CMCC Research Report 2014-2015

Research Report 2014–15 A selection of published research by CMCC faculty

Featured articles include: 7

TENS Augments Blood Flow in Somatotopically Linked Spinal Cord Segments and Scores, and Mitigates Compressive Ischemia Budgell BS, Sovak G, Soave D

17 Quantifying Strain in the Vertebral Artery with Simultaneous Motion Analysis of the Head and Neck: A Preliminary Investigation

Piper SL, Howarth SJ, Triano JJ, Herzog W 33 Review of Methods Used By Chiropractors to Determine the Site for Applying Manipulation Triano JJ, Budgell BS, Bagnulo A, Roffey B, Bergmann T, Cooperstein R, Gleberzon B, Good C, Perron J, Tepe R 76 Is Multimodal Care Effective for the Management of Patients With Whiplash-Associated Disorders or Neck Pain and Associated Disorders? A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration Sutton DA, Côté P, Wong JJ, Varatharajan S, Randhawa KA, Yu H, Southerst D, Shearer HM, van der Velde GM, Nordin MC, Carroll LJ, Mior SA, Taylor-Vaisey AL, Stupar M

Canadian Memorial Chiropractic College

Our Mission An academic institution recognised for creating leaders in spinal health

Our Vision Deliver world class chiropractic education, research and patient care

CMCC is dedicated to pursuing innovation in education, research and patient care. In this way, the institution effectively prepares its students to become tomorrow’s leaders in spinal health.

CMCC’s achievements this year demonstrate the success of this approach in paving the way toward increased collaboration with other health care professions, and helping to define the profession within the changing Canadian health care landscape.

CMCC Research Report 2014–15 A selection of published research by CMCC faculty

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Message from the President and the Dean

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Changes in Vertebral Artery Blood Flow Following Various Head Positions and Cervical Spine Manipulation Quesnele JJ, Triano JJ, Noseworthy MD, Wells GD

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Itch Sensation Through Transient Receptor Potential Channels: A Systematic Review and Relevance to Manual Therapy Lucaciu OC, Connell GP A Variant Extensor Indicis Muscle and the Branching Pattern of the Deep Radial Nerve Could Explain Hand Functionality and Clinical Symptoms in the Living Patient Kumka M TENS Augments Blood Flow in Somatotopically Linked Spinal Cord Segments and Scores, and Mitigates Compressive Ischemia Budgell BS, Sovak G, Soave D

14 Immune Cell Transcript Modules Reveal Leukocyte Heterogeneity in Synovial Biopsies of Seronegative Spondylarthropathy Patients

Hallett RM, Chew T 15 A Finite Element Evaluation of the Moment Arm Hypothesis for Altered Vertebral Shear Failure Force Howarth SJ, Karakolis T, Callaghan JP 15 The Effect of a Lumbar Support Pillow On Lumbar Posture and Comfort During a Prolonged Seated Task

Grondin DE, Triano JJ, Tran S, Soave D 16 Use of Kinetic and Kinematic Data to Evaluate Load Transfer as a Mechanism for Flexion Relaxation in the Lumbar Spine Howarth SJ, Mastragostino P 17 Quantifying Strain in the Vertebral Artery with Simultaneous Motion Analysis of the Head and Neck: A Preliminary Investigation

Piper SL, Howarth SJ, Triano JJ, Herzog W 28 Comparison of 2 Methods of Measuring Spine Angular Kinematics During Dynamic Flexion Movements: Skin-Mounted Markers Compared with Markers Affixed to Rigid Bodies

Howarth SJ 29 Neck Muscle Fatigue Alters the Cervical Flexion Relaxation Ratio in Sub-Clinical Neck Pain Patients

Zabihhosseinian M, Holmes MW, Ferguson B, Murphy B 30 Sensor Positioning and Experimental Constraints Influence Estimates of Local Dynamic Stability During Repetitive Spine Movements

Howarth SJ, Graham RB

31 A Profile of the Youth Olympic Taekwondo Athlete

Kazemi M, De Ciantis MG, Rahman A 31 The Reliability of Body Pain Diagrams in the Quantitative Measurement of Pain Distribution and Location in Patients with Musculoskeletal Pain: A Systematic Review

Southerst D, Côté P, Stupar M, Stern P, Mior S 32 Immediate Effects of Spinal Manipulative Therapy on Regional Antinociceptive Effects in Myofascial Tissues in Healthy Young Adults

Srbely JZ, Vernon H, Lee D, Polgar M 33 Review of Methods Used by Chiropractors to Determine the Site for Applying Manipulation

Triano JJ, Budgell BS, Bagnulo A, Roffey B, Bergmann T, Cooperstein R, Gleberzon B, Good C, Perron J, Tepe R 66 Retention of Blinding at Follow-Up in a Randomized Clinical Study Using A ShamControl Cervical Manipulation Procedure for Neck Pain: Secondary Analyses From a Randomized Clinical Study

Vernon H, Triano JJ, Soave D, Dinulos M, Ross K, Tran S

67 Immediate Changes in Temporomandibular Joint Opening and Pain Following Vibration Therapy: A Feasibility Pilot Study

Muir B, Brown C, Brown T, Tatlow D,

Buhay J

68 Is Low Back Pain Associated With Worse Health-Related Quality of Life 6 Months Later?

Nolet PS, Kristman VL, Côté P, Carroll LJ, Cassidy JD

69 Informed Consent for Chiropractic Care: Comparing Patients' Perceptions to the Legal Perspective

Winterbottom M, Boon H, Mior S, Facey M

70 Development and Validation of Providers’ and Patients’ Measurement Instruments to Evaluate Adverse Events After Spinal Manipulation Therapy

Pohlman KA, O'Beirne M, Thiel H, Cassidy JD, Mior S, Hurwitz EL, Westawa M, Ishaque S, Yager JY, Vohra S 71 The Effectiveness of Exercise on Recovery and Clinical Outcomes of Soft Tissue Injuries of the Leg, Ankle, and Foot: A Systematic Review by the OPTIMa Collaboration

Woitzik E, Jacobs C, Wong JJ, Côté P, Shearer HM, Randhawa K, Sutton D, Southerst D, Varatharajan S, Brison RJ, Yu H, van der Velde G, Stern PJ, Taylor-Vaisey A, Stupar M, Mior S, Carroll LJ

72 Systematic Review of Prognosis and Return to Play After Sport Concussion: Results of the International Collaboration on Mild Traumatic Brain Injury Prognosis

Cancelliere C, Hincapié CA, Keightley M, Godbolt AK, Côté P, Kristman VL, Stålnacke BM, Carroll LJ, Hung R, Borg J, Nygrende Boussard C, Coronado VG, Donovan J, Cassidy JD 73 Differentiating Intraprofessional Attitudes Toward Paradigms in Health Care Delivery Among Chiropractic Factions: Results from a Randomly Sampled Survey

McGregor M, Puhl AA, Reinhart C, Injeyan HS, Soave D 74 Examination of the Relationship Between Theory-Driven Policies and Allowed Lost-Time Back Claims in Workers' Compensation: A System Dynamics Model

Wong JJ, McGregor M, Mior SA, Loisel P 75 Is Exercise Effective for the Management of Subacromial Impingement Syndrome and Other Soft Tissue Injuries of the Shoulder?

A Systematic Review by the OPTIMa Collaboration

Abdulla SY, Southerst D, Côté P, Shearer HM, et al 76 Is Multimodal Care Effective for the Management of Patients with WhiplashAssociated Disorders or Neck Pain and Associated Disorders? A Systematic Review by the OPTIMa Collaboration

Sutton DA, Côté P, Wong JJ, Varatharajan S, Randhawa KA, Yu H, Southerst D, Shearer HM, van der Velde GM, Nordin MC, Carroll LJ, Mior SA, Taylor-Vaisey AL, Stupar M 94 Does Structured Patient Education Improve the Recovery and Clinical Outcomes of Patients with Neck Pain? A Systematic Review by the OPTIMa Collaboration

Yu H, Côté P, Southerst D, Wong JJ, Varatharajan S, Shearer HM et al 95 Can Functional Capacity Tests Predict Future Work Capacity in Patients With Whiplash-Associated Disorders?

Trippolini MA, Dijkstra PU, Côté P, ScholzOdermatt SM, Geertzen JH, Reneman MF

96 Assessing the Change in Attitudes, Knowledge, and Perspectives of Medical Students Towards Chiropractic After An Educational Intervention

Wong JJ, Di Loretto L, Kara A, Yu K, Mattia A, Soave D, Weyman K, Kopansky-Giles D

97 Conference Proceedings 2013-15

CMCC Research Report 2014–2015

Introduction

Message from the President and the Dean

It is indeed a pleasure to provide you with the 2014-2015 Research Report, a report that speaks to the sophistication and diversity of research that has emerged from CMCC’s strategic planning from 2011 through 2016 and from the dedicated, hard work of CMCC’s educators and scientists.

This Research Report contains a selection of papers and abstracts from CMCC’s academic community, published over the 2013-2014 and 2014-2015 academic years. It is the culmination of efforts from scientists and collaborators in CMCC’s three research centres: UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, the Centre for Interprofessional Health Care Dynamics, and the Centre for Mechanobiology.

Reflecting on the past two years of research, there is clear recognition of the how the different centres are related to one another as work in the areas of disability prevention and rehabilitation, health policy, clinical trials, and injury and repair are integrated.

To that end, the selection of research abstracts and articles have been partitioned into four domains: Basic Sciences, Biomechanics, Clinical Sciences, and Policy.

The generous contributions from CMCC members and donors, as well as our funding agencies, have provided critical support to CMCC’s ongoing research programs.

Grantsmanship continues to yield strong returns and research productivity, as monitored through publications and presentations remains high.

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In this report, you will see substantial work in the bench sciences exploring the relationship between manual therapy and vascular change. There is a strong presence from the clinical sciences research, including a hallmark paper on the site of manual, and systematic reviews by Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration from the UOIT-CMCC Centre.

Each highlighted article has contributed to moving the science of manual health care forward. As research continues to evolve, CMCC is committed to maximizing the integration of its key research processes to empower knowledge translation between research domains and within clinical care. Please enjoy this sample of our scientists’ recent work as we look together toward the future.

Dr. David Wickes President

Marion McGregor Acting Dean, Graduate Education & Research Programs

A selection of published research by CMCC faculty

CMCC Research Infrastructure and Productivity

Faculty Productivity 2009-2015

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CMCC Research Report 2014–2015

Grant Success Activity Grant Submissions By Funder 3% Private 7% US Govt

17% Federal Govt 10% Provincal Govt

55% Foundation 7% Corporate

Grant Success

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A selection of published research by CMCC faculty

  Basic Sciences

Changes in Vertebral Artery Blood Flow Following Various Head Positions and Cervical Spine Manipulation Quesnele JJ1, Triano JJ1, Noseworthy MD2, Wells GD3 Canadian Memorial Chiropractic College, 2McMaster University, 3University of Toronto

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Abstract Objective The objective of the study was to investigate the cerebrovascular hemodynamic response of cervical spine positions including rotation and cervical spine manipulation in vivo using magnetic resonance imaging technology on the vertebral artery (VA).

Results The side-to-side difference between ipsilateral and contralateral VA velocities was not significant for either velocities (P = .14) or flows (P = .19) throughout the conditions.

There were no other interactions or trends toward a difference for any of the other blood flow or velocity variables.

Methods The side-to-side difference between ipsilateral and contralateral VA velocities was not significant for either velocities (P = .14) or flows (P = .19) throughout the conditions.

There were no other interactions or trends toward a difference for any of the other blood flow or velocity variables.

Conclusion There were no significant changes in blood flow or velocity in the vertebral arteries of healthy young male adults after various head positions and cervical spine manipulations.

Originally published in the Journal of Manipulative and Physiological Therapeutics, 2014 Jan;37(1):22-31. Epub 2013 Nov 15. Reproduced with permission from Elsevier.

Access Online: http://dx.doi.org/10.1016/j.jmpt.2013.07.008

Itch Sensation Through Transient Receptor Potential Channels: A Systematic Review and Relevance to Manual Therapy Lucaciu OC , Connell GP Canadian Memorial Chiropractic College

Abstract Objective Patients may present with a complaint of "itchiness" or an "odd sensation" that can be relieved by manual therapy treatment options, which demonstrates the relevance of transient receptor potential (TRP) channels. There are studies that identify the role of various TRP channels as modulators of the itch sensation.

However, discrepancies in the literature exist with respect to the overall neural pathway of the itch sensation, musculoskeletal implications, and decisive therapeutic implications. The purpose of this study was to review the literature and rate the quality of published articles regarding the role of TRP channels in the itch sensation.

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CMCC Research Report 2014–2015

Methods A systematic search of relevant literature that was published in English by a peer-reviewed journal between January 2000 and June 2012 was performed in PubMed. Studies that met the predetermined inclusion criteria regarding the relationship between TRP channels and itch were identified and then evaluated for methodological quality by the Downs and Black Quality Index score system and were summarized.

Results Nine studies were identified that met the inclusion criteria, all of which had fair methodological quality from the perspective of the modified Downs and Black Quality Index. TRPA1, TRPM8, and TRPV1-4 were indicated as key channels responsible for the transmission of the itch sensation. TRPV1 channels convey histamine-dependent itch, and TRPA1 channels convey histamine-independent itch. Temperature, nerve growth factor, and substance-P were also described as important itch modulators. There are similarities between the neural pathways responsible

for itch, pain, and temperature, which explain the ability of noxious temperature to suppress the desire to scratch Although transcutaneous electrical nerve stimulation, innocuous vibration, and cutaneous field stimulation have demonstrated relatively weak attenuation of itch, the use of topical capsaicin, noxious heat, and noxious cold have been demonstrated as effective therapies.

Conclusions The findings of this review show that studies have assessed the function of TRP channels and itch, rather than identifying the relationship between itch and effective noninvasive treatment options. Therefore, TRP channels could serve as important, complex clinical targets for manual therapists.

Originally published in the Journal of Manipulative and Physiological Therapeutics, 2013 Jul-Aug;36(6):385-93.

Reproduced with permission from Elsevier.

Access Online: http://dx.doi.org/10.1016/j.jmpt.2013.05.018

A Variant Extensor Indicis Muscle and the Branching Pattern of the Deep Radial Nerve Could Explain Hand Functionality and Clinical Symptoms in the Living Patient Kumka M Canadian Memorial Chiropractic College

Abstract Purpose The purpose of this study is to document the topographic anatomy of an extensor indicis (EI) muscle with a double tendon and the associated distribution of the deep branch of the radial nerve (DBRN). Both EI tendons were positioned deep to the tendons of the extensor digitorum as they traversed the dorsal osseofibrous tunnel. They then joined the medial slips of the extensor expansion of the second and third digits. In all other dissected forearms, a tendon of the EI muscle joined the medial slip of the extensor expansion to the index finger. The DBRN provided short branches to the superficial extensor muscles, long branches to the abductor pollicis longus and extensor pollicis brevis muscles, and

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terminated as the posterior interosseous nerve. Descending deep to the extensor pollicis longus muscle, the posterior interosseous nerve sent branches to the extensor pollicis brevis and EI muscles. Understanding of the topographic anatomy of an EI with a double tendon, and the associated distribution of the DBRN, may contribute to accurate diagnosis and treatment of hand lesions.

Originally published in the Journal of the Canadian Chiropractic Association 2015 Mar;59(1):64-71.

Reproduced with permission.

A selection of published research by CMCC faculty

  Basic Sciences Feature Article

TENS Augments Blood Flow in Somatotopically Linked Spinal Cord Segments and Scores, and Mitigates Compressive Ischemia Budgell BS1, Sovak G1, Soave D1,2 1

Canadian Memorial Chiropractic College, 2 University of Waterloo

Abstract Study Design This was an acute basic physiological study in anesthetized adult male rats.

Objective The purpose of this study was to determine, in an animal model, whether innocuous somatic stimulation, in the form of transcutaneous electrical nerve stimulation (TENS), could produce a sustained augmentation of spinal cord blood flow, and whether this effect was robust in the face of relatively mild, non-destructive compression of the spinal cord.

Setting Neurophysiology laboratory, Canadian Memorial Chiropractic College, Toronto, Canada.

Methods In anesthetized adult male Wistar rats, spinal cord blood flow was measured with laser Doppler flowmetry during 5- and 15-min epochs of TENS stimulation in

uncompressed and compressed lumbar spinal cord, were sacrificed at selected times for histological and biochemical analysis.

Results TENS applied to the L4/L5 dermatomes was associated with augmentation of blood flow in somatotopically linked spinal cord segments. This augmentation was robust in the face of non-destructive compression of the spinal cord, was sustained for periods of stimulation up to 15 min and occurred in the absence of any change in the mean arterial blood pressure.

Conclusions TENS augments spinal cord blood flow in the uncompressed spinal cord and during acute, non-destructive spinal cord compression. It remains to be seen whether similar results can be achieved in chronically compressed spinal cord and spinal nerve roots, and whether these results have clinical implications in human syndromes of spinal cord compression.

Introduction The functional integrity of the spinal cord and spinal nerve roots is, of course, dependent upon adequate perfusion and the availability of oxygen. As one might expect, laboratory investigations of spinal cord/nerve root function often model the most destructive lesions in which normal anatomical and physiological relationships have been disrupted.[1,2] In rat models of traumatic spinal cord injury, it has been demonstrated that both the extent and nature of neuronal damage are linked to the degree and duration of ischemia.[3,4] Compressive injury has been shown to cause an immediate and sustained decrease in local spinal cord blood flow in

(SCBF) in rat models.[3,5,6] Furthermore, augmentation of SCBF is associated with improved recovery of motor function in rat models of spinal cord compression.[7,8] Less is known about spinal cord responses to milder compression.

With regard to the therapeutic potential of physical therapies, it is understood that various forms of somatic stimulation increase SCBF in animal models. Recent studies in urethane-anesthetized adult male rats confirm that innocuous somatic stimulation (cutaneous brushing) results in a segmentally organized reflex augmentation of regional

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CMCC Research Report 2014–2015

SCBF in the intact spinal cord.[9] Furthermore, these studies suggest that, whereas neuronal activation is probably the most important mechanism underlying increased SCBF, alpha-adrenergic receptors also participate in this process.[10,11] The studies cited [9–11] employed stimulation periods of 30–60 s, and therefore it is unclear whether animals might quickly habituate to stimulation or whether the increases in SCBF could be maintained for periods likely to have clinical relevance in humans. Furthermore, these studies were conducted in intact, non-compressed spinal cords and, therefore, to date, there are no published reports of somatic stimulation mitigating the effects of compression on spinal cord or nerve root blood flow.

Therefore, the present study was designed to determine whether innocuous somatic stimulation, in the form of transcutaneous electrical nerve stimulation (TENS), could produce a sustained augmentation of SCBF, and whether this effect was robust in the face of relatively mild, non-destructive compression of the spinal cord.

Materials and Methods General Surgical Procedures Twelve-week-old male Wistar rats (n¼20; mean weight 347±14 g) were anesthetized with urethane (1.3 g kg1 intraperitoneally (i.p.)). Core temperature was monitored (TCAT-2LV Temperature Controller; David Kopf) via a rectal probe and maintained at 37.0±0.5 1C. A carotid artery and jugular vein were catheterized to monitor blood pressure, and for the provision of supplementary anesthesia, respectively. Animals were allowed to breathe spontaneously. Data were acquired via a PowerLab 8/30 data acquisition system (ADInstruments, Boulder, CO, USA). Disposable EKG electrodes (Blue Sensor, Ambu A/S, Denmark) were placed on the skin over the dorsum of the right hind paw and over the right sacroiliac joint— approximately the L4–L5 dermatomes [12] and attached to a stimulus isolator (ML180, ADInstruments), which delivered TENS-like stimulation, that is, 0.5ms2 waves at 100Hz with intensities set at 2.0, 3.0 or 3.5mA. These intensities were selected based on the physiological responses seen in pilot experiments wherein 2.0mA caused no visible muscle contraction but occasional and intermittent palpable fasciculation in limb muscles, 3.0mA routinely caused fasciculations and occasionally caused muscle twitching, and 3.5mA routinely caused muscle twitching and occasionally caused sustained tetany of large hind-limb muscles.

The L4–L6 lumbar spinal cord was exposed by T13/L1 laminectomy, with the dura mater left intact. The T12 and

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L2 spinous processes were stabilized with vertebral clamps.

