Sarah Michiels

The assessment of cervical sensory motor control: A systematic review focusing on measuring methods and their clinimetric characteristics

BACKGROUND Cervical sensorimotor control (CSMC) becomes increasingly important in the assessment and treatment of patients with neck pain. This review aims to compare commonly used CSMC measuring methods in terms of required tasks, measuring device and clinimetric properties. SEARCH METHODS A systematic review of two databases, followed by methodological quality assessment (CBO guidelines). RESULTS The methodological quality of 34 included articles was generally good (five to seven out of eight), the inter-rater agreement was excellent (κw=0.966, p<0.01). Following tasks were found: head repositioning accuracy to the neutral head position (HRA-to-NHP) and to a target position (HRA-to-target), a virtual reality test, a continuous linear movement technique (CLMT) and an object following non-linear movement technique (NLMT) (The Fly™). Test-retest reliability was fair to excellent (ICC 0.35-0.87) for the HRA-to-NHP, very bad to excellent (ICC 0.01-0.90) for the HRA-to-target, fair to good (ICC 0.25-0.77) for the virtual reality test and moderate to excellent (ICC: 0.60-0.86) for The Fly™. The reliability of the CLMT was not documented. The HRA-to-NHP, The Fly™ and the CLMT can discriminate between patients with neck complaints and controls (discriminant validity). Currently, only The Fly™ can discriminate between different patient populations (post-traumatic and non-traumatic neck pain). The sensitivity, specificity and responsiveness of the methods have to be assessed in future research. CONCLUSIONS The dynamic method The Fly™ appears to be more reliable than the HRA-to-NHP and is able to discriminate between different patient populations. The diagnostic potential is to be confirmed in future research.

The Effect of Physical Therapy Treatment in Patients with Subjective Tinnitus: A Systematic Review.

Background: Tinnitus is a very common symptom that often causes distress and decreases the patients quality of life. Apart from the well-known causes, tinnitus can in some cases be elicited by dysfunctions of the cervical spine or the temporomandibular joint (TMJ). To date however, it is unclear whether alleviation of these dysfunctions, by physical therapy treatment, also decreases the tinnitus complaints. Such physical therapy could be an interesting treatment option for patients that are now often left without treatment. Objectives: The aim of this review was to investigate the current evidence regarding physical therapy treatment in patients with tinnitus. Data sources: The online databases Pubmed, Web of Science, Cochrane, and Embase were searched up to March 2016. Two independent reviewers conducted the data extraction and methodological quality assessment. Study eligibility criteria: Only randomized controlled trials and quasi-experimental trials were included in the review. Studies had to be written in English, French, Dutch, or German. Participants and interventions: The included studies investigated the effect of physical therapy treatment modalities on tinnitus severity in patients suffering from subjective tinnitus. Results: Six studies were included in this review, four investigating cervical spine treatment and two investigating TMJ treatment. These studies show positive effects of cervical spine treatment (manipulations, exercises, triggerpoint treatment) on tinnitus severity. Additionally, decrease in tinnitus severity and intensity was demonstrated after TMJ treatment, following splints, occlusal adjustments as well as jaw exercises. Limitations: The risk of bias in the included studies was high, mainly due to lack of randomization, lack of blinding of subjects, therapists, and/or investigators. Additionally, risk of bias is present due to incomplete presentation of the data and selective reporting. A major issue of the reviewed papers is the heterogeneity of the included study populations, treatments and outcome measures, which inhibit data pooling and meta-analysis. Conclusions: Despite the methodological issues in the included studies and the consequent low quality evidence, it is noteworthy that all included studies show positive treatment effects. Before recommendations can be made, these results need to be confirmed in larger, high quality studies, using unambiguous inclusion criteria, state-of-the-art treatment, and high quality outcome measures.

Cervicogenic somatosensory tinnitus: An indication for manual therapy? Part 1: Theoretical concept

Tinnitus can be evoked or modulated by input from the somatosensory and somatomotor systems. This means that the loudness or intensity of tinnitus can be changed by sensory or motor stimuli such as muscle contractions, mechanical pressure on myofascial trigger points, transcutaneous electrical stimulation or joint movements. The neural connections and integration of the auditory and somatosensory systems of the upper cervical region and head have been confirmed by many studies. These connections can give rise to a form of tinnitus known as somatosensory tinnitus. To date only a handful of publications have focussed on (cervicogenic) somatosensory tinnitus and manual therapy. Broadening the current understanding of somatosensory tinnitus would represent a first step towards providing therapeutic approaches relevant to manual therapists. Treatment modalities involving the somatosensory systems, and particularly manual therapy, should now be re-assessed in the subgroup of patients with cervicogenic somatosensory tinnitus. The conceptual phase of this study aims to uncover underlying mechanisms linking the auditory and somatosensory systems in relation to subjective tinnitus through (i) review of the literature (part 1) and (ii) through design of a pilot study that will explore characteristics of the study population and identify relevant components and outcomes of manual therapy in patients with cervicogenic somatosensory tinnitus (part 2). This manuscript focusses the theoretical concept of (cervicogenic) somatosensory tinnitus, either with or without secondary central tinnitus or tinnitus sensitization.

