstrated that within-session change accounted for 26% to 48% of the variability in between-session change for ROM and six per cent for pain intensity. The proportion of the within-session change for ROM maintained between sessions ranged from 42% to 63% (95% CI 25% to 88%). The odds ratios for within-session improved/not improved categorisation to predict between-session category for ROM ranged from 2.5 (95% CI 0.6 to 4.3) to 21.3 (95% CI 10.1 to 96.1), for pain intensity 4.5 (95% CI 1.2 to 14.4) and for pain centralisation 9.2 (95% CI 2.2 to 38.7) indicating greater likelihood of between-session improvement after within-session improvement. The between-session results for most patients (71% to 83%) could be classified correctly by their within-session category. The results support the use of within-session changes in ROM, centralisation, and possibly pain intensity as predictors of between-session changes for musculoskeletal disorders of the cervical spine.

Haptic Device for Capturing and Simulating Hand Manipulation Rehabilitation

This paper describes the preliminary development of a haptic setup for capturing and simulating musculoskeletal assessment and manipulation of the hand. A haptic device, called MasterFinger-2, is used for capturing one massage technique and one joint manipulation technique, and also for simulating this manipulation technique that can be used in both assessment and treatment of the hand. First, works developed demonstrate that an application of haptic devices enable quantitative characterization of forces and positions used in manipulation of musculoskeletal structures. Second, an application for simulation is developed using the MasterFinger-2 to display (both visually and haptically) manipulations of one joint of the hand around three axes. The novel aspects of this approach are the use of a multifinger device for capture, simulation, and modeling the movement of a biological joint for haptic simulation across three axes, each with nonlinear behavior.

Relation between changes in posteroanterior stiffness and active range of movement of the cervical spine following manual therapy treatment.

Study Design. Repeated measures study of active and passive movements in patients with neck pain. Objectives. To determine if, following manual therapy: (1) changes occur in active range of movement (AROM) and stiffness of posteroanterior (PA) movements, (2) such changes are dependent on the location treated, and (3) there is a relation between changes in PA stiffness and AROM. Summary of Background Data. PA movements are frequently used to assess patients with neck pain but little is known about how these movements are related to patient symptoms. Methods. One location deemed symptomatic and hypomobile and 1 asymptomatic location were selected in 20 patients with neck pain for more than 2 weeks. PA stiffness at each location and AROM were measured before and after each of 4 manual therapy interventions: PA movements to each location, a general treatment, and a control intervention. Results. The general intervention had a greater increase in each axis of AROM than the other interventions (F = 2.814 to 7.929, DF = 3) but there were no differences in PA stiffness across interventions (F = 0.945, DF = 3). Differences in PA stiffness was divided into regions by applied force. After treatment to the symptomatic location, regions of stiffness at forces above 8 N demonstrated significant correlations with total AROM (R = −0.466 to −0.628). Conclusion. After manual therapy, increased AROM is related to decreased PA stiffness in patients with neck pain, but only for the treated location and only when that location had been identified previously as symptomatic and hypomobile.

Is It Reasonable to Use an Individual Patient's Progress After Treatment as a Guide to Ongoing Clinical Reasoning?

Systematic assessment of a patients progress after an intervention is frequently used to inform decision making in ongoing conservative management of patients with musculoskeletal symptoms. Although reassessment of impairments immediately after treatment is commonplace in clinical practice, relatively little research has considered whether this method is reasonable. The history of, rationale behind, and evidence for the use of patient responses to inform clinical reasoning are explored in this commentary. Although the evidence is not conclusive, an argument is presented suggesting it is more reasonable to use a patients response to treatment to inform ongoing clinical reasoning than to follow predetermined protocols. A methodical approach that considers change in parameters such as patient impairments is likely to be a useful guide for decision making during ongoing patient management but only when the change being reassessed can be directly linked to functional goals. Changes in active range of movement or centralization of pain appear to be better indicators of treatment effectiveness than changes in either pain intensity or assessment of joint position. There is limited evidence to support the use of changes in segmental stiffness to guide ongoing management. Although reassessment of some impairments has been found to be useful, the author suggests that care is required in the selection of reassessments used to guide ongoing management. The usefulness of any reassessment is considered to rely on how well a change in the selected impairment predicts that individual patients ability to achieve their goals.

Design and construction of a novel low-cost device to provide feedback on manually applied forces.

STUDY DESIGN Design and evaluation, technical note. OBJECTIVES To describe the design of a simple, low-cost device for providing feedback of manually applied forces to the cervical spine, and to assess the device against specific design criteria. BACKGROUND The forces applied during manual therapy may vary by as much as 500% between practitioners. But consistency can be improved in students when they are provided with contemporaneous feedback. The current methods of providing feedback, however, are expensive, complex, and/or preclude their performance in a clinically relevant manner. METHODS The design of the device was assessed in accordance of the following criteria: (1) ease of use, (2) low cost, (3) minimal interference with technique, (4) ability to provide feedback with suitable accuracy at forces up to 50 N, and (5) no requirement of specialized skills to construct. RESULTS A device is described that interfaces with standard computers through the sound card and measures force, using thin, low-cost, force-sensing resistors. Evaluated against the design criteria, the device (1) is easy to set-up and use, (2) can be produced for under

Seated buttock contours: a pilot study of Australian senior high-school students

30 US dollars, (3) creates minimal interference with performance of a variety of techniques, (4) has limits of agreement from -3.8 to 4.2 N for forces of 5 to 45 N and repeatability coefficients of ± 2.0 N or 12%, and (5) can be constructed without specialized skills or knowledge. CONCLUSION A device is described that fulfills most of the design criteria for providing feedback on forces for physical therapy students and may have applications in other fields.