A laser Doppler probe (OxyFlo Probe, Oxford Optronix, UK) mounted on a pressure transducer (Fort100, World Precision Instruments, Sarasota, FL, USA) was lowered, using a micromanipulator (UM-IPF, Narishige, East Meadow, NY, USA), onto the surface of the dura mater that was depressed until it just touched the dorsal surface of the spinal cord (Figure 1). Positioning of the probe targeted the L4–L5 level of the spinal cord. Spinal cord levels were confirmed at the end of each experiment by tracing spinal nerve rootlets to the intervertebral foramina through which they appeared to exit.

The laser Doppler flow signal represents the number and velocity of red blood cells moving through the tissue to a depth of B1–2mm beneath the probe tip. The laser Doppler flow signal therefore reflects relative blood flow and is expressed in millivolts but has been found to correlate very well with changes in absolute tissue blood flow measured by other means.[13] The advantage of laser Doppler flow is that it is non-invasive and reflects real-time changes in blood flow.

Experimental Series 1 In each of six animals, in order to determine effect sizes and optimum stimulation parameters, 5-min epochs of stimulation were applied three times at each intensity (2.0, 3.0 and 3.5mA), with B2- to 3-min interstimulus intervals. SCBF and force applied through the laser Doppler probe were monitored before the onset of stimulation, for the duration of stimulation, and following stimulation until SCBF had stabilized at prestimulation levels.

In four of the six animals, the laser Doppler probe (tip diameter: 0.52mm) was subsequently lowered onto the spinal cord with sufficient force to reduce baseline SCBF by a target of 10–20%. Hence, compression targeted a range of reduction in blood flow, not a specific force.

SCBF does fluctuate spontaneously, and spinal cord tissue undergoes a degree of plastic deformation under pressure.

Thus, there was some degree of variability in the actual attenuation of SCBF. Nonetheless, the target level of SCBF attenuation was practical and did not produce gross tissue disruption (subsequently confirmed with histological examination). Five-minute epochs of stimulation were repeated in the compressed spinal cord at the three levels of current intensity.

Experimental Series 2 Effect sizes from experimental series 1 (mean relative SCBF increase/s.d.; Table 1) provided minimum sample size estimates of six animals per stimulation intensity.

Therefore, 14 animals were subjected to 3 X 15-min epochs of stimulation at a single current intensity, either 2.0mA

A selection of published research by CMCC faculty

Budgell BS et al

(n¼7) or 3.0mA (n¼7), before and after compression of the spinal cord. Because of the relatively long periods of stimulation (3 X 15 min, plus interstimulus intervals), and hence length of the entire experiment, multiple magnitudes of stimulation were not tested in each animal.

At the conclusion of SCBF measurements, sufficient anesthesia was given to ensure that the animals were deeply anesthetized. For histological examination of the spinal cord (n¼5 animals), the chest cavity was opened and the animals were perfused transcardially with cold saline followed by 10% neutral buffered formalin. The spinal cord from the T11 level to the caudal extreme was removed and transferred to 10% neutral buffered formalin for 48 h. Subsequently, the tissues were subjected to routine histological processing with hematoxylin and eosine and Luxol fast blue staining.

Serial sections (6 mm) were evaluated qualitatively to determine whether the experimental paradigm was associated with any histomorphological changes.

OutputOutput from from laser laser probe probe toto computer computer

Force transducer Force Transducer

Output fromforce force Output from transducer to transducer computer to computer Micromanipulator Micromanipulator

Laser probe

Laser probe

Fig. 1 Simultaneous measurement of SCBF and compression of the spinal cord. A laser Doppler probe is fixed to a force transducer that, in turn, is mounted on a micromanipulator allowing regulation of force applied by the probe head to the spinal cord with simultaneous measurement of SCBF and pressure applied to the spinal cord. In this figure, the probe is shown contacting the spinal cord exposed by an L1 laminectomy.

Statistical Analysis For both series of experiments, SCBF data from the three trials of stimulation at each intensity were averaged. At each stimulus intensity this averaged SCBF (i) within 1 min of the onset of stimulation, a period that normally showed a transient peak in SCBF, (ii) over the entire period of stimulation (series 1: 5min; series 2: 15min) and (iii) in the final minute of stimulation were calculated to characterize blood flow changes throughout the course of stimulation, and between stimulus intensities to determine whether stimulus intensity affected the magnitude of SCBF. Summary statistics for experimental series 1 were

calculated for sample size determination in experimental series 2. Relative SCBF change was analyzed in experimental series 2 using one-sample t-tests at each epoch and stimulation intensity. Non-parametric Wilcoxon signed rank tests were also performed for comparison as parametric statistical assumptions may not be confirmed with small sample sizes (n¼7).

Statement of Ethics We certify that all applicable institutional and governmental regulations concerning the ethical use of animals were followed during the course of this research.

Results Before compression of the spinal cord, the force exerted via the laser Doppler probe tip on the intact dura mater across all trials was 1.66±0.36 g (mean±s.d.) equivalent to 600mmHg. Following the application of compression, the force exerted via the laser Doppler probe tip was 3.38±1.33 g (mean±s.d.) equivalent to 1220mmHg. The actual pressure exerted on the spinal cord itself could not be measured.

However, compression resulted in an average attenuation of SCBF of 19±12% (mean±s.d.).

Experimental Series 1 TENS applied to the hind limb for periods of up to 5min produced a substantial augmentation of SCBF in the uncompressed and compressed spinal cord (Figures 2a and b, Table 1). Whereas Kurosawa and colleagues [9–11] had reported unimodal responses in SCBF with 30 and 60s epochs of cutaneous stimulation, in the current study there was an initial and rapid rise in SCBF within the first minute followed by a decline to a sustained plateau that scarcely seemed to decay throughout the remaining period of stimulation. The magnitude of SCBF enhancement was influenced by the magnitude of the applied current (Table 1).

In all phases of stimulation—peak, tail and over the entire 5-min duration—average augmentation appeared to be greater with 3.0 and 3.5mA than with 2.0 mA, and occurred without any significant change in the mean arterial blood pressure (two-tailed paired t-test, P40.05 in all cases).

In the uncompressed cord, the augmentation of SCBF achieved with 3.0mA stimulation was equivalent to that obtained with 3.5 mA, even though the stronger stimulation usually elicited a pronounced and sustained contraction of hind limb muscles.

Experimental Series 2 TENS stimulation of 15-min duration at either 2.0 or 3.0mA produced augmentation of SCBF for the entire duration of stimulation in both uncompressed and compressed spinal

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CMCC Research Report 2014–2015

Table 1 Augmentation of SCBF, mean + (95% C|s)+ (Cohen's d), during TENS at three stimulation intensities and in comparison with normalized pre-stimulation SCBF

Abbreviations: CI, confidence interval; SCBF, spinal cord blood flow; TENS, transcutaneous electrical nerve stimulation.

Augmentation is noted for both uncompressed ('Pre') and compressed ('Post') spinal cord

a

b

2mA 3mA 3.5mA

SCBF

SCBF

2mA 3mA 3.5mA

Time (min)

Time (min)

Fig. 2 SCBF during 5 min of TENS stimulation. SCBF measured for 20s before and then during 5 min of TENS stimulation (Time¼0–¼5 min) at three current intensities before spinal cord compression (a) in six animals, and during spinal cord compression (b) in four animals.

cord (Figures 3a and b, Table 2), without any significant change in the mean arterial blood pressure (two-tailed paired t-test, P40.05 in both cases).

In the uncompressed spinal cord and at both intensities of current, the initial peak blood flow, the average blood flow over the 15-min of stimulation and the sustained blood flow in the final minute of stimulation—the ‘tail’—were significantly higher than at baseline before the onset of stimulation (Table 2). Following compression of the spinal cord, both intensities of TENS (2.0 and 3.0mA) caused

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augmentation of SCBF. However, only in the first minute of stimulation—the ‘peak’—did the mean augmentation with 3.0mA appear to exceed the augmentation of SCBF achieved with 2.0mA. The magnitudes of compression used were sufficient to impair blood flow without causing macroscopically obvious damage. Representative histological sections from the area of compressed spinal cord in five animals confirmed that compression did not produce any distortion of spinal cord tissues, disruption of normal anatomical boundaries or bleeding into the spinal cord.

A selection of published research by CMCC faculty

Budgell BS et al

Discussion TENS stimulation applied across the L4 and L5 dermatomes in the anesthetized rat causes an immediate increase in blood flow in the associated segments of the lumbar spinal cord. Augmentation of SCBF is evident with stimulation parameters that are likely to be innocuous in conscious animals, although the degree of augmentation is linked to stimulus intensity in a non-linear manner. Specifically, stimulation sufficient to induce sustained muscle contraction in the hind limb is not associated with greater augmentation of SCBF than stimulation of lower intensity that only induces intermittent contraction or fasciculation.

Augmentation of SCBF was sustained for periods of stimulation up to 15 min, a period that is used to assess mobility in patients with lumbar spinal stenosis.[14] Cessation of TENS was associated with an immediate decline in blood flow that returned to pre-stimulation levels in about 1 min. The augmentation of SCBF by TENS stimulation occurred in the absence of any change in the mean arterial blood pressure. Punctate compression of the spinal cord with pressures insufficient to produce macroscopic or histological evidence of tissue disruption led to, on average, an B19% attenuation of SCBF.

a

However, this attenuation was mitigated by TENS stimulation. The degrees of augmentation of SCBF reported herein are quite similar to those previously reported with innocuous mechanical stimulation (stroking) of the skin.[9,10] Augmentation of cervical SCBF has also previously been reported in the cat in response to direct electrical stimulation of isolated cutaneous branches of the radial nerve.[15] In the present study, with intensities of 2.0 and 3.0mA, augmentation of SCBF was sustained for 15 min epochs of stimulation in both uncompressed and compressed spinal cord.

As the laser Doppler beam is rapidly attenuated as it passes through tissues, and as perfusion of the grey matter is substantially greater than that of the white matter, it is likely that such effects on SCBF as were recorded in this study were principally attributable to changes in perfusion of the dorsal grey matter.

Furthermore, that augmentation of SCBF occurred in the absence of any change in the mean arterial blood pressure suggests that neuronal activation, rather than a systemic cardiovascular response to stimulation, was an important driver of enhanced spinal cord perfusion.

b

2mA 3mA

SCBF

SCBF

2mA 3mA

Time (min)

Time (min)

Fig. 3 SCBF during 15 min of TENS stimulation. SCBF measured for 20s before and then during 15min of TENS stimulation (TimeŸ0–15min) at two current intensities, each in seven animals, before spinal cord compression (a), and during spinal cord compression (b).

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CMCC Research Report 2014–2015

Table 2 Augmentation of SCBF+ (95% confidence intervals)+ (P-value), during TENS at two stimulation intensities and in comparison with normalized pre-stimulation SCBF

Abbreviations: CI, confidence interval; SCBF, spinal cord blood flow; TENS, transcutaneous electrical nerve stimulation.

Augmentation is noted for both uncompressed ('Pre') and compressed ('Post') spinal cord. P-Values were obtained using both parametric one sample t-tests and non-parametric Wilcoxon-signed rank tests as parametric statistical assumptions may not be confirmed with small sample sizes

Impact and clip compression models of spinal cord injury often result in immediate macroscopic evidence of vascular damage.[16] Depending upon the parameters of injury, there may be gross intraparenchymal bleeding or edema, as well as loss of microcirculation leading to longer term pathological processes.[17,18] In contrast, histological examination of representative sections of spinal cord tissue taken from the compressed and control segments in this study showed no evidence of tissue disruption, for example, no disruption of normal tissue boundaries and no bleeding.

However, no analysis was undertaken to rule out that biochemical changes and alternative histological techniques may well have revealed more subtle changes (for example, see Kobayashi et al.[19]. Such compression as did take place produced, on average, a 19% decrease in SCBF. Depending upon the time point and intensity of stimulation, in compressed spinal cord TENS produced average augmentations of SCBF ranging from 8 to 27% (Tables 1 and 2). In other words, there was substantial mitigation of the ischemic effects of non-destructive compression. To place this effect into perspective, one rat model of lumbar stenosis reported a 30–50% reduction in SCBF associated with clear cut behavioural changes suggestive of intermittent claudication.20

Limitations The current experiments did not model a chronic compressive syndrome. Rather, they examined short-term physiological responses to an acute, punctate compression of the spinal cord. Neural tissues subjected to slowly evolving compression may well undergo adaptive changes that would alter responses to somatic stimulation. The current studies were conducted in rats that are much more resilient in the face of traumatic spinal cord injury than humans. Furthermore, the majority of clinical cases of lumbar stenosis involve the lower lumbar spine and hence impingement of the spinal nerve roots. The effect of TENS

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on perfusion of these tissues was not investigated in this study. Hence, caution should be exercised in extrapolating these results to clinical effects in humans.

Conclusions TENS stimulation applied to lumbar dermatomes in the anesthetized rat augments SCBF in somatotopically linked spinal segments, and mitigates the ischemic effect of acute, mild, non-destructive compression of the spinal cord.

Data archiving There was no data to deposit.

Conflicts of interest The authors declare no conflict of interest.

Acknowledgements This work was supported by internal research funds from Canadian Memorial Chiropractic College.

Budgell BS et al

A selection of published research by CMCC faculty

References 1.

Agrawal SK, Fehlings MG. Mechanisms of secondary injury to spinal axons in vitro: Role of Na+, Na+-K+-ATPase, the Na+-H exchanger, and the Na+-Ca2+ exchanger. J Neurosci 1996; 16: 545–552.

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Agrawal SK, Fehlings MG. Role of NMDA and Non NMNDA ionotropic glutamate receptors in traumatic spinal cord axonal injury. J Neurosci 1997; 17: 1055–1063.

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Fehlings M, Tator C, Linden R. The relationships among the severity of spinal cord injury, motor and somatosensory evoked potentials and spinal cord blood flow. Electroencephalogr Clin

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Xu XM and Zhang JH (eds) Animal Models of Acute Neurological Injuries. Humana Press: Totowa, NJ, USA, 2009, pp 411–421.

17. Park YK, Tator CH. Failure of topical DMSO to improve blood flow or evoked potentials in rat spinal cord injury. J Korean Med Sci 1998; 13: 638–644.

18. Figley SA, Khosravi R, Legasto JM, Tseng YF, Fehlings MG. Characterization of vascular disruption and blood-spinal cord barrier permeability following traumatic spinal cord injury. J Neurotrauma 2014; 31: 541–552.

19. Kobayashi S, Yoshizawa H, Shimada S, Guerrero AR, Miyachi

rats. Exp Neurol 2004; 185: 120–132.

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Tei R, Kaido T, Nakase H, Sakaki T. Secondary spinal cord hypoperfusion of circumscribed areas after injury in rats. Neurol

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neuropathic intermittent claudication in the rat: methodology

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and application. J Neurosci Methods 2001; 104: 191–198.

K. Effects of lecithinized superoxide dismutase on rat spinal cord injury. J Neurotrauma 1996; 13: 573–582.

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Nakai I, Takenobu Y, Takimizu H, Akimaru S, Maegawa H, Ito H et al. Effects of OP1206 alpha-CD on walking dysfunction in the rat neuropathic intermittent claudication model: comparison with

Originally published in Spinal Cord. 2014 Oct;52(10):7448. Epub 2014 Jul 22. Reproduced with permission from Macmillan Publishers Ltd. Access Online: http://dx.doi.org/10.1038/sc.2014.120

mifedipine, ticlopidine and cilostazol. Prostaglandins Other Lipid Mediat 2003; 71: 253–263.

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Kurosawa M, Watanabe O, Maruyama H, Budgell B. Responses of dorsal spinal cord blood flow to innocuous cutaneous stimulation in anesthetized rats. Auton Neurosci 2006; 126–127: 185–192.

10. Kurosawa M, Toda H, Watanabe A, Budgell B. Contribution of supraspinal and spinal structures to the responses of dorsal spinal cord blood flow to innocuous cutaneous brushing in rats.

Auton Neurosci 2007; 136: 96–99.

11. Toda H, Maruyama H, Budgell B, Kurosawa M. Responses of dorsal spinal cord blood flow to noxious mechanical stimulation of the skin in anesthetized rats. J Physiol Sci 2008; 58: 263–270.

12. Takahashi Y, Nakajima Y, Sakamoto T. Dermatome mapping in the rat a hind limb by electrical stimulation of the spinal nerves.

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13. Phillips JP, Cibert-Goton V, Langford RM, Shortland PJ. Perfusion assessment in rat spinal cord tissue using photoplethysmography and laser Doppler flux measurements. J Biomed Opt 2013; 18: 3.

14. Tomkins-Lane CC, Holz SC, Yamakawa KS, Phalke VV, Quint DJ, Miner J et al. Predictors of walking performance and walking capacity in people with lumbar spinal stenosis, low back pain and asymptomatic controls. Arch Phys Med Rehabil 2012; 93: 647–653.

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Immune Cell Transcript Modules Reveal Leukocyte Heterogeneity in Synovial Biopsies of Seronegative Spondylarthropathy Patients Hallett RM1, Chew T2 McMaster University, 2Canadian Memorial Chiropractic College

1

Abstract Background The objective of this study was to identify leukocyte cell types found within the synovia of patients with seronegative spondylarthropathies (SpA), such as ankylosing spondylitis (AS), using transcription based analyses.

Methods Leukocyte transcriptional profiles obtained from the NCBI's gene expression omnibus and prediction analysis of microarrays (PAM) was used to identify 25-gene leukocyte metagenes. Subsequently, transcriptional profiles from murine and clinical models of AS and SpA were interrogated to characterize the local infiltration of leukocytes in SpA synovia.

Results Analysis of a proteoglycan-induced murine model of AS reveals infiltration of dendritic cells, CD4+ T cells, monocytes, and natural killer cells to the spine. In human SpA and AS patients, transcriptional analysis of synovial biopsies revealed local infiltration of dendritic cells and CD4+ T cells.

Conclusions We identified leukocyte cell types that infiltrated the synovial of SpA patients. Our results imply a role for dendritic cells and CD4+ T cells in the local inflammation that underlies pathogenesis in patients with SpA.

Orignally published in BMC Musculoskeletal Disorders 2014, 15:446. This is an Open Access Article under license to BioMed Central Ltd. and distributed under the terms of the Creative Commons Attribution License.

Access online: http://dx.doi.org/10.1186/1471-2474-15-446

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A selection of published research by CMCC faculty

 Biomechanics

A Finite Element Evaluation of the Moment Arm Hypothesis for Altered Vertebral Shear Failure Force Howarth SJ1, Karakolis T2, Callaghan JP 2 Canadian Memorial Chiropractic College, 2University of Waterloo

1

Abstract The mechanism of vertebral shear failure is likely a bending moment generated about the pars interarticularis by facet contact, and the moment arm length (MAL) between the centroid of facet contact and the location of pars interarticularis failure has been hypothesised to be an influential modulator of shear failure force. To quantitatively evaluate this hypothesis, anterior shear of C3 over C4 was simulated in a finite element model of the porcine C3–C4 vertebral joint with each combination of five compressive force magnitudes (0–60% of estimated compressive failure force) and three postures (flexed, neutral and extended).

Bilateral locations of peak stress within C3's pars interarticularis were identified along with the centroids of contact force on the inferior facets. These measurements were used to calculate the MAL of facet contact force.

Changes in MAL were also related to shear failure forces measured from similar in vitro tests. Flexed and extended vertebral postures respectively increased and decreased the MAL by 6.6% and 4.8%. The MAL decreased by only 2.6% from the smallest to the largest compressive force.

Furthermore, altered MAL explained 70% of the variance in measured shear failure force from comparable in vitro testing with larger MALs being associated with lower shear failure forces. Our results confirmed that the MAL is indeed a significant modulator of vertebral shear failure force.

Considering spine flexion is necessary when assessing low-back shear injury potential because of the association between altered facet articulation and lower vertebral shear failure tolerance.

Originally published in Computer Methods in Biomechanics and Biomedical Engineering, 2015;18(5):545-55. Epub 2013 Aug 15. Reprinted with permission from Taylor and Francis.

