Susan A. Reid

Comparison of Mulligan Sustained Natural Apophyseal Glides and Maitland Mobilizations for Treatment of Cervicogenic Dizziness: A Randomized Controlled Trial

Background There is short-term evidence for treatment of cervicogenic dizziness with Mulligan sustained natural apophyseal glides (SNAGs) but no evidence for treatment with Maitland mobilizations. Objective The purpose of this study was to compare the effectiveness of SNAGs and Maitland mobilizations for cervicogenic dizziness. Design A double-blind, parallel-arm randomized controlled trial was conducted. Setting The study was conducted at a university in Newcastle, Australia. Participants Eighty-six people with cervicogenic dizziness were the study participants. Interventions Included participants were randomly allocated to receive 1 of 3 interventions: Mulligan SNAGs (including self-administered SNAGs), Maitland mobilizations plus range-of-motion exercises, or placebo. Measurements The primary outcome measure was intensity of dizziness. Other outcome measures were: frequency of dizziness, the Dizziness Handicap Inventory (DHI), intensity of pain, and global perceived effect (GPE). Results Both manual therapy groups had reduced dizziness intensity and frequency posttreatment and at 12 weeks compared with baseline. There was no change in the placebo group. Both manual therapy groups had less dizziness intensity posttreatment (SNAGs: mean difference=−20.7, 95% confidence interval [95% CI]=−33.6, −7.7; mobilizations: mean difference=−15.2, 95% CI=−27.9, −2.4) and at 12 weeks (SNAGs: mean difference=−18.4, 95% CI=−31.3, −5.4; mobilizations: mean difference=−14.4, 95% CI=−27.4, −1.5) compared with the placebo group. Compared with the placebo group, both the SNAG and Maitland mobilization groups had less frequency of dizziness at 12 weeks. There were no differences between the 2 manual therapy interventions for these dizziness measures. For DHI and pain, all 3 groups improved posttreatment and at 12 weeks. Both manual therapy groups reported a higher GPE compared with the placebo group. There were no treatment-related adverse effects lasting longer than 24 hours. Limitations The therapist performing the interventions was not blind to group allocation. Conclusions Both SNAGs and Maitland mobilizations provide comparable immediate and sustained (12 weeks) reductions in intensity and frequency of chronic cervicogenic dizziness.

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

BackgroundCervicogenic 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.MethodsParticipants 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.DiscussionThis 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 registrationACTRN12611000073909

Manual therapy for cervicogenic dizziness: Long-term outcomes of a randomised trial

Manual therapy is effective for reducing cervicogenic dizziness, a disabling and persistent problem, in the short term. This study investigated the effects of sustained natural apophyseal glides (SNAGs) and passive joint mobilisations (PJMs) on cervicogenic dizziness compared to a placebo at 12 months post-treatment. Eighty-six participants (mean age 62 years, standard deviation (SD) 12.7) with chronic cervicogenic dizziness were randomised to receive SNAGs with self-SNAGs (n = 29), PJMs with range-of-motion (ROM) exercises (n = 29), or a placebo (n = 28) for 2-6 sessions over 6 weeks. Outcome measures were dizziness intensity, dizziness frequency (rated between 0 [none] and 5 [>once/day]), the Dizziness Handicap Inventory (DHI), pain intensity, head repositioning accuracy (HRA), cervical spine ROM, balance, and global perceived effect (GPE). At 12 months both manual therapy groups had less dizziness frequency (mean difference SNAGs vs placebo -0.7, 95% confidence interval (CI) -1.3, -0.2, p = 0.01; PJMs vs placebo -0.7, -1.2, -0.1, p = 0.02), lower DHI scores (mean difference SNAGs vs placebo -8.9, 95% CI -16.3, -1.6, p = 0.02; PJMs vs placebo -13.6, -20.8, -6.4, p < 0.001) and higher GPE compared to placebo, whereas there were no between-group differences in dizziness intensity, pain intensity or HRA. There was greater ROM in all six directions for the SNAG group and in four directions for the PJM group compared to placebo, and small improvements in balance for the SNAG group compared to placebo. There were no adverse effects. These results provide evidence that both forms of manual therapy have long-term beneficial effects in the treatment of chronic cervicogenic dizziness.

Effects of Cervical Spine Manual Therapy on Range of Motion, Head Repositioning, and Balance in Participants With Cervicogenic Dizziness: A Randomized Controlled Trial