Cervical sensorimotor control in idiopathic cervical dystonia: A cross-sectional study

Patients with idiopathic adult‐onset cervical dystonia (CD) experience an abnormal head posture and involuntary muscle contractions. Although the exact areas affected in the central nervous system remain uncertain, impaired functions in systems stabilizing the head and neck are apparent such as the somatosensory and sensorimotor integration systems. The aim of the study is to investigate cervical sensorimotor control dysfunction in patients with CD.

Diagnostic Value of Clinical Cervical Spine Tests in Patients With Cervicogenic Somatic Tinnitus

Background Tinnitus can be related to many different etiologies, such as hearing loss or a noise trauma, but it also can be related to the somatosensory system of the cervical spine. The diagnosis of cervicogenic somatic tinnitus (CST) is made when the predominant feature is the temporal coincidence of appearance or increase of both neck pain and tinnitus. Objective The aim of this study was to assess the diagnostic value of clinical cervical spine tests in people with CST. Design A cross-sectional study was conducted. Setting The study was conducted at a tertiary referral center. Patients Consecutive adult patients with chronic subjective nonpulsatile tinnitus were included. Exclusion criteria were vertigo, Ménière disease, middle ear pathology, intracranial pathology, cervical spine surgery, whiplash trauma, and temporomandibular dysfunction. Measurements A full ear, nose, and throat examination was conducted to classify patients into CST and non-CST groups. The physical therapist examination included completion of the Neck Bournemouth Questionnaire (NBQ) and the following clinical cervical spine tests: manual rotation test, adapted Spurling test (AST), trigger point tests, and tests for strength and endurance of the deep neck flexors. Results Eighty-seven patients with tinnitus were included, of whom 37 (43%) were diagnosed with CST. The diagnosis of CST becomes less likely with NBQ scores of <14 points (sensitivity of 80%, likelihood ratio [LR] of 0.3, and posttest probability of 19%). Absence of trigger points corresponded to an LR of 0.3, a sensitivity of 82%, and a posttest probability of 22%. A positive manual rotation test and AST indicate a higher probability of CST (LR of 5, specificity of 90%, and posttest probability of 78%). Limitations A limited number of clinical cervical spine tests were used in this study. Although tests with good validity and reliability were included, additional tests could provide more information on cervical spine dysfunction in patients with CST. Conclusions Clinical cervical spine tests can support the diagnostic process for CST. An NBQ score of <14 points and the absence of trigger points can help to exclude CST. In contrast, a positive manual rotation test and AST can help to include CST. In future studies, these tests should be included in a multidisciplinary assessment of patients with suspected CST.

Diagnostic Criteria for Somatosensory Tinnitus: A Delphi Process and Face-to-Face Meeting to Establish Consensus

Since somatic or somatosensory tinnitus (ST) was first described as a subtype of subjective tinnitus, where altered somatosensory afference from the cervical spine or temporomandibular area causes or changes a patient’s tinnitus perception, several studies in humans and animals have provided a neurophysiological explanation for this type of tinnitus. Due to a lack of unambiguous clinical tests, many authors and clinicians use their own criteria for diagnosing ST. This resulted in large differences in prevalence figures in different studies and limits the comparison of clinical trials on ST treatment. This study aimed to reach an international consensus on diagnostic criteria for ST among experts, scientists and clinicians using a Delphi survey and face-to-face consensus meeting strategy. Following recommended procedures to gain expert consensus, a two-round Delphi survey was delivered online, followed by an in-person consensus meeting. Experts agreed upon a set of criteria that strongly suggest ST. These criteria comprise items on somatosensory modulation, specific tinnitus characteristics, and symptoms that can accompany the tinnitus. None of these criteria have to be present in every single patient with ST, but in case they are present, they strongly suggest the presence of ST. Because of the international nature of the survey, we expect these criteria to gain wide acceptance in the research field and to serve as a guideline for clinicians across all disciplines. Criteria developed in this consensus paper should now allow further investigation of the extent of somatosensory influence in individual tinnitus patients and tinnitus populations.