Access online: http://dx.doi.org/10.1080/10255842.2013.820717

The Effect of a Lumbar Support Pillow on Lumbar Posture and Comfort During a Prolonged Seated Task Grondin DE, Triano JJ, Tran S, Soave D Canadian Memorial Chiropractic College

Abstract Background Several risk factors exist for the development of low back pain, including prolonged sitting and flexed spinal curvature.

Several investigators have studied lumbar support devices and spinal curvatures in sitting, however few have investigated a pain population and reported a quantitative measure of comfort. The purpose of the current project was to determine whether a lumbar support pillow, outfitted with a cut-out to accommodate the bulk of posterior pelvic soft

tissue volume, is more effective than a standard chair in promoting a neutral spinal posture and improving subjective and objective measures of comfort in healthy individuals and patients with low back pain.

Methods Twenty eight male participants with and without a history of low back pain sat in a standard office chair and in a chair

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with the lumbar support pillow for 30 minutes. Lumbar and thoracolumbar postures were measured through electromagnetic markers. Comfort was determined based on the least squares radius of centre of pressure shifting, measured at the buttock-chair interface as well as reported discomfort through visual analog scales. Chair support effects were assessed through ANOVA methods. The study was approved by the Canadian Memorial Chiropractic College research ethics board.

Results There was a main effect of condition on lumbar posture (p = 0.006) and thoracolumbar posture (p = 0.014). In the lumbar region, the support and standard chair differed by 2.88° (95% CI; 1.01-4.75), with the lumbar support being closer to neutral than the standard chair. In the thoracolumbar region, the support and standard chair differed by -2.42° (95% CI; -4.22 to -0.62), with the standard

chair being closer to neutral than the support device. The centre of pressure measure was significantly improved with the pillow (p = 0.017), however there were no subjective changes in comfort.

Conclusions A lumbar support pillow with a cut-out for the posterior pelvic tissues improved an objective measure of comfort in healthy individuals and patients with low back pain.

Lumbar flattening was decreased and thoracolumbar curvature was increased. However, angular changes were small and future work is required to determine clinical relevance over the long term.

Originally published in Chiropractic & Manual Therapies 2013; 21: 21.Published online 2013 Jul 4. This is an Open Access Article distributed under the terms of the Creative Commons Attribution License.

Access Online: http://dx.doi.org/10.1186/2045-709X-21-21

Use of Kinetic and Kinematic Data to Evaluate Load Transfer as a Mechanism for Flexion Relaxation in the Lumbar Spine Howarth SJ, Mastragostino P Canadian Memorial Chiropractic College

Abstract Flexion relaxation (FR) in the low back occurs when load is transferred from the spine's extensor musculature to its passive structures. This study investigated the influence of added upper body mass on low back kinetics and kinematics at the FR onset. Sixteen participants (eight male, eight female) performed standing full forward spine flexion with 0%, 15%, and 30% of their estimated upper body mass added to their shoulders. Electromyographic data were obtained from the lumbar erector spinae. Ground reaction forces and kinematic data from the lower limbs, pelvis, and spine were recorded. Extensor reaction moments (determined using a bottom-up linked segment model) and flexion angles at

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the FR onset were documented along with the maximum spine flexion. The angle at the FR onset increased significantly with added mass (p < 0.05). Expressing the FR onset angle as a percent of the full range of trunk flexion motion for that condition negated any differences between the added mass conditions. These findings demonstrate that low back kinetics play a role in mediating FR in the lumbar spine.

Originally published in Journal of Biomechanical Engineering, 2013 Oct 1;135(10):101004-6. Reproduced with permission from the American Society of Mechanical Engineers.

Access Online: http://dx.doi.org/10.1115/1.4025112

A selection of published research by CMCC faculty

 Biomechanics Feature Article

Quantifying Strain in the Vertebral Artery with Simultaneous Motion Analysis of the Head and Neck: A Preliminary Investigation Piper SL1, Howarth SJ1, Triano JJ1, Herzog W2 Canadian Memorial Chiropractic College, 2University of Calgary

1

Abstract Background Spontaneous vertebral artery dissection has significant mortality and morbidity among young adults. Unfortunately, causal mechanisms remain unclear. The purpose of this study was to quantify mechanical strain in the vertebral artery while simultaneously capturing motion analysis data during passive movements of the head and neck relative to the trunk during spinal manipulation and cardinal planes of motion.

Methods Eight piezoelectric crystals (four per vertebral artery) were sutured into the lumen of the left and right vertebral arteries of 3 cadaveric specimens. Strain was then calculated as changes in length between neighboring crystals from a neutral head/neck reference position using ultrasound pulses. Simultaneously, passive motion of the head and neck on the trunk was captured using eight infrared cameras. The instantaneous strain arising in the vertebral artery was correlated with the relative changes in head positions.

Findings Strain in the contralateral vertebral artery during passive flexion-rotation compared to that of extension-rotation is variable ([df=32]:−0.61 b r b 0.55). Peak strain does not coincide with peak angular displacement during spinal manipulation and cardinal planes of motion. Axial rotation displayed the greatest amount of strain. The greatest amount of strain achieved during spinal manipulation was comparably lower than strains achieved during passive end range motions and previously reported failure limits.

Interpretation The results of this study suggest that vertebral artery strains during head movements including spinal manipulation, do not exceed published failure strains.

This study provides new evidence that peak strain in the vertebral artery may not occur at the end range of motion, but rather at some intermediate point during the head and neck motion.

Introduction Spontaneous vertebral artery dissection (sVAD), although low in prevalence rates (2.5–5 per 100,000 population), has significant mortality (23%) and morbidity, such as motor, sensory and cognitive deficits reported as high as 28% among young adults (Hassan et al., 2011). In addition, sVAD accounts for up to 25% of ischemic stroke in young adults 45 years old (Hassan et al., 2011). Given that stroke has an estimated annual cost of $73.1 billion (US) and that ischemic stroke accounts for 87% of all strokes, it follows that the approximate economic burden of sVAD may be up to $15.9 billion (US) (Lloyd-Jones et al., 2010). Unfortunately, causal mechanisms associated with sVAD remain unclear.

Case reports have described sVAD that occurred from movement of the head and neck during activities of daily living such as yoga, sleeping awkwardly, receiving dental work and cervical spinal manipulation (Haldeman et al., 2002; Haneline and Lewkovich, 2005; Kawchuk et al., 2008).

These case reports, however, cannot be used to establish mechanisms of injury linking head and neck motion with sVAD. Previous clinical guidelines suggested provocative testing of the vertebral artery, including sustained rotation of the head on the neck, may help to elicit symptoms of sVAD (Magarey et al., 2004), while other studies report using positional testing, such as the extension rotation test lacks validity (Cote et al., 1995). In addition, reports

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on cervical spinal manipulation as it relates to ischemic stroke are unclear about the type of manipulation delivered (Wynd et al., 2013). There is also variability that exists with application of spinal manipulation techniques between clinicians, and repeatability of consistent parameters, that makes interpretation of forces imparted difficult to assess (Descarreaux et al., 2012).

To date, we know that once a tear has occurred in the intimal lining of the vertebral artery (VA), blood may accumulate within the arterial layers; obstructing blood flow and leading to stroke (Kim and Schulman, 2009). Previous mechanistic studies have focused on hemodynamics and formation of embolisms, yet none of these explain the development of strain in the intimal lining that may lead to initial tearing of the VA (Callaghan et al., 2011). It is important to realize that although trivial, certain motions of the head and neck may create more intimal strain than others.

A previous case–control study addressed the arterial stress placed on the internal carotid artery (ICA) during head movements in subjects who previously experienced spontaneous ICA dissection (Callaghan et al., 2011). The study made use of finite element modeling (FEA). The results suggested that stress placed on the intimal layer of the ICA is comparable in spontaneous ICA dissection patients versus healthy controls (Callaghan et al., 2011).

FEA is a valuable tool, but relies on assumptions of constitutive equations, tissue dynamics and local deformations (Duan et al., 2009). FEA is typically employed when physical measurements cannot be determined and, therefore, independent validation of direct observation of the tissue stress and strain is lacking.

Mechanical failure of the ex vivo VA begins with a force of approximately 8.2 N to 8.8 N, and strain between 53% and 62% of its original resting length (Symons et al., 2002).

Previous in vitro studies have reported peak VA strains up to 12.2% at the end range of head and neck motion in flexion/ extension, lateral bending and axial rotation, with the largest strains being produced in axial rotation (Symons et al., 2002). Rapid neck movements, such as those produced during high-velocity, low-amplitude spinal manipulation (SM), have generated peak strains up to 12.9%, which is within the tolerable limits of VA (Herzog et al., 2012; Wuest et al., 2010). Previous in vitro studies have reported VA strains between 3.3% and 12.2% during motions of the head and neck in flexion/extension, lateral bending and axial rotation with the largest strains being produced in axial rotation (Symons et al., 2002). Rapid neck movements, such as those produced during high velocity low-amplitude

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spinal manipulation (SM), generated strains ranging between 0.9% and 3.8%, which were considerably lower than strains observed during cardinal planes of motion (Herzog et al., 2012; Wuest et al., 2010). Measurements from previous work suggest that strain does appear to fluctuate based on head and neck movements, such as head rotation, although a degree of motion has yet to be determined (Wuest et al., 2010).

The complex anatomy and coupled motions of the cervical spine complicate interpretation of previous results on VA strain (Herzog et al., 2012). The VA branches off the subclavian artery (V1 segment), before traveling vertically through the transverse foramen of the cervical vertebrae from C6 to C2 (V2 segment) (Netter, 2006). As the VA exits through C1 transverse foramen, it makes a radical shift in its path (V3 segment). The V3 segment of the VA shifts from a vertical orientation into a horizontal as it travels posteriorly, before entering the occiput (Netter, 2006).

The V3 segment of the VA is the most common reported site of an ischemic event and it also is noted for having the greatest amount of motion (Haldeman et al., 2002). One may hypothesize that due to the increased motion occurring in the V3 segment, there are large strains in the VA that may explain dissection of the artery at the V3 location.

Ultrasonography has been used to estimate strain in the V3 segment during motions of the head. However, these strains have not been linked to either the segmental or global kinematics of the head and neck (Callaghan et al., 2011).

Global kinematics of the head and neck are quantitatively reliable (Lansade et al., 2009) and are assumed to be bound biomechanically to segmental coupled motions to create arterial strain. Vertebral joint geometry and intersegmental tissue properties govern segmental motion coupling that sums to a global movement of the neck, with respect to the thorax.

The purpose of this study was to quantify the segmental mechanical strain in the VA, while simultaneously capturing kinematic data during passive global motion of the head and neck. In particular, flexion rotation and extension rotation, on the same side in cadaveric specimens, were quantified.

Secondary aims include quantitatively describing the variability in strain between multiple cadaveric specimen segment levels during passive range of motion (RoM) tests, in addition to observing strain and global motion of the head and neck during SM with varying clinicians. Our null hypothesis was that the relative strain (elongation from neutral) in the VA at the V3 segment during maximum flexion-rotation passive RoM, was not associated with the strain in maximum extension-rotation passive RoM.

A selection of published research by CMCC faculty

Piper SL et al

Methods This study was approved by both the Canadian Memorial Chiropractic College Research Ethics Board and the University of Calgary Conjoint Health Research Ethics Board.

order by a licensed chiropractor with one year of experience, and educated in RoM testing. Additional SM trials were conducted by three additional other licensed chiropractors, with varying years of experience (1–5 years). During each data collection trial, the head was moved in the chosen direction before being returned to the neutral position.

Study design This study used a cross-sectional sample to observe a potential relationship between the measured VA strain and passive global motion of the head and neck relative to the torso during extreme combined displacements in the cardinal planes.

Sample specification A convenience sample of three fresh, unembalmed, post-rigor cadavers was used. A priori sample size estimate indicated that six vertebral arteries (three cadaveric specimens) were required to achieve sufficient statistical power (see Justification of sample size and data analysis).

Any excessive superficial plaque formation observed on the outside layer of the VA as a result of calcification of the VA was also noted, however not excluded. To ensure that relatively normal ranges of motions were observed, cadavers were excluded if, upon visual inspection after dissection, they were noted to have obvious osteophytes or other indications of bilateral osteoarthritis which could impede motion of the cervical spine. The experienced anatomist and experimenter came to agreement, on visual inspection, that ranges of motion would not be impeded.

A RoM pre-screen was performed by an examiner, using a goniometer placed on the head of the cadaver. Side to side asymmetry, with a tolerance of 5° of variance, was allowed.

If the cadaver did not achieve previously listed values, it was excluded from testing. Kinematic data obtained from the goniometer allowed for exclusion on the basis of previous RoM guidelines, determined in healthy living subjects (Lansade et al., 2009). Other exclusion criteria included visually observed damage to the VA at any level.

Description of experimental maneuvers Following the RoM pre-screen evaluation, an experienced (10 years) anatomist exposed the anterolateral aspect of the VA, between each vertebral body segment, bilaterally using blunt dissection. A small incision was made above C1 at the V3 segment and also at each VA segment between the cervical vertebrae from C2 to C4 (V2). Piezoelectric ultrasonic crystals with a diameter of 0.5 mm (Sonometrics Corp., London, Ontario, Canada), were then sutured into the vertebral artery wall at each level (Fig. 1). A total of 4 crystals were inserted into each vertebral artery. Range of motion and SMT trials were performed in random

Fig 1. Pictorial representation of piezoelectric ultrasonic crystals insertion into left VA.

All RoM data were collected using a data acquisition system (Motion Analysis Corp., Santa Rosa, California, US) using eight infrared cameras, recording at 200 Hz, to monitor the positions of spherical 1.0 cm retroreflective markers. Three markers were affixed to a rigid plate over a centered anatomical landmark of the head (Fig. 2,marker I). The Frankfort plane was used to construct the head's local coordinate system. The Y-axis, in the coronal plane (positive to the left) was calculated using right and left tragions, in the notch just above the tragus. A vector connecting the lateral canthus of the eye, perpendicular to the Y-axis, determined the X-axis in the sagittal plane (forward is positive) (Fig. 2, marker II). The Z-axis was then positive superiorly. The position for the head center of mass (COM) was approximately 15 mm forward along the X-axis of the Frankfort plane (COM) (Fig. 2, X). The COM of the head was designated as the location for the coordinate system in relation to the rigid body marker set. The trunk of the specimen was anchored to the examining table using a strap. Markers for the trunk were mounted on a second plate, fixed to the sternum, and a second local coordinate system was constructed parallel to the head system, to define a neutral relative starting position. Prior to the examiner moving the head and neck, the VA was perfused with ultrasonographic gel to amplify the sound wave and to approximate the fluid filled state of the VA. During all RoM trials, passive head movements were controlled by manual contacts on the base of the occiput

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and zygomatic arches, avoiding contact with the exposed vertebral artery regions in the neck (Fig. 3). Three RoM trials were performed for each cardinal plane and combined movements of either flexion-rotation or extension-rotation were performed. The order of movement direction was randomly determined prior to testing. After each group of three RoM trials, the head was returned to neutral for a period of 2min, to limit the effects of stress relaxation in subsequent trials.

Outcome measures Ultrasonography Strain measurements were quantified using sonomicrometry sampled at 200.8 Hz. The piezoelectric crystals oscillate at high frequencies, to produce an ultrasonic pulse that travels at the relative speed of 1440 m/s. The distance between crystals at any instant during head motion, was quantified by multiplying the speed of the ultrasonic pulse by the time for the wave to travel between a pair of crystals. This method has been previously demonstrated to have a spatial resolution of 16 μm (Symons et al., 2002). The experimental procedure for previous spatial resolution was repeated for this study in an aqueous gel medium with similar outcomes.

The distance between pairs of crystals, with the head in the neutral position represented the initial length and was used as a reference for calculating VA strain ([L−L0] / L0) during the subsequent RoM and SM trials.

left VA was considered to be ipsilateral and the right VA was considered to be contralateral. The average peak angles of displacement were then synchronized with strain in the VA. Data capture for kinematics and ultrasound were initiated by assistants who triggered collection based on a verbal countdown from the examiner. Recording was stopped upon return of the head to the neutral start position and cueing from the examiner. Since the ultrasonography was collecting at 200.8 Hz and the kinematic analysis at 200 Hz, a post process digital synchronization was performed to line up signals in time.

Fig. 2. Definition of head-embedded reference frame used for kinematic analysis of head and neck motion relative to the trunk.

Kinematic analysis The average peak displacement angles achieved during RoM and SM trials were collected at 200 Hz, using a joint coordinate system. A joint coordinate system was used to calculate the relative 3D angular movements (flexion–extension, lateral bend and axial rotation) between the head and the trunk (Kintrak, University of Calgary Human Performance Laboratory, Calgary, AB, Canada).

The Euclidean norms of the component angular kinematic data were then used to calculate the overall angular displacement between the head and trunk.

Maximum peak strain and the strain at maximum angular displacement, were measured during all RoM testing (cardinal planes of movement and combined movements) and during the diversified rotary SM trials.

Displacements on opposite sides of the cardinal planes were considered independent from each other (flexion and extension). In combined motions involving more than one plane, descriptions were classified as being ipsilateral or contralateral with respect to the direction of head movement. For example, during rotation to the left, the

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Data filtering.

The kinematic data were not filtered. The ultrasonographic crystal data were filtered with a 2nd order dual pass Butterworth filter with a cutoff frequency of 1 Hz. The cutoff frequency was derived from residual analyses performed on the displacements derived from the crystals.

Justification of sample size and data analysis.

Descriptive statistics (mean and standard deviation) were used to characterize the peak strain, and the strain at maximum angular displacement was measured during all RoM testing (cardinal planes of movement and combined movements) as well as during the diversified rotary SM trials. A Pearson's product correlation coefficient quantified any association between the strains on the VA during combined motion of flexion-rotation versus extension-rotation. The sample size estimate was based on Cohen's “r” for a proposed correlation coefficient of 0.9 with a Type I error of 0.05 and a Type II error of 0.2.

A correlation as high as 0.9 as the boundary for clinical relevance, accounting for 81% of variability, was chosen since the potential impact of small relational changes in

Piper SL et al

A selection of published research by CMCC faculty

Fig. 3. Contact position for all RoM and SM trials (a) and example of head rotation to the left (b).

motion to sVAD leading to stroke is unknown. A total of 3 cadavers involving data from both arteries were required (Cohen, 1977).

Results The demographic information obtained for each specimen, including gender, height, weight, cause of death and pre-existing medical conditions, suggested that all causes of death and pre-existing medical conditions were unrelated to sVAD (Table 1). Only Specimen 3 demonstrated notable anatomic features of the vertebral bodies and arteries on inspection of the spine after dissection. Significant osteophytes on the vertebral bodies were observed that did not appear to encroach on the vertebral artery itself.

The VA appeared to bifurcate above the subclavian artery with one branch traversing through the left transverse process of C6 and a second branch that rejoined the V2 segment at the C5–C6 levels. Furthermore, anomalies were observed in the V3 segment of the VA in Specimen 3.

The artery, with its transition from vertical to horizontal orientation typically noted above C1 was instead, observed inferior to the C1 transverse processes bilaterally. None of the observed anomalies in Specimen 3 appeared to affect the pre-screen RoM. In addition post-testing observation of kinematic data and strain data collected was comparable to previous specimen.

Range of motion trials The mean angular displacements in the cardinal planes of motion, achieved in all three subjects, were comparable to previous results in healthy age-matched populations.

(Lansade et al., 2009) The strains observed in all trials were comparable to previous results measuring strain in the VA (Herzog et al., 2012). The correlation between strain

developed in the contralateral VA during flexion rotation and extension rotation was variable and did not achieve a positive correlation greater than 0.55 (Pearson's r ranges [df = 32]: −0.61 to 0.55) (Table 2). The VA strain at maximum angular displacement of the head and neck, relative to the trunk, varied remarkably across the artery's segments and between different movements (Table 2). Axial rotation of the head on the trunk produced the largest amount of strain in the contralateral VA (Table 3). In general, the maximum VA strain, that occurred during either combined or cardinal planar movements, did not coincide with the maximum angular displacement (Fig. 4).

Spinal manipulation trials.