OBJECTIVEnTo evaluate and compare the effects of 2 manual therapy interventions on cervical spine range of motion (ROM), head repositioning accuracy, and balance in patients with chronic cervicogenic dizziness.nnnDESIGNnRandomized controlled trial with 12-week follow-up using blinded outcome assessment.nnnSETTINGnUniversity School of Health Sciences.nnnPARTICIPANTSnParticipants (N=86; mean age ± SD, 62.0 ± 12.7 y; 50% women) with chronic cervicogenic dizziness.nnnINTERVENTIONSnParticipants were randomly assigned to 1 of 3 groups: sustained natural apophyseal glides (SNAGs) with self-SNAG exercises, passive joint mobilization (PJM) with ROM exercises, or a placebo. Participants each received 2 to 6 treatments over 6 weeks.nnnMAIN OUTCOME MEASURESnCervical ROM, head repositioning accuracy, and balance.nnnRESULTSnSNAG therapy resulted in improved (P ≤.05) cervical spine ROM in all 6 physiological cervical spine movement directions immediately posttreatment and at 12 weeks. Treatment with PJM resulted in improvement in 1 of the 6 cervical movement directions posttreatment and 1 movement direction at 12 weeks. There was a greater improvement (P<.01) after SNAGs than PJM in extension (mean difference, -7.5°; 95% confidence interval [CI], -13° to -2.0°) and right rotation (mean difference, -6.8°; 95% CI, -11.5° to -2.1°) posttreatment. Manual therapy had no effect on balance or head repositioning accuracy.nnnCONCLUSIONSnSNAG treatment improved cervical ROM, and the effects were maintained for 12 weeks after treatment. PJM had very limited impact on cervical ROM. There was no conclusive effect of SNAGs or PJMs on joint repositioning accuracy or balance in people with cervicogenic dizziness.

Tension of the Ulnar, Median, and Radial Nerves During Ulnar Nerve Neurodynamic Testing: Observational Cadaveric Study

Background The ulnar nerve upper limb neurodynamic test (ULNT3) uses upper limb positioning to investigate symptoms arising from the ulnar nerve. It is proposed to selectively increase tension of the nerve; however, this property of the test is not well established. Objective The aim of this study was to determine the upper limb position that results in: (1) the greatest tension of the ulnar nerve and (2) the greatest difference in tension between the ulnar nerve and the other 2 major nerves of the upper limb: median and radial. Design This was an observational cadaver study. Methods Tension (in newtons) of the ulnar, median, and radial nerves was measured simultaneously using 3 buckle force transducers in 5 upper limb positions in 10 embalmed human cadavers (N=20 limbs). Repeated-measures analysis of variance (ANOVA) with Bonferroni post hoc tests determined differences in tension among nerves and among limb positions. Results The addition of shoulder horizontal abduction (H.Abd; 12.62 N; 95% confidence interval [95% CI]=10.76, 14.47) and combined shoulder abduction and internal rotation (H.Abd+IR; 11.86 N; 95% CI=9.96, 13.77) to ULNT3 (scapular depression, shoulder abduction and external rotation, elbow flexion, forearm pronation, and wrist and finger extension) produced significantly greater ulnar nerve tension compared with the ULNT3 alone (8.71 N; 95% CI=7.25, 10.17). The ULNT3+H.Abd test demonstrated the greatest difference in tension among nerves (mean difference between ulnar and median nerves=11.87 N; 95% CI=9.80, 13.92; mean difference between ulnar and radial nerves=8.47 N; 95% CI=6.41, 10.53). Limitations These results pertain only to the biomechanical plausibility of the ulnar nerve neurodynamic test and do not account for other factors that may affect the clinical application of this test. Conclusions The ULNT3+H.Abd is a biomechanically plausible test for detecting peripheral neuropathic pain related to the ulnar nerve. In situations where the shoulder complex will not tolerate the combination of shoulder external rotation in abduction, performing upper limb neurodynamic tests with internal rotation instead of external rotation is a biomechanically plausible alternative.

Improving the radial nerve neurodynamic test: An observation of tension of the radial, median and ulnar nerves during upper limb positioning

The radial nerve neurodynamic test (ULNT2b), used to implicate symptoms arising from the radial nerve, is proposed to selectively increase strain of the nerve without increasing strain of adjacent tissue, though this has not been established. This study aimed to determine the upper limb position that results in: (1) the greatest tension of the radial nerve and (2) the greatest difference in tension between the radial nerve and the other two major nerves of the upper limb: median and ulnar. Tension (N) of the radial, median and ulnar nerves was measured simultaneously using three buckle force transducers during seven upper limb positions in the axilla of ten embalmed whole body human cadavers (n = 20 limbs). Repeated measures analysis of variance (ANOVA) with Bonferroni post-hoc tests determined differences in tension between nerves and between limb positions. A Composite position consisting of ULNT2b (scapular depression, shoulder internal rotation, elbow extension, forearm pronation, wrist flexion) with the addition of shoulder abduction 40° and extension 25°, wrist ulnar deviation and thumb flexion demonstrated significantly greater tension of the radial nerve than any other tested position (mean tension 11.32N; 95% CI 10.25, 12.29, p < 0.01), including ULNT2b (2.20N; 1.84, 2.57; p < 0.01). Additionally, the Composite position demonstrated the greatest difference in tension between the radial and median (mean difference 4.88N; 95% CI 3.16, 6.61; p < 0.01) and radial and ulnar nerves (9.26N, 7.54, 10.99; p < 0.01). This position constitutes a biomechanically plausible test to detect neuropathic pain related to the radial nerve.