Improving performance in golf: current research and implications from a clinical perspective

Both posture and comfort of a chair are influenced by the contour and characteristics of the seat. Knowledge of seat contours of a student population could thus be useful in the design of school chairs. This study investigated seated buttock contours of senior high-school students in order to determine: (a) their general characteristics, (b) the effect of gender and sitting posture and (c) the relationship between the contours and selected anthropometric variables (stature and mass). A contour measurement device was developed and used to measure buttock contours in five sitting postures (typing, sitting up, sitting back, slumping and writing). Buttock contours were quantified by constructing anterior–posterior (AP) and lateral profiles from which six discrete profile dimension measurements were made. AP and lateral profiles were found to have a consistent shape across all participants. Five out of six profile dimensions were significantly different between genders, with just one significantly different between sitting postures (typing and sitting back). Correlations between anthropometric measures and profile dimensions were relatively low (r < 0.34) with no clear patterns evident. Overall results of this study suggest that buttock contours are influenced by gender to a greater extent than sitting posture.

Preferred seat orientation of senior high-school students

Golf, a global sport enjoyed by people of all ages and abilities, involves relatively long periods of low intensity exercise interspersed with short bursts of high intensity activity. To meet the physical demands of full swing shots and the mental and physical demands of putting and walking the course, it is frequently recommended that golfers undertake golf-specific exercise programs. Biomechanics, motor learning, and motor control research has increased the understanding of the physical requirements of the game, and using this knowledge, exercise programs aimed at improving golf performance have been developed. However, while it is generally accepted that an exercise program can improve a golfers physical measurements and some golf performance variables, translating the findings from research into clinical practice to optimise an individual golfers performance remains challenging. This paper discusses how biomechanical and motor control research has informed current practice and discusses how emerging sophisticated tools and research designs may better assist golfers improve their performance.

Reliability of the ECHOWS Tool for Assessment of Patient Interviewing Skills

The height of the front of the seat is the primary determinant of appropriate seat size in the school setting. In the present study, this dimension was fixed at 445 mm and, using a brief adjustment period, students adjusted the angle of the seat to their preferred rear seat height (PRSH) under three fixed and one adjustable desk height conditions and for one desk height, under two time conditions. PRSH was significantly greater at an 800 mm desk height (454±14 mm) compared to 735 mm (447±15 mm) and 720 mm (444±16 mm). When desk height as well as rear seat height were adjustable, PRSH was 446±15 mm and preferred desk height 751±25 mm. Taller students or those with larger popliteal heights selected lower PRSHs at all desk heights, with PRSH more strongly related to popliteal height (r = −0.54 to −0.59) than stature (r = −0.44 to −0.50). No differences were found in PRSH between short (<5 min) and long (30 min) adjustment periods for the 735 mm desk height. The nearly horizontal seat positions found in this study were between those recommended by other authors.

Spinal PA movements behave ‘as if’ there are limitations of local segmental mobility and are large enough to be perceivable by manual palpation: A synthesis of the literature

Background History taking is an important component of patient/client management. Assessment of student history-taking competency can be achieved via a standardized tool. The ECHOWS tool has been shown to be valid with modest intrarater reliability in a previous study but did not demonstrate sufficient power to definitively prove its stability. Objective The purposes of this study were: (1) to assess the reliability of the ECHOWS tool for student assessment of patient interviewing skills and (2) to determine whether the tool discerns between novice and experienced skill levels. Design A reliability and construct validity assessment was conducted. Methods Three faculty members from the United States and Australia scored videotaped histories from standardized patients taken by students and experienced clinicians from each of these countries. The tapes were scored twice, 3 to 6 weeks apart. Reliability was assessed using interclass correlation coefficients (ICCs) and repeated measures. Analysis of variance models assessed the ability of the tool to discern between novice and experienced skill levels. Results The ECHOWS tool showed excellent intrarater reliability (ICC [3,1]=.74–.89) and good interrater reliability (ICC [2,1]=.55) as a whole. The summary of performance (S) section showed poor interrater reliability (ICC [2,1]=.27). There was no statistical difference in performance on the tool between novice and experienced clinicians. Limitations A possible ceiling effect may occur when standardized patients are not coached to provide complex and obtuse responses to interviewer questions. Variation in familiarity with the ECHOWS tool and in use of the online training may have influenced scoring of the S section. Conclusion The ECHOWS tool demonstrates excellent intrarater reliability and moderate interrater reliability. Sufficient training with the tool prior to student assessment is recommended. The S section must evolve in order to provide a more discerning measure of interviewing skills.