VA strain that occurred at the maximum angular displacement during SM varied across VA segments and between clinicians (Table 4). The maximal amount of strain values produced in the VA during diversified rotary adjustments, from various clinicians, did not exceed the maximum strain achieved during the RoM trials (Tables 2, 4 and 5). The maximum angular displacement achieved during manipulation also varied between the four clinicians (Table 5). Interestingly, the two clinicians who produced larger angular displacements during manipulation also produced larger strains in the contralateral VA at the maximum angular displacement (Table 5). The clinician with the largest observed angular displacement had similar patterns of displacement in flexion and lateral bend compared to other clinicians in the study, however the axial rotation was much greater (Table 5, Fig. 5). Peak strain on the contralateral VA also appeared higher in the upper segments of the neck during spinal manipulation done by clinicians 1 and 3 (Table 5). Similar to the RoM trials, the maximum VA strain that occurred during SM did not coincide with maximum angular

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Table 1 Demographic information of fresh, unembalmed cadaveric specimen

Table 2 RoM trials. Segmental level strain (% length change) observed at maximum angular displacements (degrees) of glbal head and neck motion relative to the trunk. Values in parentheses represent minimum and maximum of segmental level strains. Pearson's r correlation values compares VA strain values observed during opposing directional movements.

a

Mean value

head displacement (Fig. 6). Although the VA strain patterns shown in Fig. 6 appear to precede the maximum angular displacement, a statistical trend was not observed.

Overall, the maximum strain value in the VA achieved during any trial of this study, either SM and/or RoM trials, did not exceed previous values with respect to global failure limits of the VA reported by Symons et al.

(Symons et al., 2002) (Fig. 7).

Discussion Lansade et al. reported a three-dimensional (3D) kinematic analysis on a large sample of living asymptomatic subjects to compare the impact of age and gender of subjects on active neck movements (Lansade et al., 2009). The results suggested that aging is associated with a decrease in cervical active RoM in the cardinal planes, but does not affect coupled motions, and gender does not appear to affect cervical RoM (Lansade et al., 2009). All specimens in our study were female and, therefore, no observations on gender specific differences with respect to motion and strain could be made. Additionally, it was observed that specimens in our study had similar neck and head RoM to healthy age-matched populations, although overall range of motion was lower than that observed in the majority of the population measured by Lansade et al. (2009). Additionally, it was observed that specimens in our study had neck and head RoM similar to the healthy age-matched populations;

22

although the results should be interpreted with caution, as the Lansade et al. (2009) study measured active range of motion and it should be assumed that passive motion in these healthy subjects should be greater than the subjects used in this study. It should also be noted that overall range of motion was lower than the majority of the population measured by Lansade et al. (2009). Dvorak et al. (1992) have previously measured cervical passive range of motion in a large sample of healthy subjects. The results of this study are comparable to the Dvorak et al. (1992) study of females over the age of 60 years except flexion/extension measures.

As previous literature suggests, range of motion decreases as age increases. Since the values of the current study are similar to the previous results, one could assume strain values may also be similar to some extent, although future detailed studies of segmental motion are required.

VA strain was not linearly related to passive global motion of the head and neck.

There appears to be a relationship between strain and motion, specifically rotational motion, although segmental movements (not measured) of the vertebral bodies may be better correlated to VA strain than global head and neck movements. Rotational motions produced the greatest VA strains. Considering the contralateral VA during rotation, one would expect an increase in strain while the ipsilateral VA would decrease in strain. This was not a consistent

A selection of published research by CMCC faculty

Piper SL et al

Table 3 RoM trials. Angular displacement (degrees) observed at maximum segmental level strain (% length change). Values in parentheses represent minimum and maximum of segmental level strains.

Strain (% length change)

Mean value

ROM (degrees)

a

Time (seconds) Primary Y axis: Angular ROM displacement (Euclidean norm of extension, rotation, lateral flexion) Secondary Y axis: Contralateral VA C0-C1 segmental level strain Secondary Y axis: Ipsilateral VA C0-C1 segmental level strain

Fig. 4. Representative RoM trial (extension-rotation) displaying maximum angular displacement (degrees) of global head and neck motion relative to the trunk and strains (% length change) in the ipsilateral and contralateral C0–C1 levels VA segments during combined extension-rotation movements (Angular displacement calculated using Euclidean norms of extension, rotation and lateral flexion).

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Table 4 SM trials. Segmental level strain (% length change) observed at angular displacements (degrees) of the global head and neck motion relative to the trunk. Values in parentheses represent minimum and maximum of segmental level strains.

Completed by 4 different clinicians.

a

Mean value

Table 5 SM trials. Angular displacement (degrees) observed at maximum segmental level strain (% length change). Values in parentheses represent minimum and maximum of segmental level strains. Completed by 4 different clinicians.

a

Mean value

Clinician 2 (2 Years of experience) Angular displacement (degrees)

Angular displacement (degrees)

Clinician 1 (1 Year of experience)

Time (seconds) Flexion

Lateral Bend

Time (seconds) Axial Rotation

Flexion

Axial Rotation

Clinician 4 (5 Years of experience)

Angular displacement (degrees)

Clinician 3 (2 Years of experience)

Angular displacement (degrees)

Lateral Bend

Time (seconds) Flexion

Lateral Bend

Time (seconds) Axial Rotation

Flexion

Lateral Bend

Axial Rotation

Fig. 5. Representative SM trial (left diversified rotary) of four clinicians of varying experiences (1–5 years) displaying 3D angular displacements of global head and neck motion relative to trunk. Planes of motion contribution separated into flexion, lateral bend and axial rotation.

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A selection of published research by CMCC faculty

Piper SL et al

in nature and will need to be interpreted with caution until future studies can reproduce similar results. The authors speculate that tissue viscoelasticity and segmental motion may play an important role in determining at what point the slack of the VA is taken up. A previous report suggests that arterial tissue has non-linear viscoelastic behavior when stressed in a longitudinal direction (Garcia et al., 2012). Theoretically then, the stress relaxation behavior of the VA may also not behave in a linear fashion. A narrative review on segmental cervical spine motion, provided by Bogduk and Mercer (2000), suggests that vertebrae may move independently of each other. Furthermore, a cervical segment may achieve its own end range of motion and proceed slightly into an opposite range, prior to the global neck reaching full end range of motion. Theoretically then, and based on the findings from the current study, a vertebral segment may reach end range, and therefore have the greatest strain on the VA, prior to reaching global end range of motion.

During SM, the rotational component of head and neck motion contributes the greatest amount to the VA strain.

It is worth noting that clinicians 1 and 3, with the least number of years of experience, used the largest amount of rotation to accomplish the SM's. In addition, although all

Strain (% length change)

finding with this study although mean values did appear to be slightly higher overall in the contralateral VA when compared to the ipsilateral VA, during opposing direction of movement. It should also be noted that translational motion (long axis distraction of the head and neck on the torso) was not measured in this study and, therefore, it is difficult to determine how much slack in the VA is taken up during rotation. An important clinical finding of this study is that all peak VA strains during SM and RoM testing were considerably smaller than the smallest VA failure strain.

(Symons et al., 2002) Previous studies reported similar results of VA strains during RoM and SM testing, but here, we add the important component of head and neck motion during these testing procedures. To date, this is the first study attempting to quantify an amount of angular displacement of the head and neck with respect to observed strain in the VA. Although our results are preliminary, future work may provide important quantitative relationships between head and neck motion, corresponding to segmental VA strains. Also, of clinical relevance is that maximum VA strains precede maximum angular displacements during passive global motion of the head and neck and SM (Fig. 6).

The greatest VA strains occurred at different time points prior to maximum angular displacement (Figs. 4 and 6, Tables 2–5). The reliability of these results is preliminary

Time (seconds) Primary Y axis: Angular ROM displacement (Euclidean norm of extension, rotation, lateral flexion) Secondary Y axis: Contralateral VA C0-C1 segmental level strain Secondary Y axis: Ipsilateral VA C0-C1 segmental level strain

Fig. 6. Representative SM trial (right diversified rotary) displaying the angular displacement of the head relative to the trunk (degrees) and corresponding strains in the ipsilateral and contralateral C0–C1 VA segments (% length change) during diversified rotary adjustment.

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clinicians in our study reported using a diversified technique for the upper rotary cervical adjustment, clinicians 1 and 3 graduated from the same college in the same year and, therefore, may have been taught by the same instructors.

The clinicians were not instructed to contact a reported segment of the cervical spine nor were they told to take the head to preload range typically performed in clinical practice. Therefore, a rotary thrust greater than what is typically seen in clinic may have been achieved. This would suggest that there may be less rotation during adjustments in clinical practice. Future studies will need to address the degree of angular displacements achieved by more experienced clinicians. Previous work by Symons et al. (2012) suggests, regardless of clinician experience or training, that forces delivered during SM on cadavers are greater than forces exerted on live human subjects. The authors speculate that based on the Symons et al. (2012) results, angular displacements may also be greater during SM in cadaveric studies when compared to live human subjects.

There are several limitations of the current study. A convenience sample of 3 female cadavers was used for this study. Therefore, a limitation of gender bias in global motion of the head and neck may exist. Previous studies suggest that there may be gender differences in cervical range of motion (Dvorak et al., 1992); however, it should be noted that gender differences in the Dvorak et al. (1992) study were not denoted in ages greater than 80 years of age. Lansade et al. (2009) also suggested that women may have greater mobility than men, in primary movements of the cervical spine, although statistical significance was only achieved for females compared to males aged 70–79 years. Based on these previous studies, the 3 females used in this study may have had greater motion compared to age matched males and a younger sample set. This might also suggest that the strain on the vertebral artery in our subjects may have increased variability, as their motion may have been greater.

A second limitation is the calcification of arterial tissue in the VA. The authors speculate that calcification of the intimal layer of VA would cause stiffening and therefore decrease the amount of strain observed. Although a superficial observation of the VA was completed post-dissection and none of our subjects were excluded due to excessive plaque formation, a more detailed observation of the intimal lining was not completed. A previous study suggests calcifications of the VA are common in older adults who have had ischemic stroke (96.3%) however the authors could not conclude whether the plaque formation and subsequent calcification caused the stroke (Pikija et al., 2013). A third limitation to the study is the reproducibility of motion patterns in the RoM

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and SM trials. The results of this study were highly variable.

Since the movement of the head and neck does not occur in a linear fashion when repeated, perhaps this will effect small undetectable changes in the VA segment. The use of a single technique of upper rotary cervical chiropractic adjustments with an occiput contact applied by four chiropractors of similar skill and experience may also limit generalizability to the wide variety of chiropractic adjustment techniques used in general practice. A fourth limitation is that maximal VA failure strain is likely greater than strains where micro-tearing of the intimal layer may occur. To date, only histological studies can show micro-tearing of the VA, thus assessing micro-damage is beyond the scope of current in vivo technology.

Max. failure strain

Max. ROM strain

Max. SMT strain

Fig. 7. Comparison of the maximum VA strain values observed during previous ex vivo failure testing (Symons et al., 2002) and VA strains obtained in this study during RoM and SM testing.

The fifth limitation is the dependence of samples, which also limits our conclusions, as both VA's from the same cadaver were assessed. The anatomy, biomechanics and segmental movements in one VA may not be independent of the opposite VA in the same specimen and future studies will need to assess segmental movements. The sixth limitation is that although blunt dissection and movement during testing may decrease tissue integrity, any compromise of tissue may result in an underestimation of how much local strain a typical VA can handle. Finally, the measurement of strain used in this study differs slightly from the typical engineering strain and is worth mentioning. The strain measurements in this study calculated change in distance from an initial resting position in which the VA V3 segment is slack. Engineering strain would suggest that measurement begins when the VA begins to deform and takes up a measurable amount of stress (visually observed at typically 12% strain) (Chaffin and Andersson, 1984; Symons et al., 2002). Currently, there is no feasible method to directly measure segmental motion of the cervical vertebrae combined with engineering strain in the VA V3 segment.

A selection of published research by CMCC faculty

Piper SL et al

Conclusion

Acknowledgements

The results of this study suggest that the strains on the VA during global head and neck movements, including SM, do not exceed published failure strains. Furthermore, this study supports previous evidence that the greatest amount of strain in the VA occurs during rotation (Herzog et al., 2012). This study provides new evidence that peak strain in the VA may not actually occur at the end range of motion, but rather at some point when the end range has not been reached yet. This finding leads to the conclusion that sVAD, due to global head and neck movements, is not predictable unless achieving large amounts of strain causing global failure, which was never observed in the current study.

The authors would like to thank Dr. Conrad Tang (chiropractor), Dr. Evan Durnin (chiropractor), Dr. Tim Leonard (technical assistance), Ms. Glenda McNeil (technical assistance), Mr. Calvin Cockerline (anatomist) and Mr. Hoa Nguyen (technical assistance) for their time and expertise.

This study was funded by the Canadian Chiropractic Research Foundation and the Alberta College and Association of Chiropractors (RT691362). This study was awarded with the Ontario Chiropractic Association/ Canadian Memorial Chiropractic College Student Research Award, 2012.

References 21. Bergmann, T., Peterson, D., 2010. Chiropractic Techniques: Principles and Procedures, Third ed. Mosby, New Jersey.

22. Bogduk, N., Mercer, S., 2000. Biomechanics of the cervical spine. I: normal kinematics. Clin. Biomech. 15 (2000), 633–648.

23. Callaghan, F.M., Luechinger, R., Kurtcuoglu, V., Sarikaya, H., Poulikakos, D., Baumgartner, R.W., 2011. Wall stress of the cervical carotid artery in patients with carotid dissection: a case–control study. Am. J. Physiol. Heart Circ. Physiol. 300 (4), H1451–H1458.

24. Chaffin, D., Andersson, G., 1984. Occupational Biomechanics.

John Wiley and Sons, New York.

25. Cohen, J., 1977. Statistical Power Analysis for the Behavioral Sciences, second ed. Academic Press, New York.

29. Dvorak, J., Antinnes, J., Panjabi, M., Loustalot, D., Bonomo, M., 1992. Age and gender related normal motion of the cervical spine. Spine 17 (10S), S393–S398.

30. Garcia, A., Martinez, M., Pena, E., 2012. Viscoelastic properties of the passive mechanical behavior of the porcine carotid artery: influence of proximal and distal positions.

Biorheology 49, 217–288 31. Haldeman, S., Kohlbeck, F.J., McGregor, M., 2002. Stroke, cerebral artery dissection, and cervical spine manipulation therapy. J. Neurol. 249 (8), 1098–1104.

32. Haneline, M., Lewkovich, G., 2005. An analysis of the etiology of cervical artery dissections: 1994 to 2003. J. Manip. Physiol.

Ther. 28 (8), 617–622.

33. Hassan, A.E., et al., 2011. Determinants of neurologic

26. Cote, P., Kreitz, B., Cassidy, J., Thiel, H., 1995. The validity of

deterioration and stroke-free survival after spontaneous

the extension-rotation test as a clinical screening procedure

cervicocranial dissections: a multicenter study. J. Stroke

before neck manipulation: a secondary analysis. J. Manip.

Physiol. Ther. 19 (3), 159–164.

27. Descarreaux, M., Nougarou, F., Dugas, C., 2012.

Cerebrovasc. Dis. 22 (4), 389–396.

34. Herzog,W., Leonard, T., Symons, B., Tang, C., Wuest, S., 2012.

Vertebral artery strains during high-speed, low amplitude

Standardization of spinal manipulation therapy in humans:

cervical spinal manipulation. J. Electromyogr. Kinesiol. 22

development of a novel device designed to measure dose–

(5), 1

response. J. Manip. Physiol. Ther. 36 (2), 78–83.

28. Duan, S., He, H., Lv, S., Chen, L., 2009. Three-dimensional CT study on the anatomy of vertebral artery at atlantoaxial and intracranial segment. Surg. Radiol. Anat. 32 (1), 39–44.

Originally published in Clinical Biomechanics, 2014 Dec;29(10):1099-107. Epub 2014 Oct 23. Reproduced with permission from Elsevier.

Access Online: http://dx.doi.org/10.1016/j.clinbiomech.2014.10.004

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Comparison of 2 Methods of Measuring Spine Angular Kinematics During Dynamic Flexion Movements: Skin Mounted Markers Compared With Markers Affixed to Rigid Bodies Howarth SJ Canadian Memorial Chiropractic College

Abstract Objective The purpose of this study was to compare the spine flexion angle time histories computed with the 2 described techniques (dot product [DP] and a modified joint coordinate system [JCS] approaches) that used vector algebra and used skin-mounted markers to the spine flexion angles derived using local coordinate systems constructed from rigid bodies affixed to the pelvis and thorax during spine flexion movements.

Methods Discrepancies between the simplified marker setup and a criterion standard (CS) method for measuring spine kinematics were quantified. Sixteen participants performed full forward spine flexion. Three-dimensional kinematic data were obtained from markers affixed bilaterally over the greater trochanters, iliac crests, and 10th ribs. Time varying spine flexion angles were derived from the 3-, and 2-dimensional marker data using a DP and a modified JCS approach. Criterion standard spine kinematics were obtained from clusters of markers adhered to 2 rigid fins that were affixed over the pelvis and trunk. The DP and

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JCS methods were compared with the CS by computing root mean squared differences and correlations during the spine flexion trials. Descriptive measurements of missing kinematic data were also obtained.

Results On average, root mean squared differences were 30.1% lower for the JCS method of deriving spine flexion angles.

Correlations were also higher for the JCS method by 2.5%, compared with the DP method.

Conclusion The findings suggest that the adapted JCS method is superior to the DP method for deriving spine flexion angles.

This is especially true when only 2-dimensional coordinate data are available.

Originally published in the Journal of Manipulative and Physiological Therapeutics, 2014 Nov-Dec;37(9):688-95.

Epub 2014 Oct 30. Reproduced with permission from Elsevier.

Access Online: http://dx.doi.org/10.1016/j.jmpt.2014.10.006

A selection of published research by CMCC faculty

Neck Muscle Fatigue Alters the Cervical Flexion Relaxation Ratio in Sub-Clinical Neck Pain Patients Zabihosseinian M1, Holmes MW1, Ferguson B2, Murphy B1 University of Ontario Institute of Technology, 2Canadian Memorial Chiropractic College

1

Abstract Background The cervical flexion relaxation ratio is lower in neck pain patients compared to healthy controls. Fatigue modulates the onset and offset angles of the silent period in both the lumbar and cervical spine in healthy individuals; however, this response has not been studied with neck pain patients. The purpose of this study was to determine if cervical extensor fatigue would alter the parameters of the cervical flexion relaxation more in a neck pain group than a healthy control group.

Methods Thirteen healthy and twelve neck pain patients participated.

Cervical extensor activity was examined bilaterally and kinematics of the neck and head were collected.

An isometric, repetitive neck extension task at 70% of maximum elicited fatigue. Participants performed 3 trials of maximal cervical flexion both pre and post fatigue.

Findings The healthy controls and neck pain groups fatigued after 56 (41) and 39 (31) repetitions, respectively. There was a significant interaction effect for the flexion relaxation ratio between the control and neck pain groups from pre to post fatigue trials (F1,96=22.67, P=0.0001), but not for onset and offset angles (F1, 96=0.017, P=0.897), although the onset and offset angles did decrease significantly for both groups following fatigue(F1,96=9.26, P=0.002).

Interpretation The healthy controls and neck pain groups fatigued after 56 (41) and 39 (31) repetitions, respectively. There was a significant interaction effect for the flexion relaxation ratio between the control and neck pain groups from pre to post fatigue trials (F1,96=22.67, P=0.0001), but not for onset and offset angles (F1, 96=0.017, P=0.897), although the onset and offset angles did decrease significantly for both groups following fatigue(F1,96=9.26, P=0.002).

Originally published in Clinical Biomechanics, 2015 Jun;30(5):397-404. Epub 2015 Mar 27. Reproduced with permission from Elsevier.