Cervical Proprioception in a Young Population Who Spend Long Periods on Mobile Devices: A 2-Group Comparative Observational Study

Objectives: The purpose of this study was to evaluate if young people with insidious‐onset neck pain who spend long periods on mobile electronic devices (known as “text neck) have impaired cervical proprioception and if this is related to time on devices. Methods: A 2‐group comparative observational study was conducted at an Australian university. Twenty‐two participants with text neck and 22 asymptomatic controls, all of whom were 18 to 35 years old and spent ≥4 hours per day on unsupported electronic devices, were assessed using the head repositioning accuracy (HRA) test. Differences between groups were calculated using independent sample t‐tests, and correlations between neck pain intensity, time on devices, and HRA test were performed using Pearsons bivariate analysis. Results: During cervical flexion, those with text neck (n = 22, mean age ± standard deviation [SD]: 21 ± 4 years, 59% female) had a 3.9° (SD: 1.4°) repositioning error, and the control group (n = 22, 20 ± 1 years, 68% female) had a 2.9° (SD: 1.2°) error. The mean difference was 1° (95% confidence interval: 0–2, P = .02). For other cervical movements, there was no difference between groups. There was a moderately significant correlation (P ≤ .05) between time spent on electronic devices and cervical pain intensity and between cervical pain intensity and HRA during flexion. Conclusion: The participants with text neck had a greater proprioceptive error during cervical flexion compared with controls. This could be related to neck pain and time spent on electronic devices.

The validity and reliability of DrGoniometer, a smartphone application, for measuring forearm supination

Study Design: Clinical measurement (reliability and validity) study. Introduction: Forearm supination is important in many daily activities and is thus measured by therapists and researchers usually with a universal goniometer. DrGoniometer, a SmartPhone application, has been validated for other joint angles in the body. Purpose of the Study: To establish the reliability and validity of DrGoniometer (CDM S.r.L, Cagliari, Italy) for measuring forearm supination in healthy populations and those with forearm fractures. Methods: Participants had sustained a distal radius fracture that was treated non‐surgically. Forearm supination of the participants fractured (n = 30) and healthy forearm (n = 30) was measured using DrGoniometer and the universal goniometer by two assessors. The assessors were blinded to each others measurements and their own previous measurements. Reliability was established by calculating Intra‐class Correlation Coefficients, standard error of measurement and minimal detectable change. The validity of DrGoniometer was established against the universal goniometer using Pearsons correlation co‐efficient. Results: Intra‐rater reliability of both DrGoniometer and the universal goniometer was high for both fractured and healthy forearms (ICCs ranged from 0.74–0.88). Inter‐rater reliability of both DrGoniometer and the universal goniometer was also high in the fractured forearm group (0.76 and 0.72 respectively), but low in the healthy forearm group (0.34 and 0.42 respectively). Correlation between the tools was excellent across the fractured and healthy forearm groups (0.94 and 0.93 respectively). Discussion: Both goniometers demonstrated good‐to‐excellent intrarater and iner‐rater reliability except in the healthy forearm group where both goniometers demonstrated poor inter‐rater reliability which could be due to assessor instructions. The speed the photo can be taken and the digital record obtained are valuable aspects of DrGoniometer. Conclusion: DrGoniometer is a valid, alternate tool for measuring forearm supination. HIGHLIGHTSDrGoniometer is a valid measurement tool for forearm supination.Excellent correlation between DrGoniometer and the universal goniometer.Correlation found for those with fractured forearms and healthy forearms.

Utility of a brief assessment tool developed from the Dizziness Handicap Inventory to screen for Cervicogenic dizziness: A case control study

BACKGROUNDnCervicogenic dizziness (CGD) is hard to diagnose as there is no objective test.nnnOBJECTIVEnCan a brief assessment tool be derived from the Dizziness Handicap Inventory (DHI) to assist in screening for CGD?nnnDESIGNnCase-control study with split-sample analysis.nnnMETHODn86 people with CGD and 86 people with general dizziness completed the DHI as part of the assessment of their dizziness. Descriptive statistics were used to assess how frequently each question on the DHI was answered yes or sometimes by participants with CGD and by participants with general dizziness. The questions that best discriminated between GCD and general dizziness were compiled into a brief assessment tool for CGD. Data from 80 participants (40 from each group) were used to generate a receiver operating characteristic (ROC) curve to establish a cut-off score for that brief assessment tool. Then, data from the remaining 92 participants were used to try to validate the diagnostic ability of the brief assessment tool using that cut-off score.nnnRESULTSnQuestions 1, 9 and 11 were the most discriminatory and were combined to form the brief assessment tool. The ROC curve indicated an optimal threshold of 9. The diagnostic ability of the brief assessment tool among the remaining 46 participants from each group was: sensitivity 77% (95% CI: 67 to 84), specificity 66% (56-75), positive likelihood ratio 2.28 (1.66-3.13), and negative likelihood ratio 0.35 (0.23-0.53).nnnCONCLUSIONnA brief assessment tool of three questions appears to be helpful in screening for CGD.