Letter to the Editor concerning: Dizziness and neck pain: a correct diagnosis is required before consulting a physiotherapist, by Van Leeuwen and Van der Zaag-Loonen 2016

After reading the abovementioned manuscript we want to react on several issues. We have the impression that the authors start with a strong disbelief in the existence of dizziness originating from the cervical spine and a consequent disbelief in the effect of treatments that are directed to the cervical spine to alleviate the dizziness complaints. The authors state that there is no scientific background for the concept of cervicogenic dizziness (CD). One of the proposed mechanisms for CD is a sensorimotor conflict caused by impaired cervical afference. Proof of the presence of altered cervical afference in patients with dizziness is found in various experiments. These include tests with infiltrations in the upper cervical spine, the application of vibration on suboccipital muscles, with isometric contractions and induced muscle fatigue on cervical muscles. An overview can be found in the included references [1–4]. In these tests, the disturbance of cervical afference led to dizziness complaints. In clinical research, cervical sensorimotor control is measured via head repositioning tasks [5, 6]. Patients after a whiplash trauma display greater sensorimotor deficits than patients with neck pain of insidious onset. This impairment is even larger in those patients that experience dizziness after their whiplash trauma. This indicates an underlying sensorimotor mechanism for their dizziness complaint [7, 8]. CD is indeed a controversial diagnosis and it is only to be considered after ruling out other causes of dizziness such as benign paroxysmal positional vertigo, hyperventilation, and multisensory deficit. This is since long recognized in the physiotherapy field [9, 10]. CD can be suspected when a patient experiences dizziness (not vertigo) in combination with neck pain. This neck pain should be related in time (onset and duration) with the dizziness complaint. The dizziness is described as giddiness, unsteadiness or instability [4, 11]. The absence of a gold standard hampers the development of valid diagnostic criteria and tests. The lack of positive tests which might indicate another cause of dizziness is therefore of more diagnostic importance. The authors quite firmly state that there are no scientific studies concerning the effects of physical therapy treatment, directed to the cervical spine, on dizziness. However, Lystad et al. performed a systematic review including 15 studies. They concluded that manual therapy (i.e., spinal mobilisations) can be beneficial for patients with CD (level 2, moderate evidence) [12]. An additional RCT was performed which included 86 patients with CD. All were screened by a neurologist. Significant differences were found between the control group (placebo laser) and both manual therapy groups (4.2 treatments on average) regarding the dizziness intensity (immediately after treatment and after 12 weeks), frequency and Dizziness Handicap Inventory scores (up to 12 months follow-up) & W. De Hertogh willem.dehertogh@uantwerpen.be

Response to Letter to the Editor: "Cervical Spine Dysfunctions in Patients with Chronic Subjective Tinnitus".

1. Michiels S, De Hertogh W, Truijen S, Van de Heyning P. Cervical spine dysfunctions in patients with chronic subjective tinnitus. Otol Neurotol 2015;36:741Y5. 2. Zhan X, Pongstaporn T, Ryugo DK. Projections of the second cervical dorsal root ganglion to the cochlear nucleus in rats. J Comp Neurol 2006;496:335Y48. 3. Bolton JE, Humphreys BK. The Bournemouth Questionnaire: a shortform comprehensive outcome measure. II. Psychometric properties in neck pain patients. J Manipulative Physiol Ther 2002;25:141Y8. 4. Hogg-Johnson S, van der Velde G, Carroll LJ, et al.; Bone and Joint Decade 2000Y2010 Task Force on Neck Pain and Its Associated Disorders. The burden and determinants of neck pain in the general population: results of the Bone and Joint Decade 2000Y2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976) 2008;33:S39Y51. 5. Crocetti A, Forti S, Ambrosetti U, Bo LD. Questionnaires to evaluate anxiety and depressive levels in tinnitus patients. Otolaryngol Head Neck Surg 2009;140:403Y5. 6. Folmer RL, Griest SE. Tinnitus and insomnia. Am J Otolaryngol 2000;21:287Y93. 7. Krog NH, Engdahl B, Tambs K. The association between tinnitus and mental health in a general population sample: results from the HUNT Study. J Psychosom Res 2010;69:289Y98. 8. Bongers PM, Ijmker S, van den Heuvel S, Blatter BM. Epidemiology of work related neck and upper limb problems: psychosocial and personal risk factors (part I) and effective interventions from a bio behavioural perspective (part II). J Occup Rehabil 2006;16: 279Y302.