Access Online: http://dx.doi.org/10.1016/j.clinbiomech.2015.03.020

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Sensor Positioning and Experimental Constraints Influence Estimates of Local Dynamic Stability During Repetitive Spine Movements Howarth SJ1, Graham RB2 Canadian Memorial Chiropractic College, 2Nipissing University

1

Abstract Application of non-linear dynamics analyses to study human movement has increased recently, which necessitates an understanding of how dependent measures may be influenced by experimental design and setup. Quantifying local dynamic stability for a multi-articulated structure such as the spine presents the possibility for estimates to be influenced by positioning of kinematic sensors used to measure spine angular kinematics. Oftentimes researchers will also choose to constrain the spine's movement by physically restraining the pelvis and/or using targets to control movement endpoints. Ten healthy participants were recruited, and asked to perform separate trials of 35 consecutive cycles of spine flexion under both constrained and unconstrained conditions. Electromagnetic sensors that measure three-dimensional angular orientations were positioned over the pelvis and the spinous processes of L3, L1, and T11. Using the pelvic sensor as a reference, each sensor location on the spine was used to obtain a different

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representation of the three-dimensional spine angular kinematics. Local dynamic stability of each kinematic time-series was determined by calculating the maximum finite-time Lyapunov exponent (ƛmax). Estimates for ƛmax were significantly lower (i.e. dynamically more stable) for spine kinematic data obtained from the L3 sensor than those obtained from kinematic data using either the L1 or T11 sensors. Likewise, ƛmax was lower when the movement was constrained. These results emphasize the importance of proper placement of instrumentation for quantifying local dynamic stability of spine kinematics and are especially relevant for repeated measures designs where data are obtained from the same individual on multiple days.

Originally published in the Journal of Biomechanics 2015 Apr 13;48(6):1219-23. Epub 2015 Feb 2. Reproduced with permission from Elsevier.

Access Online: http://dx.doi.org/10.1016/j.jbiomech.2015.01.036

A selection of published research by CMCC faculty

Clinical Sciences

A Profile of the Youth Olympic Taekwondo Athlete Kazemi M, De Ciantis MG, Rahman A Canadian Memorial Chiropractic College

Abstract Our study aims to identify trends in anthropomorphic attributes and competitive strategies of successful (medalists) versus non medalist young Olympic Taekwondo competitors by gender in terms of body mass, body-mass index (BMI) and fighting technique at the Youth Olympic Games 2010. Results were then compared to adult Taekwondo Olympic athletes in 2000, 2004 and 2008. Data on 96 Taekwondo athletes were obtained from the official Youth Olympic website. A LOGIT analysis was performed on the following six independent variables: height, body mass, body mass index, gender, techniques used to score, and

warnings obtained during a match. The study did find some differences between winners and non-winners for males and female, although none of the differences were statistically significant. Consequently, training personnel may enhance winning potential of Taekwondo competitors by focusing on offensive versus defensive techniques and improving the quality of punching.

Originally published in the Journal of the Canadian Chiropractic Association, 2013 Dec;57(4):293-300.

Reproduced with permission.

The Reliability of Body Pain Diagrams in the Quantitative Measurement of Pain Distribution and Location in Patients with Musculoskeletal Pain Southerst D1,3 , Côté P1,2,4 , Stupar M3 , Stern P4 , Mior S4 UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology, 2University of Ontario

1

Institute of Technology, 3University of Toronto, 4Canadian Memorial Chiropractic College

Abstract Objective The purpose of this study was to perform a systematic review of test-retest, intraexaminer, and interexaminer reliability of measuring pain location and distribution using the body pain diagram.

Methods We conducted a systematic review of the literature using a search conducted in Medline, CINAHL, and Nursing and Allied Health from inception to March 1, 2012. Articles were screened and selected by pairs of reviewers using

predetermined inclusion criteria. Internal validity was assessed independently by 2 reviewers using a modified version of the QUADAS instrument. Articles with adequate internal validity were included in the best evidence synthesis.

Results We reviewed 10 studies. Of those, 6 were included in the best evidence synthesis. We found varying levels of evidence that pain location and pain distribution can be measured

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reliably using the body pain diagram in patients with acute and chronic low back pain with or without radiculopathy.

The test-retest reliability for measuring pain distribution ranged from intraclass correlation coefficient of 0.58 to 0.94. Similarly, the test-retest reliability for measuring pain location ranged from kappa (ĸ) of 0.13 to 0.85. The intraexaminer and interexaminer reliability for measuring pain distribution were intraclass correlation coefficient of 0.99 and 0.99, respectively. The intraexaminer and interexaminer reliability for measuring pain location ranged from ĸ of 0.77 to 0.88 and 0.61 to 1.00, respectively.

Conclusions We found important variations in the test-retest reliability of pain location and distribution across different test-retest scenarios and across body regions. The intraexaminer and interexaminer reliability for the measurement of pain distribution and pain location using the body pain diagram in patients with acute and chronic low back pain with or without radiculopathy are adequate.

Originally published in the Journal of Manipulative and Physiological Therapeutics 2013 Sep;36(7):450-9. Epub 2013 Jul 8. Reproduced with permission from Elsevier.

Access Online: http://dx.doi.org/10.1016/j.jmpt.2013.05.021

Immediate Effects of Spinal Manipulative Therapy on Regional Antinociceptive Effects in Myofascial Tissues in Healthy Young Adults Srbely JZ1,2 , Vernon H2 , Lee D2 , Polgar M1 University of Guelph, 2Canadian Memorial Chiropractic College

1

Abstract Objective The purpose of this study was to investigate if spinal manipulative therapy (SMT) can evoke immediate regional antinociceptive effects in myofascial tissues by increasing pressure pain thresholds (PPTs) over myofascial trigger points in healthy young adults.

Methods A total of 36 participants (19 men, 17 women; age, 28.0 [5.3] years; body mass index, 26.5 [5.7] kg/m2) with clinically identifiable myofascial trigger points in the infraspinatus and gluteus medius muscles were recruited from the University of Guelph, Ontario, Canada. Participants were randomly allocated to 2 groups. Participants in the test group received chiropractic SMT targeted to the C5-C6 spinal segment.

Participants in the control group received sham SMT. The PPT was recorded from the right infraspinatus and gluteus medius muscles at baseline (pre-intervention) and 1, 5, 10. and 15 minutes post-intervention.

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Results Three participants were disqualified, resulting in a total of 33 participants analyzed. Significant increases in the PPT (decreased pain sensitivity) were observed in the test infraspinatus group when compared with test gluteus medius, control infraspinatus, and control gluteus medius groups (P < .05). No significant differences in PPT were observed at any time point when comparing test gluteus medius, control infraspinatus, and control gluteus medius groups (P > .05).

Conclusions This study showed that SMT evokes short-term regional increases in PPT within myofascial tissues in healthy young adults.

Originally published in the Journal of Manipulative and Physiological Therapeutics 2013 Jul-Aug;36(6):333-41.

Epub 2013 Jul 3. Reproduced with permission from Elsevier.

Access Online: http://dx.doi.org/10.1016/j.jmpt.2013.01.005

Triano JJ et al

A selection of published research by CMCC faculty

â&#x20AC;&#x201A; Clinical Sciences Feature Article

Review of Methods Used By Chiropractors to Determine the Site for Applying Manipulation Triano JJ1, Budgell BS1, Bagnulo A 2, Roffey B2, Bergmann T2, Cooperstein R4, Gleberzon B1, Good C5, Perron J2, Tepe R6 Canadian Memorial Chiropractic College, 2Private Practice, 3Northwestern Health Sciences University, 4Palmer College, 5University of

1

Bridgeport, 6Logan College of Chiropractic

Abstract Background With the development of increasing evidence for the use of manipulation in the management of musculoskeletal conditions, there is growing interest in identifying the appropriate indications for care. Recently, attempts have been made to develop clinical prediction rules, however the validity of these clinical prediction rules remains unclear and their impact on care delivery has yet to be established.

The current study was designed to evaluate the literature on the validity and reliability of the more common methods used by doctors of chiropractic to inform the choice of the site at which to apply spinal manipulation.

Methods Structured searches were conducted in Medline, PubMed, CINAHL and ICL, supported by hand searches of archives, to identify studies of the diagnostic reliability and validity of common methods used to identify the site of treatment application. To be included, studies were to present original data from studies of human subjects and be designed to address the region or location of care delivery. Only English language manuscripts from peer-reviewed journals were included. The quality of evidence was ranked using QUADAS for validity and QAREL for reliability, as appropriate. Data were extracted and synthesized, and were evaluated in terms of strength of evidence and the degree to which the evidence was favourable for clinical use of the method under investigation.

Results A total of 2594 titles were screened from which 201 articles met all inclusion criteria. The spectrum of manuscript quality was quite broad, as was the degree to which the evidence favoured clinical application of the diagnostic methods reviewed. The most convincing favourable evidence was for methods which confirmed or provoked pain at a specific spinal segmental level or region. There was also high quality evidence supporting the use, with limitations, of static and motion palpation, and measures of leg length inequality. Evidence of mixed quality supported the use, with limitations, of postural evaluation. The evidence was unclear on the applicability of measures of stiffness and the use of spinal x-rays. The evidence was of mixed quality, but unfavourable for the use of manual muscle testing, skin conductance, surface electromyography and skin temperature measurement.

Conclusions A considerable range of methods is in use for determining where in the spine to administer spinal manipulation. The currently published evidence falls across a spectrum ranging from strongly favourable to strongly unfavourable in regard to using these methods. In general, the stronger and more favourable evidence is for those procedures which take a direct measure of the presumptive site of care methods involving pain provocation upon palpation or localized tissue examination. Procedures which involve some indirect assessment for identifying the manipulable lesion of the spine such as skin conductance or thermography tend not to be supported by the available evidence.

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Introduction The primary focus of chiropractic practice is the evaluation and management of disorders of the neuromusculoskeletal system. Treatment of these disorders includes manual manipulation procedures directed toward normalizing alterations of the locomotor system [1]. With increasing evidence of clinical benefit for spinal manipulation (for example, see Gross et al. [2]; Rubinstein et al. [3]; Bronfort et al. [4], there is growing interest in identifying the appropriate indications for localizing the site of care.

Patient evaluation can be viewed as a sequence of procedures designed to progressively narrow the focus of attention, first to region then local site and, sometimes, tissue. In the ideal circumstance, the clinical value of a test or maneuver is based more on the health consequences from using it rather than on its accuracy alone [5]. In the case of the spine, however, over 90% of complaints have been categorized as a heterogeneous grouping which might be termed “non-specific” spinal pain [6]. An additional 5% to 9% are attributed to neurological deficits referable to the spine. Currently, there is no consensus on the mechanism(s) or identity of the pain generators of non-specific spinal pain. Even the validity and impact on care delivery of recent clinical prediction rules remain uncertain [7]. Consequently, there is no gold standard for diagnosis, in the traditional sense. A more pragmatic concept, the clinically important manipulable or functional spinal lesion, has emerged that recognizes the heterogeneous clinical manifestations from local tissue strains and altered neuromotor control [8,9] seen in these patients.

As in other fields of medicine, it is the clinical presentation, rather than a gold standard diagnosis, that directs decision making [10-12]. Faced with the dilemma of an absent gold standard [10] and yet a duty to care [13], one of the options is to evaluate the consequences of the disorder being treated. For example, there currently is no means to differentiate the specific pain generator in the presence of multiple abnormalities on imaging [14]. For a patient who has radicular pain, an imaging abnormality that has the potential to produce symptoms must be concordant with the location and distribution of signs and symptoms to correctly frame the diagnosis. This is the framing of gold standard that is adopted for use within the remainder of this article.

The pathophysiologic consequences of manipulable lesions have been loosely aggregated, primarily from common clinical wisdom and collective experience, into related categories: Pain, Asymmetry, relative Range of motion,

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changes in Tissue temperature/texture/tone, and findings from Special tests (P.A.R.T.S.). Thus, P.A.R.T.S. is commonly viewed [15] as a required foundation for manipulation treatment and is likely the most widely utilized method to justify a treatment application site [16].

There appear to be six core and overlapping constructs underlying the P.A.R.T.S. These constructs define somatotopic relationships between the patient’s signs and symptoms and biological substrates including dermatomes, sclerotomes and myotomes, as detailed below: • ○○

• ○○

• ○○

• ○○

○○

• ○○

Pain-P Findings from self-report and the reproduction of pain through diagnostic manoeuvres are spatially related to the local presence of pathology dysfunction.

Asymmetry-A A.Anatomical landmarks present an observable cephalo-caudal pattern, within the sagittal plane, and/or a bilateral symmetry in their location, motion and compliance/stiffness in response to challenge or perturbation.

Range of motion-R R.Joints, within a linkage system, contribute a predictable proportion and path to the regional movement expressed by the linkage system as a function of task.

Tissue temperature, texture and tone-T Muscle, as both a sense organ and actuator, responds to pathology that is spatially related with hypertonicity, hypotonicity, hypertrophy or atrophy as a function of the primary tissue disease process present.

In the presence of pathology/dysfunction, a spatially consistent change in the relative ratio of fluid (edema) to cellular and acellular components is observable.

Special Test-S In the presence of pathology/dysfunction, there is a spatially consistent neurogenic activity that demonstrates a muscular, kinematic, vascular, or secretory response that is observable.

When a course of manipulation is elected, the provider must use her/his clinical judgment, often employing the constructs above, to determine which procedures to apply and where. It is this topic that motivates the present work.

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To be clear, the topic of investigation was not to determine the bases for a judgement to apply manipulation, rather that once such a judgement has been made, what are the foundations to determine the site to which treatment would be directed. The purpose of this study is to identify the best available evidence as to what methods of assessment can inform the provider as to localization of treatment.

Methods The core question on where to site the application of manipulation treatment, while simple in concept, is remarkably complex to answer. The literature involves a breadth of evidence which often has been studied using heterogeneous methods or measures and requires contextual interpretation. The approach used was a hybrid method allowing for both a consensus process, after the work of Bigos et al. [17], Haldeman, Chapman- Smith and Petersen [18] and the RAND expert panels on the appropriateness in use of manipulation [19,20], with the use of explicit and systematic tools to evaluate the quality of evidence in the manner of a systematic review [21]. Unlike the evaluation of outcome-related studies that lend themselves to use of PRISMA [21], MOOSE [22] or RAMSES [23] guidelines, studies that evaluate the “accuracy” of tests require different criteria to appropriately assess the quality of studies and the potential for bias [24].

A team of reviewers was assembled under sponsorship of the Association of Chiropractic Colleges (ACC) in conjunction with the Council on Chiropractic Guidelines and Practice Parameters (CCGPP). Two team leads (JT & BB) were identified who together held prior experience and publications in methods of literature synthesis and/or analysis. Administrative support was provided by two recent graduate clinicians (AB & BR) who tracked article reviews and team member participation. A request for nominations to the review panel was sent to constituent members of the ACC and CCGPP. The panel of reviewers consisted of 7 members (1 PhD; 2 DC, PhD; 1 DC, MSc; 3 DC) representing 5 different chiropractic institutions. One reviewer was based in private practice, 5 DCs were in part-time practice or had recently retired from full time practice. The panel conducted reviews and developed consensus for conclusions presented in this report, independently from the sponsors.

Electronic searches were conducted using EBSCO host search engine within Medline, PubMed, CINAHL and ICL through July 2010. A series of terms were searched individually and concatenated with anatomical region (i.e. spine, vertebr*, cervical spine or neck, thoracic spine or mid back, lumbar spine or low back, sacroiliac joint or pelvis)

A selection of published research by CMCC faculty

and/or treatment type (i.e. manip* or mobilis* or mobiliz*) and/or discipline (e.g. chiropract*). The terms list was inclusive of the following: applied kinesiology, arm fossa test, current perception threshold, diagnos*/ assessment, electromyography/electromyograph*/emg joint play/ challenge, leg length inequality/asymmetry, muscle testing/ manual muscle test*, neurocalometer/ neurocalomet*, orthopedic/orthopedic test, pain/pain provocation, palpation–static and motion, P.A.R.T.S (pain, asymmetry, range of motion, tone and texture and special tests) , physical examination, posture, radiography/radiograph*/ x-ray, range of motion/rom.

Hand searches of publication references and of archives were also conducted. References retained for review by the team had to meet five prospective inclusion criteria: 1) topics focused on diagnostic validity and/or reliability for methods of patient evaluation used to identify the site of care by manual treatment, 2) articles were primary source research reports containing original data obtained from humans, 3) examiners were experienced providers or health sciences students, 4) for validity studies, at least some of the subjects must have been symptomatic or have had a known anatomical anomaly, and 5) publication was in the indexed and peer reviewed English language literature. No limits were placed on the date of publication.

In addition to searching for studies pertaining to individual assessment procedures, studies that investigated clusters of tests were also retrieved. Search topics were informed by the background focus on spinal manipulation and the P.A.R.T.S. constructs. Searching was assisted and full text copies of papers were made available for administrative review through the services of the Cleveland Chiropractic College and Canadian Memorial Chiropractic College Libraries.

The administrative screening confirmed eligibility of the paper according to the prescribed inclusion criteria checklist. Subsequently, each eligible paper was assigned to one of two research assistants who worked independently of the reviewers and who extracted data which was placed in an evidence table. In addition to manuscript metadata (author, journal etc.), the evidence table recorded the spinal region investigated, the reference standard (‘gold standard’), disease spectrum of patients/subjects, whether the manuscript referred to intra-rater reliability, inter-rater reliability or validity, a summary of the experimental design, the statistics/outcome measures reported, and any limitations to be taken into consideration in interpreting the findings.

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Table 1 Rankings of validity studies per QUADAS scores

Summary scores (not shown) were generated using weightings of QUADAS checklist items, where weights of individual items were based on the inverse of their prevalence with this cohort of articles. Subsquently, articles were ranked according to their normalized (Percentile) score and relative position (Rank) with this cohort of articles.

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Table 2 Rankings of reliability studies per QAREL scores

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Table 2 Rankings of reliability studies per QAREL scores (continued)

Summary scores (not shown) were generated using weightings of QAREL checklist items, where weights of individual items were based on the inverse of their prevalence with this cohort of articles. Subsquently, articles were ranked according to their normalized (Percentile) score and relative position (Rank) with this cohort of articles.

Each article then was assigned, on a rotating basis, to two reviewers. Within the two classes of studies, validity and reliability, papers were scored independently by each reviewer based on their content using the QUADAS [25,26] and QAREL [27] instruments, respectively. Some validity studies contained nested reliability studies for specific aspects of the methods under investigation. These minor reliability exercises were not scored independently. Each member of the team participated in training with respect to use of the two instruments under supervision of an experienced user (BB). Exercises consisting of review and scoring of validity and reliability studies were conducted using literature unrelated to the purpose of this study. Scored checklists were returned to the research assistants, who were not part of the review team, and results were recorded. If there was disagreement between reviewers on any element of the QUADAS or QAREL ratings, communication over the point of disagreement was facilitated by the research assistant to attempt reconciliation. For any disagreement not reconciled between reviewers, the topic was set aside for the full review panel meeting and discussion.

Item response theory was used to weight QUADAS and QAREL items based on the inverse of their prevalence among the papers reviewed (see Nakayama and Budgell 2009) [28]. A separate manuscript, under preparation, describes the validation of this approach for QUADAS and QAREL. In brief, however, papers were not simply awarded

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1 point for each criterion which they satisfied. Rather, criteria were weighted and their ability to discriminate between papers of higher and lower quality was confirmed.

These scores only indicate relative quality within the cohort of papers reviewed and only based on the QUADAS and QAREL checklists. The full listing of scores by primary author and date may be found in Tables 1 and 2. Question level data for each paper scored with QUADAS and QAREL may be found in Additional files 1 and 2, respectively.

The full team met to review scores and to summarize the evidence. Seed definitions for quality of evidence, prepared in advance of the team meeting by the project support staff, were derived from the earlier work by Bronfort et al. [4].

Final definitions for consensus were adopted by vote at the outset of the meeting. Each reviewer presented summary overviews on up to 3 of the patient assessment methods, discussing the quality and content of each paper and the overall quality and content of the body of literature on the topic. Discussion was conducted following presentation of each summary, using a facilitated round-robin method [29,30].

Thus, after each reviewer had made their presentation, each participant was addressed, in turn, with the opportunity to comment with respect to a topic and to ask questions until he/she was satisfied. Following one round, a second round was conducted where each member was offered a further opportunity to emphasize or introduce comments. Summary notes on comments were maintained electronically and on a

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white-board. Then, by consensus vote, the group ranked the quality of the body of literature on each topic and the degree to which the literature supported the use of the modality in question. Consensus summary scores for each paper served to rank the quality of each article as a percentile within its cohort of reliability or validity papers.

Where both intra- and inter-examiner reliability was assessed, we chose to weight only the latter as it speaks more to the generalizability of use. Similarly, where papers reviewing literature on reliability and/or validity were used to establish topic background and context, the precursor studies were not independently rated.

A mechanism for a minority opinion report was prospectively designed for the circumstance where a consensus by simple majority could not be achieved. Final recommendations on whether or not the diagnostic tool should be utilized in practice came from the consensus rankings.

Results The interprofessional relevance of the literature retrieved will be immediately evident. Not unexpectedly, while the search strategies were narrowed to those topics arising from or related to the PARTS concepts and the discipline focus, work from authors of various disciplines were represented and suggests that the findings reported herein have broader application than to the chiropractic discipline alone.

A total of 2577 titles identified through the electronic literature search were screened, and, from these, 184 articles met all inclusion criteria and were accepted into this study. In the course of the project, an additional 17 articles were brought forward by reviewers, determined to meet the inclusion criteria and were incorporated into the analysis.

Hence, the great majority of studies identified in our initial literature search were excluded from analysis. The most common reasons were that the studies were not directed towards identifying the site of care, region or segment, to be treated, and that the study involved subjects who were, in the main or entirely, healthy (Figure 1). Topic areas were aggregated following the P.A.R.T.S. constructs with the number of studies at each level of evidence listed with the section title. Some papers were included in more than one section if they investigated more than one assessment modality. A summary of the literature representative of the breadth of quality scores is provided under each heading with panel recommendations and ratings of the evidence. No conflicts on QUADAS or QAREL scores remained between reviewer pairs for the consensus meeting agenda. Similarly, no minority reports resulted from the consensus rankings.

A selection of published research by CMCC faculty

Literature Search Strategy Medline/Pubmed, CINHAL, Index to Chiropractic Literature

2577 articles recovered Screening to Meet Inclusion Criteria and Remove Duplicates (performed by research assistant) -Peer-reviewed English language literature -Human diagnostic studies -Original data -Intent to determine site of care -Examiners were health professionals/students -For validity, subjects had some abnormality/complaint

2293 articles excluded

284 articles sent to pairs of reviewers Scoring against QUADAS and QAREL Checklists (performed by pairs of reviewers) -Reviewers identified articles which did not appear to meet inclusion criteria

100 articles excluded

184 articles sent for evaluation by full review group 17 new articles nominated by reviewers in course of project and approved by at least 2 reviewers

Total of 201 articles evaluated by full review group

Fig. 1 Literature search strategy

Consensus and levels of evidence Consensus was defined as an agreement of greater than or equal to 70% by panel vote. Following the reviewer ranking according to QUADAS and/or QAREL scores, each paper was considered as providing a ‘high’ level of evidence if it achieved a quality score ≥ 70%, a ‘moderate’ level of evidence if its score ranged between 40% and 69%, and a “low” level of evidence if the score was ≤ 39% (see Table 3, Column 2). These criteria were set based on what appeared, early in the study, to be natural clusterings of scores.

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Interpretations of reliability Kappa (ĸ) scores follow the work of Viera and Garrett [31] and for intra-class correlations (ICC) that of Fleiss [32]. Definitions relating score value with levels of agreement are provided, for convenience, in Table 4.

A summary of recommendations, themselves reported at the end of each section below, can be found in Tables 5 and 6. Table 5 provides a description of each of the five possible types of recommendation while Table 6 gives a summary of recommendations for each category of evaluation method.

It should be emphasized for clarity that there were a significant number of the studies that offered evidence on more than one assessment approach. The definitions for rating of evidence (Table 3) were based on the number of papers for which the QUADAS or QAREL scoring met or exceeded the threshold level.

good to excellent reliability (0.72 ≤ ĸ ≤ 1.0) included mode of onset, nature of symptoms, prior episodes, downward or upward looking, and sleeping postures aggravating symptoms. The inter-rater reliability of patient classification ranged from 0.68 ≤ ĸ ≤ 0.88, with judgments made strictly from recorded data on forms showing the lower reliability [38] . Fortin [35], in a low quality study, looked at the validity of patients pointing and thereby localizing symptoms to the sacroiliac joint. Sixteen subjects received provocative joint injections. All were positive for local pain. A subset of 10 subjects was further evaluated for comorbid discogenic or zygapophyseal joint pain generators with negative results for these conditions.

Recommendation: Favourable, based on moderate quality evidence, for use of pain history to increase reliability of symptom provoking findings during the assessment of site to apply treatment.

Pain [Quality scores: Validity 0 low, 1 moderate, 11 high; Reliability 12 low, 17 moderate, 1 high].

Provocative manoeuvres, evoking relief or aggravation of familiar pain, augmented by historical factors, have been used to localize the suspected pain generator throughout the spine [33-67].

Pain on provocation–tenderness [Quality scores: Validity 0 low, 0 moderate, 5 high; Reliability 5 low, 7 moderate, 2 high]

In general, reliability of evaluations suffers unless pain provocation or pain history associated with the physical examination are taken into account [34-39]. In work on the cervical spine by Bertilson et al. [37], the awareness of complaint history enhanced reliability, measured by kappa, from 0.57 to 0.67 for evaluation of dermatomal sensitivity to pain, and from 0.4 to 0.49 for tenderness assessment.

Cleland et al. [39] conducted a wide ranging study of reliability for history and physical findings related to neck pain.

Categorical variables from the history that resulted in very

The finding of tenderness connotes an unusual or increased sensitivity to pressure on palpation that localizes to the area examined. Where possible, the sensitivity of a site is evaluated by comparison to its contralateral asymptomatic counterpart. Twenty-two papers dealing with pain/ tenderness on palpation were reviewed [33,40-50]. Bryner [43] used patient self-report of painful region as a reference standard to evaluate validity of examiner marked pain drawings for areas of tenderness to palpation. Sensitivity (0.73) and specificity (0.98) were excellent between the examiner and patient reports with respective positive (0.78) and negative (0.96) predictive values. Tenderness of the cervical articular pillars was evaluated in patients with neck pain and in healthy controls by Sandmark and Nissel 1995 [45]. High sensitivity (0.82) and specificity (0.79), with moderate positive (0.62) and high negative (0.91) predictive values were found. Leboeuf-Yde et al. [48], in a high quality

Table 3 Levels of evidence defined by quality scores of individual papers

Table 4 Definitions of levels of agreement for reliability study scores

Pain History [Quality scores: Reliability 0 low, 5 moderate, 0 high].

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study, looked at tenderness of the spinous processes on percussion, finding tenderness to have low sensitivity (0.39) and positive predictive (0.41) values with high specificity (0.78) and negative predictive (0.78) values.

Lundberg and Gerdle [47] found substantial agreement between abnormal passive mobility tests of the lower lumbar spine and segmental pain provocation tests at L4/5 (ĸ=0.71) and L5/S1 (ĸ=0.67), somewhat better than the results reported by Hicks et al. (2003) [57]. Inter-rater reliability was substantial (ĸ=0.68) among seven examiners of neck pain patients in the report by Hubka and Phelan [44].

For the thoracic spinal region [50,51] and rib cage, substantial (0.62 ≤ ĸ ≤ 0.70) and almost perfect (ĸ=0.88) inter-rater reliability were reported for tenderness to pressure on the spinous and transverse processes, respectively.

Tender points in the anterior and posterior soft tissue compartments of the upper neck [46] showed moderate inter-rater agreement (ĸ = 0.45).

King et al. investigated the validity of palpation for cervical facet joint pain using response to medial branch nerve blockade as the reference standard. Whereas preliminary work by Jull et al. [53] reported 100% sensitivity and near 100% specificity, King et al. reported that manual palpation provided high sensitivities (0.88–0.89) and low specificities (0.39–0.50) but with low likelihood ratios of 1.4 to 1.8. The most common joint involvements in this study were C2-3 and C5-6. The high prevalence of C2-3 and C5-6 lesions, consistent with other reports, erodes the sensitivity values, drawing into question the ability to localize pain to the zygapophyseal joint itself [47].

[52]

The study by Viikari-Juntura et al. [33] evaluated inter-rater reliability of examination findings in 52 neck pain patients referred for myelography. Pain response to pin prick had moderate agreement (0.41 ≤ ĸ≤ 0.51), with change in light touch (0.1 ≤ ĸ≤ 0.6) and palpatory tenderness (0.24 ≤ ĸ≤ 0.56) rating only fair to moderate. The inter-rater reliability of localizing pain to the upper, mid and lower cervical spine

A selection of published research by CMCC faculty

gave moderate (ĸ=0.53) agreement in the report by Maigne et al. [54]. A positive, but low, correlation (r=0.35, p<0.007) was noted between the number of areas of tenderness and the patient’s neck disability questionnaire scores.

Agreement [54] for tenderness over neck muscle insertions ranged from fair (ĸ=0.33) to substantial (ĸ=0.62). Boline et al.[40,55] reported that pain on palpation over spinal/ paraspinal osseous and soft tissue structures showed inter-rater reliability (0.48 < ĸ < 0.90) that was moderate to almost perfect in agreement.

Recommendation: Favourable, based on high quality evidence for validity and reliability of using tenderness to localize treatment.

Pain provocation by orthopedic manoeuvres [Quality scores: Validity 1 low, 0 moderate, 2 high; Reliability 11 low, 15 moderate, 5 high].

In terms of the quality of the evidence, two studies [48,56] evaluating validity were of high quality, while one was of low quality [57]. Eleven reliability studies [41,57-66] were ranked as being of low quality, fifteen were ranked as moderate quality [33,34,36,37,39,67-76] and five, three of which contained nested reliability studies, were ranked as high quality [54,77-80].

Leboeuf et al. [48], using low back pain symptom history as a gold standard, evaluated the validity of provocation of pain by movement and seated forced extension with added manual pressure. Ranges of sensitivity (0.22–0.44), specificity (0.98–1.0), and positive (0.86–1.0) and negative (0.77–0.82) predictive values were found, depending on the direction of movement. Forced extension was sensitive at 0.78 with specificity at 0.71, a positive predictive value of 0.52 and a negative predictive value at 0.89. Hicks et al. [74] found moderate to near perfect reliability for the findings considered to be related to instability, including i) a painful arc in flexion (0.42 <ĸ < 0.77) ii) pain on return to upright posture (0.42 < ĸ< 0.63) and iii)the prone instability test (0.74 < ĸ < 1.00).

Table 5 Definitions for each of the possible type of recommendation

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Table 6 Summary of recommendation for each category of evaluation method

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Van Dillen et al. [36], in a reliability study using 5 examiners, looked at symptom behavior during various postural tasks involving standing, sitting, supine and prone recumbency, hook lying and quadraped kneeling. For all 28 items, kappa values for inter-examiner reliability were ≥ 0.75 when symptom response was included, but reduced to ≥ 0.40 without them. Maher and Adams [34] found similar results when 3 pairs of examiners assessed spinal segment stiffness manually. Intra-class correlation coefficients were higher (0.67 ≤ ICC ≤ 0.72) when pain provocation was considered, but dropped dramatically (0.03 ≤ ICC ≤ 0.37) when it was not. Symptom provoking movement assessments, in the work of Haswell et al. [56], showed a hierarchy of reliability with movements which they termed side-bending (ĸ = 0.6), flexion-side-bend rotation (ĸ = 0.39), side-bend rotation (ĸ = 0.29), extension side-bend rotation (ĸ= 0.29) and rotation (ĸ = 0.17). Inter-rater reliability between two examiners was assessed by McCombe et al.

[41] for straight leg raising, in two separate groups of low back pain patients using a correlation model. The angular position of pain onset and the maximum tolerated pain both correlated strongly (0.68 < r < 0.86). Maigne et al. [54] found good inter-examiner reliability for pain with cervical flexion (ĸ= 0.71) and extension (ĸ = 0.76).

A series of studies has examined the validity and inter-rater reliability of provocative postural manoeuvres to classify patients into categories of mechanical versus non-mechanical back pain.

Laslett et al. [79] used provocative discography as a gold standard to evaluate the classification of patients by "centralization” of pain during the examination. Sensitivity, specificity, and positive likelihood ratios for centralization were 40%, 94%, and 6.9 respectively. Clare et al. [81] studied the construct validity of the predicted response of extension in groups classified by provocative maneouvre as mechanical derangement versus non-derangement.

The global perceived effect was significantly higher (p < 0.001) after treatment in the derangement group.

Inter-rater agreement for classification of low back patients into the subgroups of mechanical back pain, overall, has been good. Razmjou et al. [75] found very good agreement on derangement subsyndromes with ĸ = 0.96. Inter-rater agreement for presence of lateral shift, relevance of lateral shift, relevance of lateral component, and deformity in the sagittal plane were ĸ = 0.52, 0.85, 0.95, and 1.00, respectively. Kilpikoski et al. [76] found that agreement on centralization and direction of preference for helpful movements were substantial (0.7 < ĸ < 0.9). Clare et

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al. [82] found nearly perfect reliability for classifying both low back patients (ĸ = 0.89) and neck pain patients (ĸ = 0.84).

Laslett et al. [78] and Laslett et al. [79,80] used criterion validity to evaluate a cluster of orthopedic manoeuvres for pain which was considered to arise from the sacroiliac joint, contrasting these manoeuvres against pain relief from intra-articular joint anesthesia. The choice of manoeuvres was based on earlier literature [67]; Kokmeyer et al. [69] citing “acceptable” inter-rater reliability for iliac distraction, thigh thrust, Gaenslen’s test, lateral recumbent iliac compression and prone sacral thrust. Using ROC curves they determined that, as a cluster, Gaenslen’s tests did not contribute to increased accuracy. With two or more of the remaining tests positive, the cluster sensitivity was reported at 0.94 with a specificity of 0.78 and predictive values positive at 0.68 and negative at 0.96.

Leboeuf-Yde et al. [48] evaluated the “stork” (a.k.a. Gillet) test for sacroiliac motion during the standing leg lift maneuver with generally poor results (sensitivity = 0.41, specificity = 0.75, positive predictive value = 0.39 and negative predictive value = 0.56). Levangie [56], in a high quality study, assessed the relationship between four clinical tests for sacroiliac function (Gillet, standing flexion test, sitting flexion test, and the supine-to-sit test) and both objectively measured pelvic torsion and low back pain. She found very little concordance with each other in any of the tests or with low back pain with the exception of the Gillet test (likelihood ratio 4.57). However all four tests had low to moderate sensitivity (range, 0.08 to 0.44) and moderate to high specificity (range, 0.64 to 0.93) with only moderate predictive values (range, 0.28 to 0.78).

The study by Viikari-Juntura et al. [33], rated a moderate quality study, evaluated inter-rater reliability of examination findings in 52 neck pain patients referred for myelography.

Neck compression orthopedic testing varied in reliability (0.28 ≤ ĸ ≤ 0.77) according to head position at the time of axial compression. The reliability of brachial plexus tension tests was fair (ĸ = 0.35) while that of shoulder abduction relief was slight to fair (0.21 ≤ ĸ ≤ 0.40) and reliability of relief of symptoms by cervical traction was moderate (ĸ = 0.50). McCombe et al. [41] found provocation with movement to be variable in reliability depending on the direction of movement (0.1 ≤ ĸ ≤ 0.56).

Recommendation: Favourable, with high quality evidence for both validity and reliability in use of orthopedic manoeuvres to narrow the region of interest for applying treatment. Evidence supports seated forced extension; pain on lumbar motion (side-bending > flexion side-bending rotation > sidebend rotation > extension side-bend-rotation > rotation); three or more

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sacroiliac manoeuvres (iliac distraction, thigh thrust, lateral recumbent iliac compression and prone sacral thrust); cervical compression and traction tests; and McKenzie manoeuvres including lateral shift, relevance of lateral shift, relevance of lateral component, and deformity in the sagittal plane. A painful arc in flexion and/or on return to upright posture and the prone instability test may suggest local instability.

Asymmetry The assumptions of bilateral symmetry and some sort of structural and physiological axial pattern are common to a number of modes of patient examination. Absence of symmetry in some cases (e.g. scoliosis) is sufficient to result in a distinct diagnosis. In the majority of cases, however, it is the comparison from side-to-side or axially that is considered meaningful. In terms of assessment for localizing treatment to a specific site, the forms of examination involving symmetry include postural evaluation, palpation for stiffness of tissues/segments, static palpation of landmarks, segmental motion palpation, bilateral leg length measurement and manual muscle testing.

Postural assessment [Quality scores: Validity 0 low, 0 moderate, 1 high; Reliability 5 low, 4 moderate, 0 high].

Examiners inspect the relative positions of body segments/ landmarks with respect to each other and with respect to an idealized configuration. Methods include visual inspection, photography, radiography and palpation of surface landmarks with or without aids. Deviations are noted and tend to direct further investigation. Nine articles which satisfied the inclusion criteria addressed postural assessment [39,41,48,68,83-87].

In the report by Lebouef-Yde et al. [48], validity of antalgic posture was assessed through the capture of data on subjects with known histories of back pain ranging from none in their life time to one or more episodes across preceding intervals up to one year. Antalgia was low in sensitivity (0.11) and positive predictive value (0.18) but high in specificity (0.80) and negative predictive value(0.69).

Lordosis measurement, as the distance from the point of maximum thoracic kyphosis to maximum sacral kyphosis, was assessed by McCombe et al. [41]. Pearson correlations were calculated on measures taken by two examiners (0.67 < r < 0.7) from two sets of low back pain patients.

Cleland et al. [39] found that the inter-rater reliability for evaluation of hyperkyphosis above T6 was better (0.69 <ĸ < 0.79) than for hypokyphosis (ĸ= 0.58). Photographic assessment of body surface landmarks [87] determined by palpation through tight fitting clothing resulted in poor

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reliability for judgment of kyphosis (ĸ= 0.441) and lordosis (ĸ = 0.327 ), but good reliability for scoliosis (ĸ= 0.769). In the work by Normand et al. [86], three examiners used palpation independently to locate surface landmarks and to place reflective markers. ICCs were calculated with both a conservative and liberal approach. Three landmarks from different angles served as input to a commercial computer program (PosturePrintW) which evaluated displacements of the head, rib cage, and pelvis (in degrees of rotation or millimeters of translation) from a normal upright stance. Depending on the vagaries of ICC analysis, results ranged from good to excellent (0.51 < ICC < 0.97).

Leard et al. [87] assessed the reliability of 22 clinical measures related to posture, including some manoeuvres that would be regarded as orthopedic tests. Intra-class correlations were reported for quantitative measures and weighted kappas for qualitative measures. Two clinicians, using a palpation meter (PALMeter™), produced ICCs ≥ 0.997 in measuring intra-rater reliability for sagittal pelvic inclination and ≥ 0.9661 for inter-rater reliability.

Frontal plane inclination, however, had very low inter-rater reliability, with ICCs of approximately zero. Piva et al. [85] also looked at the iliac crest level in the frontal plane (i.e., pelvic obliquity) using a caliper mounted inclinometer. ICCs in their study were much higher than those of Leard et al. [87] 0.80 and 0.73 for standing and sitting, respectively.

French et al. [68] monitored the reliability of 5 examiners with respect to their conclusions as to the necessity to treat at a given site. A cluster of exam methods included postural inspection, patient self-report of pain characteristics, leg length assessment, motion and static palpation of the spine, as well as neurologic and orthopedic tests chosen at their discretion. Unfortunately, no breakdown of the analysis was reported by examination method. The yield in pooled reliability, for the cluster as a whole across the extent of the spinal column was only fair (ĸ = 0.27).

Cowherd et al. [83] attempted a criterion related validity study of common postural indices from digitized surface landmarks during erect stance using a triaxial, digitizing goniometer (Metrecom™). Results were compared to radiographs taken without changing position. While a stronger analysis would use an ICC, correlation of measures between the postural analysis and the radiographs showed only a weak association with significant (p<0.001) differences suggesting large offsets between the measures.

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Recommendation: High quality evidence is favorable with limitations to the specificity of antalgia and reliability of postural assessment for kyphosis, lordosis and scoliosis. The evidence is unfavourable for the use of postural analysis to determine the local site of care.

Palpatory stiffness During the process of tissue palpation, the examiner attempts to assess the relative stiffness (conversely, compliance) to postural or applied load to a segment.

Recent work in biomechanics has shown that the paraspinal soft tissues, particularly the multifidus muscles, differ in transverse stiffness based on patient posture and clinical state. Using the effective Young’s modulus, a direct measure of stiffness of the muscle estimated by force deformation data from ultrasound elastography, Chan et al. [88] found a 50% to 300% increase (p<0.001) in elastic modulus depending on posture (prone, standing, 25° and 45° flexion). Similarly, with the exception of prone recumbency, chronic back pain patients showed a higher modulus than healthy subjects. The difference decreases with increased flexion, ranging from 30% to 14% in the mean. Effective spinal stiffness was similarly evaluated by Fritz et al. [89] before and after manipulation therapy. Improvements in self-reported disability correlated with decreases in stiffness (0.01≤ p ≤ 0.025). In parallel work [90], multifidus thickening was observed. Their results raise a question as to the interpretation of multifidus thickness, since 53.4% of subjects increased muscle dimension while 46.6% decreased after treatment.

The challenge that paraspinal stiffness poses to the clinician is finding evaluation methods that are able to discern these changes across the spectrum of disease and across the multiple spinal regions beyond the low back. Studies meeting the inclusion criteria fell into two categories, those that used manually applied forces and those using instrumentation.

Stiffness–manual assessment [Quality scores: Validity 0 low, 1 moderate, 3 high; Reliability 1 low, 8 moderate, 1 high] Thirteen studies used manual assessment to evaluate segmental stiffness/mobility. The works of Abbott and Mercer[77], a high quality study, and Fernandez-de-las- Pinas et al. [91], a moderate quality study, both examined the validity of assessing hypomobility. Two high quality [42,92] studies and five moderate quality studies [34,39,93-95] and one low quality study [96] evaluated PA pressure or springing tests in the thoracic/lumbar spine, while evidence from two moderate quality studies [46,97] and one low quality study addressed the neck region [49].

A selection of published research by CMCC faculty

Patients and healthy subjects were evaluated by four examiners using observation of active and abnormal ranges of motion, and motion palpation manoeuvres to assess for passive physiological intervertebral motion (PPIVM) and passive accessory intervertebral motion (PAIVM). Sensitivity ranged from 42% to 75%, while sensitivity was 35% to 89%[77]. Radiographic measures of segmental displacement on flexion/extension x-rays of the same subjects revealed that the number of segments falling more than 2 standard deviations below the mean of normal subjects is much higher in low back pain subjects than expected (Χ 2, p < 0.001). Fernandez-de-las-Pinas et al. [91] evaluated manual lateral glide stiffness compared to intervertebral radiological motion in lateral bending.

Radiologically visualized intervertebral motion on the hypomobile side (mean 19.1 mm, SD 2.1 mm) was 3.44 mm ± 1.9 mm less than on the contralateral side (mean 22.6 mm, SD 2.5 mm) with p = .002 by Wilcoxon rank test.

Taylor et al. [42] evaluated prone joint springing for fixation in the thoracic spine and found a moderate agreement (ĸ= 0.48) with tenderness on skin rolling to determine spinal joint dysfunction within one vertebrae above or below the level of the tender point. In a report by Downey et al. [92], three pairs of examiners attempted to identify the symptomatic segment through posterior-to-anterior pressures. While examiners showed fair agreement (ĸ= 0.37) in locating segments (± 1 segment), they were less reliable in agreeing on the name of the segment (ĸ= 0.09), introducing an alternative source of error.

Agreement of thoracic springing with provocation of pain was fair to moderate in the work of Cleland et al. [39], depending on spinal level. Similarly, inter-rater reliability ranged from fair to substantial [39,94], with symptomatic subjects producing more reliable responses (ĸ ≥ 0.6) [95].

Maher and Adams [34] found manual spinal segment stiffness intra-class correlation coefficients higher (0.67 ≤ ICC ≤ 0.72) when pain provocation was considered, but dropped dramatically (0.03 ≤ ICC ≤ 0.37) without pain provocation.

Studies of palpation of the cervical spine are less common.

The work by Hanten et al.[49], a lower quality study, used subjects who met the International Headache Society criteria for cervicogenic headache. A panel of 15 cervical mobility and palpation tests was studied for reliability using two examiners. The inter-rater agreement for tests that exceeded ĸ> 0.50 included: cervical protraction and retraction, both with and without overpressure, and pressure sensitivity paraspinally at C1 and C2. The mean number of positive findings per subject was 3.50, with a Spearman rho =0.943 over two days of testing. However,

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mixed results were described for overpressure testing (−0.09 ≤ ĸ ≤ 0.46) by others [97]. Comeaux et al. [93] and McPartland and Goodridge[46] found cervical stiffness testing to have fair to moderate in reliability.

Recommendation: Unclear, based on moderate quality evidence, for examination montages contributing any more than their component elements to the decision to localize treatment

Stiffness–instrumented [Quality scores: Validity 0 low, 0 moderate, 0 high; Reliability 2 low, 1 moderate, 0 high].

Few mechanized methods for evaluation of stiffness are accessible in general practice. Three studies [98-100] investigated the usefulness of identifying joint stiffness by instrumentation to locate the site of care. The work of Latimer et al. [100], with a laboratory based instrument, is notable as it observes that the level of stiffness detected is a function of magnitude of the application force. Similarly, the more stable measures of effective stiffness arise from applied forces above 50 N (11.25 lbs).

Leach et al. [98], in a study ranked as being of moderate quality, measured inter- and intra-examiner reliability using a commercially available instrument (Pulstar™) which provides impulse force to the spine above the 50 N threshold for stable measures. Two examiners evaluated 18 healthy 20-to-25 year old subjects for patterns of stiffness along the spine. Good agreement was observed in the pattern of stiffness measures along the length of the spinal column. Inter-examiner ICC=0.87 while intra-examiner findings were 0.78 and 0.89 yielding good to excellent results for reliability.

The work of Owens et al. [99] was rated as low quality evidence.

Using a custom built device, posterior-to-anterior spinal stiffness of the lumbar spinal segments was assessed by 9 examiners in low back pain patients. The ICC for inter-rater reliability was very good at 0.79. A quantitative stiffness value of 11.2 N/mm (±3.5) was found, although no differences between segments or comparisons with healthy subjects were available.

Recommendation: Favorable with limitations based on low quality evidence.

Limitations are based on instrument availability and uncertainty concerning the generalizability of results to the broader population.

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Static palpation [Quality scores: Validity 0 low, 0 moderate, 2 high; Reliability 4 low, 7 moderate, 4 high].

The identification and evaluation of relative position of topographical or percutaneous landmarks has long been a part of health care practice. Of the six high quality studies, two evaluated validity [101,102] and four assessed reliability [103-106]. Seven more moderate quality studies [94,107-112] and four low quality studies [113-116] also addressed reliability.

The work of Jende and Peterson [101] utilized what may be termed a ‘proof-by-contradiction’ approach to evaluate seated palpation of C1. Posing an alternative explanation for palpatory prominence as originating from osseous asymmetry (±2 mm), the authors compared the lateral prominence of C1 on palpation in 47 patients against radiographic measures.

The ICC for repeated measure of atlas transverse length on x-ray was 0.93. In 57% of cases with laterality on palpation, radiographic measures were equal or more prominent on the opposite side, suggesting that palpatory laterality was not due to an anatomical variant. Unfortunately, no clinical information was reported. The validity and reliability of locating spinal levels and pelvic landmarks have been reported in six studies [102,108,109,111,112,116] using various means including radiographs to quantify site identification error.

Examiners differed in localization of landmarks across a range from 0.5 cm to 2.5 cm, (0.28 ≤ ĸ ≤ 0.98), often reporting findings from adjacent segments.

Fryer et al. [104] evaluated the intra-examiner and inter-examiner reliability of trained and untrained osteopathic students palpating symmetry in anatomical landmarks (anterior and posterior superior iliac spines (ASIS and PSIS), medial malleoli, sacral inferior lateral angle (SILA) and performing the seated flexion test (SFL). Inter-examiner agreements (kappa scores) for the trained versus untrained examiners were: medial malleoli, 0.31 vs 0.28; ASIS, 0.24 vs −0.01; SFT, 0.14 vs 0.07; PSIS 0.08 vs 0.15; SILA 0.04 vs −0.01. Others [106,115] have followed similar protocols with essentially the same results. Holmgren and Waling [105] and Binkley et al. [107] explored inter-examiner reliability for identifying segmental levels (−0.03 ≤ ĸ ≤ 0.69, across studies), with comparable results. The prone posture was shown as the more reliable patient positioning for locating spinous processes (inter-examiner agreement (69 < ĸ < 81) by Byfield and Humphreys [114].

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Special cases of static palpatory findings have been studied by others [94,103,110]. In a high quality study, intra-examiner agreement on skin fold thickness and compliance were mixed (−.41 ≤ ĸ ≤ .23; 0.25 ≤ ICC ≤ 0.28) [96]. Similar results were found by Moran and Gibbons [110] in evaluating ICCs for cranial rhythmic impulses. Conversely, agreement on the identification of the piriformis muscle and iliolumbar ligaments has been reported as substantial (0.61 < ĸ < 0.87).

Recommendation: Based on high quality evidence, the validity of palpation for localizing the site of care is unclear. A recommendation of favorable with limitations, depending upon the target structure, is made for reliability in localizing common anatomical landmarks.

Motion palpation [Quality scores: Validity 1 low, 0 moderate, 8 high; Reliability 8 low, 9 moderate, 11 high].

The underlying premise of motion palpation, particularly with segmental dysfunction of the spine, is that there may be abnormal patterns in relative motion. That the response to manipulation may be related to the degree to which segments are more or less stiff has been shown

by Fritz et al. [89]. Motion palpation uses examiner guided motions to manually monitor the relative displacement of bony landmarks through the skin surface. Motions are categorized as being limited/restricted; excessive/unstable or aberrant, suggesting a deviation in path at some point within the range of motion.

Nine studies have assessed validity of motion palpation alone [89,117-121], twenty-five studies have assessed reliability alone [47,50,72,74,104,107,122-139], and three studies have assessed both reliability and validity [140-142].

Humphreys et al. [120] evaluated motion palpation in asymptomatic volunteers with congenital block vertebrae (C2-3 or C5-6) in the cervical spine. Substantial overall agreement (C2-3, ĸ = 0.65; C5-6, ĸ = 0.76) was found for identification of the site of greatest hypomobility. Sensitivity ranged from 55% to 78%, greater for the C2-3 level, with specificity that was high (91–98%) for both. Ogince et al. [121] assessed cervicogenic headache patients and asymptomatic controls for C1/2 dysfunction using seated flexion-rotation tests. Blinded examiners identified dysfunction with 91% sensitivity and 90% specificity. Abbott et al. [118] tested the validity of passive physiologic intervertebral motion

A selection of published research by CMCC faculty

(PPIVM) of the lumbar spine in recurrent/chronic low back pain patients. Flexion/extension movement of vertebral segments, induced by flexion of the thigh on the pelvis in a side-lying posture, was compared to flexion/extension radiographs. Abnormal motion was defined as a range of normalized movement (segment range/region range) beyond 2 standard deviations (+/−) for a given level in comparison to a sample of healthy subjects. Inter-rater reliability of the radiographic measures, to set the gold standard, ranged between 0.83 ≤ ICC ≤ 0.99). Motion palpation was highly specific (99.5%) for increased translation but was very poor for sensitivity (5%).

Likelihood ratios (7.1) for low back pain were significant only for translation in extension.

Landel et al. [119] evaluated a slow application of posterior-to-anterior force to the lumbar spine under MRI imaging, and separately by two examiners, attempting to localize the least and most flexible segments. The study reported substantial and fair inter-examiner reliability of the least (ĸ = 0.71) and most (ĸ= 0.29) mobile segments, respectively. Similarly, Abbott et al. [118] looked at posteriorto-anterior translation in response to pressure, with flexion and extension x-rays as the gold standard. Translation was found to be significantly associated with recurrent/ chronic low back pain (p < 0.05), with specificity of 89% but poor sensitivity of 29%. Subjects with a positive test had a likelihood ratio of 2.52. The opposite conclusion was found for flexion where specificity was high (99.5%) but sensitivity was low (5%). Using lateral recumbent patient posture during tests for passive intersegmental motion, the agreement between abnormal flexibilities and pain provocation at the same level was substantial (0.67 < ĸ < 0.71) for Lundberg and Gerdle[47]. Inter-rater reliability for abnormal motions alone was moderate to substantial (0.59 <ĸ < 0.75). Phillips and Twomey [142], rated as high quality evidence, compared analysis of lumbar passive segmental movement, coupled with pain provocation response, and results from anesthetic blocks obtained retrospectively in one group and prospectively in another. Sensitivity was 60%, with specificity of 100% in the retrospective group, and 94% sensitivity with 100% specificity in the prospective group.

Others have had much less promising results.

Reliability results for motion palpation, absent a gold standard, have been inconsistent. Three studies reported moderate agreement (ĸ ≥ 0.40) and three reported fair

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agreement (ĸ <0.40). Haas et al. [126] evaluated manual end play palpation of the thoracic spine and found a moderate intra-examiner reliability (ĸ= 0.5) but only slight inter-examiner reliability (ĸ = 0.14). Christensen et al. [50], Brismee et al. [132,140] and Smedmark et al. [129] reported fair (0.22 ≤ ĸ ≤ 0.24) [50] to substantial agreement (ĸ ≤ 0.65) [132,140]. Others [74,107,117,132,141] have had less impressive outcomes, with mixed agreements on passive segmental flexibility (−0.02 ≤ ĸ ≤ 0.26, across studies) in the prone position. In asymptomatic subjects [125] agreement between examiners of the cervical spine has been no greater than chance.

Qvistgaard et al. [136] assessed both the intra and inter-examiner reliability of two experts using the stork test, pelvic girdle rotation, and the lumbar spring test to identify dysfunctional lumbar spinal levels. The study considered two definitions of reliability; perfect match (PER) defined as positive results on the same segmental level, and acceptable match (ACC) defined as positive results within one segmental level. The study found moderate and substantial levels of intra-examiner reliability (PER, ĸ = 0.60; ACC, ĸ = 0.70) with fair and moderate levels of inter-examiner reliability (PER, ĸ = 0.21; ACC,ĸ = 0.57).

The work of Love [123] and Mootz et al.[124] indicated only chance agreement.

Robinson et al. [137] found near perfect inter-examiner reliability among expert examiners assessing passive sacroiliac joint play (0.78 ≤ ĸ ≤ 0.88). Similar results were obtained by Hungerford et al. [135] (0.67 ≤ ĸ ≤ 0.77). In contrast, Schneider et al. [138] reported mixed results (− 0.17 ≤ ĸ ≤ 0.17) for two experts utilizing a segmental mobility test to assess normal or restricted mobility across the lumbar spine and sacroiliac joints. Fryer et al. [104] looked at the seated flexion test for sacroiliac fixation finding slight levels of inter-examiner reliability (ĸ = 0.14). Vincent-Smith and Gibbons [128] had better results with the standing flexion test (ĸ = 0.052). Arab et al. [72] constructed composite tests from motion palpation (standing flexion, seated flexion, Gillet, prone knee flexion test, leg length) and provocation manoeuvres (Patrick-Fabre, thigh thrust, resisted abduction). With positive findings on three or more of the palpation tests and two or more of the provocation manoeuvres, the inter-examiner agreement was substantial to excellent (prevalence-adjusted and bias-adjusted kappa; 0.52 ≤ ĸ ≤ 0.92). Meijne et al. [127], Tong et al.[133] and Carmichael [122] found the same manoeuvres individually less reliable (−0.32 ≤ ĸ ≤ 0.27, across studies).

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A few investigators have attempted to identify procedural characteristics that improve inter-rater reliability. Marcotte et al.[130] suggest that the orientation of the examination input force, but not amplitude of force [131] may increase reliability (from ĸ=0.34 to ĸ = 0.68).Cooperstein et al. [139] found that high examiner confidence raises agreement to ĸ= 0.82.

Recommendation: Favorable with limitations (region of the spine, direction of movement and method employed), based on high quality evidence for both validity and reliability for use in localizing the site of care.

Leg length inequality (LLI) [Quality scores: Validity 1 low, 1 moderate, 4 high; Reliability 6 low, 4 moderate, 6 high] Much attention has been given to the question of relative leg length and change in apparent relative leg length as an indicator for site of treatment. Six articles pertaining to the validity of measures of LLI [143-148] and fourteen articles pertaining to the reliability of LLI assessment [106,108,148-159] were retrieved and reviewed. Most of the studies assessed LLI with the subject in the prone position, but some had subjects in the standing or supine position.

The construct validity for an etiological role of LLI in lower quadrant and low back dysfunction is controversial.

Motion, alignment and muscular endurance of the low back and pelvis are altered in the presence of leg length differences[160], yet cross-sectional studies [160-162] fail to show a relationship between LBP and LLI alone. At the same time, in a 4 year prospective study of 136 students, Twellaar et al.[161] found pelvic obliquity to be associated with injury rates including backache. Knutson [146] measured leg length inequality among selected volunteers who were partitioned according to their history of recurring low back pain. Pain scales were higher (p < 0.001) in subjects with length asymmetry, with sensitivity of 87% and specificity of 84%. Petrone et al. [148] found similar validity and reliability of standing evaluations using the PALM™ assessment of iliac crest level using a gold standard of standing pelvic radiographs with the central ray at the level of the femoral heads. The ICC for inter-rater reliability was 0.97. The agreement between tape measure assessment (ASIS to the medial malleoli and scanogram) fared less well with 0.359 ≤ ICC ≤ 0.770.

Hinson et al. [152], Woodfield et al. [159], Kmita and Lucas [106], and Fryer [156] found supine visual leg checks to show varying degrees of inter-examiner reliability. Cooperstein et al. [163] evaluated the validity and reliability of prone

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compressive leg length assessment using standardized foot wear containing shims of various thicknesses in one shoe.

Artificial leg length differences over 3.7 mm were reliably identified with an intra-examiner ICC of 0.85. Fuhr and Osterbauer [149], Nguyen et al.[153], Schneider et al. [157], and Holt et al. [158] used prone compressive leg length estimates of volunteers, finding substantial reliability (0.65 ≤ ᴋ≤. 0.70).

Some clinicians follow prone compressive leg length checks with knee flexion to 90 degrees in order to reveal change in relative length. Schneider et al. [157] found this maneuver to result in a high prevalence (95%) of increased length on the short leg side, confounding calculation of the kappa statistic.

Holt et al. [158] were able to define reliability with knee flexion at ĸ = 0.65. Low level evidence from Eriksen [145] examined change in leg length with specific challenge to a vertebral level on an unspecified number of subjects. Of 18 variables, only one had a notable concordance (ĸ < 0.40) between the change in LLI and x-ray findings.

Blocking methods insert varying sized blocks/lifts under the feet to level the standing pelvis or to simulate LLI. The method investigated by Gross et al. [151] was less accurate (±0.46 cm) and of lower inter-rater reliability (ICC=0.77) than prone compression or the PALM™ method. Hanada et al. 2001 [154] found nearly identical results, comparing block height with scanogram measures. Gibbons et al.[155] assessed the ability of examiners to palpate the iliac crest levels on subjects who had an artificially created asymmetry in standing leg length, finding that they were unable to reliably detect discrepancies of l cm or less.

Three reports were identified which met the inclusion criteria and specifically addressed the question of leg length as an indicator for the site of care. Montgomery et al.[144], in a low quality validity study, reported substantial agreement (ĸ = 0.664) between palpatory findings of unilateral sacral prominence suggestive of pelvic torsion and radiographic findings of leg length difference. Using variants in positioning of the extremities and head, leg length has been offered as a means to identify the site for necessary care. Younqvist et al. [150] evaluated this maneuver for the C1 segment, reporting a ĸ= 0.52. In contrast, Schneider et al. [157] evaluated head positioning in subjects with leg length difference ≤ 0.25 inch with mixed, but poor reliability (−0.02 ≤ ĸ ≤ 0.04).

Recommendation: Favorable with limitations for assessing the pelvis, based on high quality studies. Validity for relationship to symptoms has not been demonstrated. Reliability appears method-dependent.

A selection of published research by CMCC faculty

Manual muscle testing [Quality scores: Validity 1 low, 0 moderate, 1 high; Reliability 3 low, 3 moderate, 1 high].

Manual examination of the capacity to produce powerful contraction by muscle is a classical part of the examination for neuromotor control. Traditionally, it has been used as a graded system [164] of testing individual or isolated groups of muscles related to a specific function (e.g. deltoid for abduction). In this role, muscle testing may provide information consistent with the myotomal connections, potentially indicating nerve root involvement.

Its use has been extended from assessing frank neuromuscular pathology to determination altered function which is not necessarily pathological [165-167].

Nine papers were identified within the inclusion criteria[33,39,41,165,167-171]. Used to grade strength, McCombe et al. [41] found inter-rater reliability for motor power in the lower extremities was substantial to perfect (0.65 ≤ ĸ ≤ 1.0) for one pair of examiners, but only poor to moderate (0.02 ≤ ĸ ≤ 0.35) for another pair. The study by ViikariJuntura et al. [33] in neck pain patients, found agreement on muscle atrophy was fair to substantial (0.35 ≤ ĸ ≤ 0.81) while reliability for grading muscle strength was moderate to substantial (0.40 ≤ ĸ ≤ 0.64). Cleland et al. [39], in a limited sample of muscle tests, found inter-rater agreement to vary depending on the muscle being tested, with overall agreement ranging from 41% to 91%.

Used as an indicator of altered function, not necessarily pathological, the validity of muscle testing was evaluated

by Ludtke et al. [170] in a double blind study with 4 examiners using 7 volunteers with confirmed allergy (IgE production) to wasp venom. The venom or a saline solution vial was randomly placed below the umbilicus, and change in muscle strength (anterior deltoid) was evaluated. The correct assessments of placebo versus allergen were 60% and 40%, respectively. Inter-rater reliability overall was ĸ= −0.01, suggesting less than chance agreement. Calderon and Lawson [165] found a highly mixed inter-rater reliability, based on which muscle was being isolated for testing (−0.07 < ĸ < 0.90). The same data was replicated (for purposes of this report, scored only once) in a publication under Lawson and Calderon [166]. Patient initiated strength by dynamometry [168] has been shown to have substantial reliability (ĸ = 0.96–0.99) whereas doctor initiated testing showed lower reliability (ĸ= 0.55–0.76). Haas et al. [169] evaluated the reliability of muscle testing in response to a provocative challenge attempting to localize the vertebral site needing treatment in both

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symptomatic and asymptomatic subjects. A 5 kg force directed to produce rotational stress was applied to thoracic spinous processes, preceded and followed by a manual muscle test of the strength in the piriformis muscle.

Inter-rater reliability approached zero (ĸ = −0.04, symptomatic; ĸ = −0.02, asymptomatic) indicating agreement by chance alone. Caruso and Leisman[171], in a low quality study, suggest that accuracy in functional muscle testing improves with years of clinical experience. While reliability was claimed, no kappa or ICC values were presented.

Pollard et al.[167] took a novel approach asking whether a change in muscle strength (deltoid) following identification of palpatory tenderness over the lower right quadrant (ileocecal valve/McBurney’s point) may be related to the presence of low back pain. While one cell of the 2x2 table was underpopulated, the authors calculated a sensitivity of 0.86 and specificity of 0.97.

Recommendation: Favorable, with a moderate level of evidence, for strength grading to localize nerve/nerve root levels. Unfavorable as a diagnostic indicator of non-pathological altered function leading to localizing site of care.

Range of motion

[Quality scores: Validity 1 low, 0 moderate, 3 high; Reliability 12 low, 8 moderate, 2 high].

Many studies have investigated range of motion in healthy and unhealthy subjects. Five high quality studies[54,172-175], eight moderate quality studies [33,39,97,111,176-179] and twelve low quality studies [41,180-190] which met the inclusion criteria for this review were identified. Four assessed validity [48,172,175,182] and the others assessed reliability.

The construct validity of reduced range of motion in painful disorders has been examined by several groups. Viitanen et al. [172] correlated different spinal ranges of motion (ROM) and the results of 17 repeated tests with spinal radiological changes in 52 male patients with ankylosing spondylitis.

Inter-rater reliability on motion measures was good to excellent (0.84 ≤ ICC ≤ 0.98). Osterbauer et al. [182] measured kinematic parameters of head motion during tracking tasks (flexion, extension, etc.), and cervical ROM was measured via a head mounted optoelectronic inclinometer. Pain and disability were assessed via the neck disability index questionnaire and visual analog pain scale. A scoring system of kinematic abnormalities was created ranging from 0 to 3. A cutoff of ≥ 0.5 correctly identified the greatest number of subjects and minimized false positives (sensitivity 77%, specificity 82%, likelihood ratio 4.5). ROM performed similarly well at a cutoff of 1 SD below the normative mean

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(sensitivity 77%, specificity 84%, likelihood ratio 3.9). Hall and Robinson[177] also found a strong correlation (r = 0.8) between severity of headache and restriction, with excellent reliability (0.92 ≤ ICC ≤ 0.99) in measuring neck motion. Mayer et al.[182] examined reliability and responsiveness of inclinometric measures of rigidity at intervertebral levels during lumbar flexion/extension and lateral bending in seventy chronic low back pain patients. Four had measurable rigidity at one level, thirty-six at two, and thirty at three levels. Repeatability was assessed, with high correlation in flexion/extension (0.90 < r < 0.97, p < 0.01) and moderate correlation for lateral bending (0.65 < r < 0.95, p < 0.05). Patients were assigned to one of two treatment groups: exercise only, or exercise with localized joint anesthesia. Pain intensity (VAS) and ROM improved with treatment and patients who received joint anesthesia showed greater improvements in ROM. Leboeuf-Yde and colleagues[48] evaluated the range of motion in 166 individuals, 46 of whom had never had low back pain, 18 of whom had pain on the day of examination, the remainder having had a history of pain sometime within the past year.

Sensitivity for “low back pain today” was low, ranging from 22% to 44% in a hierarchy of rotation < flexion < side bending <extension. Specificity fared better (range 98% to 100%) with side bending < extension = flexion = rotation. All tests reported high levels of positive predictive value (range= 86%-100%) and negative predictive value (range=77%-90%).

A novel description of the quality of movement, “gearbox flexion” denoting an uneven path of motion, was evaluated.

This type of movement was highly specific (1.0), with strong positive (1.0) and negative (0.73) predictive values, although the finding had very low prevalence.

Goniometric devices of several kinds have been studied[111,175,180,182-186,188,190]. These devices include gravity and electronic goniometers, optoelectronic monitoring of body markers and tape measure approaches. In general, the reliability of measures has been good to excellent (0.72 ≤ ICC ≤ 0.995). Several special circumstances have been noted with range of motion measures. Haynes et al. [186] observed degradation in repeated measures with forward head tilt of up to 10 degrees. Lateral neck flexion was only fair in agreement for Hoppenbrouwers et al. [178]. Using a tape measure [41,172,190] to monitor landmark displacements is comparable to goniometry in reliability. Whether active or passive neck ROM is measured, extension may be more reliable (ĸ ≥ 0.85) than flexion (ĸ ≥ 0.33). Piva et al. 2006 [85] found substantial and almost perfect levels of inter-examiner reliability (0.78 ≤ ĸ ≤ 0.94) in examining the neck, while Viikari-Juntura et al. [33] reported lower levels of reliability (0.40 ≤ ĸ ≤ 0.56). Also for the neck, Cleland et al. [39] showed good reliability (0.57 < ICC < 0.78) for measuring range of

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motion, and moderate to substantial kappa agreement in eliciting self-report of symptom aggravation with specific motions. Maigne et al. [54] found moderate agreement (ĸ = 0.57) when examiners classified patients as being slightly, moderately or severely restricted.

Recommendation: Favourable for use to localize the site of treatment within a spinal region, based on high quality evidence for validity and reliability.

Tissue temperature, texture, and tone [Quality scores: Validity 0 low, 0 moderate, 5 high; Reliability 5 low, 4 moderate, 4 high].

Modern thermography uses infrared sensing devices to evaluate the relative levels of heat emitted through the skin, while thermometry uses direct skin contact via thermocouples. The temperature of tissues is determined by a number of factors, including metabolic activity, perfusion and environmental temperature. Two papers [191,192] suggest that while thermometry may provide valid measures of skin temperature, stringent environmental control is necessary to achieve stable readings. Readings are perturbed by the skin contact accompanying spinal manipulation, at least with instrumented methods, and the responses to manipulation are multiphasic, confounding interpretation.

Four additional studies met the inclusion criteria for examining the validity of skin temperature [193-196] to identify the site for application of treatment. Chafetz et al. [193] evaluated a small sample of patients with confirmed L4/5, L5/S1 root distortion on CT scans versus healthy controls. The authors reported specificity of 60% and sensitivity of 100% in thermographic results. McCulloch et al. [194], in somewhat larger groups, reported sensitivities for two examiners at 60% and 50%, and specificities at 45% and 48%, using patients with clinical sciatica, and CT or MRI results as the gold standard. More recently, Zaproudina et al. [196] evaluated the side-to-side differences in temperature of the plantar surface in chronic low back pain patients. Differences were observed between patients with low back pain only versus those with referred leg pain (Mann–Whitney test p < 0.05). The severity of Oswestry scores for current LBP disability level correlated with the magnitude of temperature differences with coefficients of correlation of 0.502 (p = .000). There were also correlations between magnitude of temperature asymmetry and both straight leg raise (p < 0.005) and side bending motion (p < 0.05). A study which was ranked as providing low quality evidence [195] reported poor to moderate correlation between thermography and palpatory findings of segmental restrictions, defined by tenderness, positive skin rolling and motion palpation.

A selection of published research by CMCC faculty

Plaugher et al. [197] which was ranked as providing high quality evidence, reported inter-examiner reliability ranging from slight to substantial (0.03≤ ĸ ≤ 0.65) and fair to substantial intra-examiner reliability (0.03 ≤ ĸ ≤ 0.66,) depending upon the region of spine. Two other studies, ranked respectively as of moderate [40] and low quality[55] found slight to moderate agreement (0.0 < ĸ < 0.63) of paraspinal skin temperature measures. Hart et al. [198] attempted reliability testing with 10 minute intervals between samples with good ICCs of > 0.75, while Owens et al. [199] reported excellent ICCs using a handheld thermographic device (0.918 < ICC < 0.975).

The inter-rater reliability of mastoid fossa temperature measurement was also good (0.671 < ICC < 0.748) [200].

Finally, Owens et al.[199] were able to obtain excellent reliability when repeated measures were obtained over 3 minute intervals.

Five papers evaluated tissue texture assessment. Differences in response to skin rolling have been claimed to be a function of surface/subsurface texture (e.g. Diakow et al. [195]. Tests using skin rolling, however, do not have any independent measure of texture. In a variation of classical palpation, a high quality paper compared pain production on skin rolling with pressure algometry readings. A highly significant (p < 0.0005) decrease in pain threshold tolerance at the level of tenderness on skin rolling was found in comparison to non-tender control points in the thoracic spine [42].

Degenhardt et al. [201] defined a positive test for tissue texture as the presence of localized edema or fibrotic changes.

After an interval of consensus training for 2 examiners, agreement on tissue texture was moderate (ĸ=0.45).

McPartland and Goodridge [46] used palpatory sense of ‘fullness’ over articulations of the upper cervical spine, rated on a 10 point scale, with only slight agreement (ĸ =0.19) but had a low prevalence which may have artificially reduced the kappa score. A more clear definition of texture was given by Paulet and Fryer [202] as an abnormal hardness, bogginess, or ropiness of the underlying paraspinal muscles.

Inter-examiner agreement for the site with the most marked tissue texture changes was fair (k = 0.26).

Recommendation: The evidence from studies with high validity and reliability is favorable for the use of thermography/thermometry of the lower limb in confirming frank sciatica. The evidence from high quality studies is unfavourable toward the use of paraspinal skin temperature measures to locate the site of care, due to limited reliability. Evidence of moderate quality is favourable toward the use of skin rolling and palpatory assessment of tissue texture, although the relationship of skin rolling to tissue texture is uncertain.

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Specialized tests Current perception threshold [Quality scores: Validity 0 low, 1 moderate, 2 high; Reliability 0 low, 2 moderate, 0 high].

Current perception threshold (CPT) is a measure of peripheral sensory nerve sensitivity to surface electrical stimulation and was introduced by Rendell et al.[203] in the management of diabetic sensory neuropathy. Segmental specificity of CPT for lumbar radiculopathy was validated

by Yamashita et al. [204] and Imoto et al. [205]. Tests demonstrated significant differences (p<0.01) in sensory function between healthy volunteers and patients with unilateral disc herniation confirmed by magnetic resonance imaging and pain within the distribution of the corresponding lumbar nerve root (L5 or S1). Attesting to the validity of CPT in identifying the level of neuropathy, Imoto et al.[205] demonstrated that following microdiscectomy, 66% of cases showed significant improvement in CPT (p<0.05), along with symptomatic improvement. Patients who did not show improvement in symptomatology, as a cohort, did not show any significant change in CPT. Recommendation: High quality evidence is favourable for the validity of using CPT to identify the segmental level of frank neuropathy. No evidence which met our inclusion criteria addresses the validity or reliability of CPT in otherwise localizing the site for manual treatment.

Galvanic skin response [Quality scores: Validity 0 low, 1 moderate, 0 high; Reliability 1 low, 0 moderate, 0 high] Galvanic skin response (GSR) is the measure of electrical conductance of the skin and in the short term is most strongly influenced by the rate of sweat secretion, since higher moisture content improves electrical conductance.

Because sweat secretion is modulated by the sympathetic nervous system, GSR has sometimes been used as an indirect measure of changes in sympathetic nervous system activity, as for example occurs in some instances of psychological or physiological stress. Two articles concerning GSR satisfied the inclusion criteria [206,207].

Nansel and Jansen [206] were unable to validate GSR changes by examining concordance with findings on manual palpation. While they did not publish their kappa values, reliability was low. Plaugher et al.[207] reported moderate to substantial inter-examiner reliability in a study which was rated as low quality.

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Recommendation: The evidence from a small number of studies of low to moderate quality is unfavorable, in terms of both validity and reliability, for the use of GSR in determining the site of care.

Surface electromyography (SEMG] [Quality scores: Validity 0 low, 1 moderate, 3 high; Reliability 2 low, 1 moderate, 1 high].

Three recent reviews of the literature have evaluated the validity [208,209] and reliability Danneels et al. [210] of SEMG as a tool for identifying subjects with back pain. SEMG results vary widely [208,209] based on test methodology.

Multiple technical factors complicate the interpretation of results including the choice of electrodes, the variation in skin impedance from site-to-site, the site of electrodes in relation to muscle motor points, the signal normalization method, the temperature of the muscle and skin, the fat layer thickness and the presence of postural support.

While SEMG does not reliably isolate the activity of a specific muscle [208], the results of intramuscular EMG and SEMG seem correlated with each other [209].

Geisser et al. [208] conducted a meta-analysis of studies evaluating SEMG in static posture, isometric tasks, and myoelectric response to expected or unexpected sudden loads. Five studies showed no difference between healthy and unhealthy subjects in upright posture, including no difference in side-to-side asymmetry, except during forward flexion. Another five showed higher SEMG amplitudes for static upright postures in low back pain patients than in controls. Patients with disc disorders had higher amplitudes during seated SEMG tasks than normals and other LBP patients. No group differences were observed when SEMG was measured while subjects were lying prone or sitting unsupported. Studies consistently found a lower flexion-relaxation response among subjects with LBP witha large effect size, and good sensitivity (88.8%), specificity (81.3%) and responsiveness to treatment.

Within the context of the present study, only six additional studies met the inclusion criteria for examining the validity and reliability of using SEMG to target sites for spinal manipulation. Dankaerts et al. [211], found differences between healthy subjects and subgroups of chronic low back pain patients (p<0.001). However, the myoelectric differences were dependent upon clinical pre-classification into groups according to postural habits. Fryer et al. [212] demonstrated resting paraspinal muscle variation in the thoracic spine with poor to moderate repeatability using either intramuscular (0.55 ≤ ICC ≤ 0.94) or surface (0.35≤ ICC ≤ 0.69 ) electrodes. Under conditions of maximal

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voluntary contraction, however, both methods of measure had increased reliability (ĸ ≥ 0.91). When EMG measures were partitioned between sites considered by two experienced clinicians as being normal to palpation versus sites with local abnormality in tissue texture and tenderness, no statistical differences were found for either intramuscular (F1,14=3.18, P=.10) or for SEMG electrodes (F1,18=1.53, P=.76). A study ranked as high quality [213], examined the reliability and validity of surface EMG in identifying the laterality and segmental level of dysfunction in patients with low back pain. Repeatability of measures was acceptable over several days in pain free subjects (ICC > 0.75). However, static tests showed no ability to identify the laterality or segmental levels of tenderness to palpation in subjects with back pain. A study rated of low quality found that inter-examiner agreement was mixed (0.20 < ICC < 0.55; -0.13 ≤ ĸ ≤ 0.59) and unacceptable for clinical application[55].

Leach et al.[214], in a study consistent with the review by Geissler et al.[208], examined a small sample of acute LBP patients and control subjects without neurological deficit.

Robust group differences were seen in flexion-relaxation between groups, negatively correlated (−0.74 < r < −0.50) with straight leg raising, and were responsive to treatment, improving in terms of disability as measured by the Oswestry scale (r = .42).

Recommendation: The current evidence, which is of high quality, is favorable with limitations towards the validity and reliability of using SEMG to identify cohorts of patients with abnormal neuromuscular control, such as an altered flexion-relaxation response. However, evidence of moderate quality is unfavourable toward the use of SEMG in localizing treatment to a

A selection of published research by CMCC faculty

measures. Radiographic measures of sacral angle show poor correlation with measures taken by an inclinometer placed externally over the sacrum [220]. However, none of these measures have been shown to have predictive value for assessing individual patients.

Abbott et al. [118], examined the hypothesis that palpable intersegmental hypermobility correlated with hypermobility revealed in lateral flexion-extension radiographic studies in chronic low back pain patients. The authors concluded that, overall, the clinical examination procedures displayed moderate validity in comparison to radiography, with palpation of translation in the sagittal plane faring better than rotation. Continuing on this theme, Abbott and colleagues [221] looked at the prevalence of radiographic movement disorders related to low back symptom status.

Using flexion-extension lateral radiographs from cohorts of healthy and chronic/recurrent low back patients, the relative contribution of each segment’s motion to the regional motion was computed. Lumbar segmental movement disorder was defined by 2 methods: i) motion beyond 2 standard deviations from the mean of a healthy, control cohort and ii) a normalized, within subject measure of segmental motion beyond 2 standard deviations from the mean of the relative contributions of each lumbar segment. The latter measure was more sensitive, but both identified significantly more instances of lumbar segmental movement disorder in the low back pain patients than in the health controls. Lumbar spine translational rigidity (as opposed to rigidity in rotation or instability in general) was associated with higher disability scores (p=0.010) Again, the predictive value for individual patients has not been determined.

specific site.

Radiographic imaging [Quality scores: Validity 1 low, 1 moderate, 5 high; Reliability 5 low, 5 moderate, 1 high].

The validity of computer modeling for differentiating normal from symptomatic cases based on x-ray digitization of the lumbar and cervical lordoses has been studied by the Harrison group [215,216]. X-ray digitization itself has shown inter-examiner reliability for three examiners ranging from 0.71 to 0.99, depending on the measure [217,218]. Differences in ellipse parameters fit to spinal curvature and some standard radiographic measures demonstrated significant (lumbar, 0.0001 ≤ p ≤ 0.0113; cervical, 0.0001 ≤ p ≤ 0.05) differences between groups of healthy and unhealthy subjects. Careful repeated positioning of patients for x-ray can be achieved [219] with no significant difference in

Independent radiologists [118] have evaluated the concurrent validity and reliability of manual tracings and computer generated measures of sagittal rotation (ICC =0.98) and translation (ICC=0.98). Harrison et al. [222] repeated x-rays of subjects at intervals of 3 to 12 months. Follow-up measures in control subjects were similar in the mean to baseline measures; however, no reliability statistics were performed. Jende and Peterson [101], in a high quality validity study with a small nested intra-examiner reliability study took bone geometry measures from the same radiographs on separate occasions, giving an ICC = 0.93. Similarly, two examiners digitized x-ray landmarks twice[215], obtaining ICCs for intra-examiner and inter-examiner that were described as “high” with standard error of measure< 2%.

Reliability of radiographic markings from the Gonstead system of analysis was tested by Plaugher and

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Hendricks[223]. Examiners were independent and, for the study of intraexaminer reliability, blinded on their second evaluation with respect to findings on their first evaluation Intraexaminer scores (0.846<ICC<0.999) tended to be minimally higher than inter-examiner scores (0.812< ICC <0.995). Antos et al.[224], in a paper ranked as of low quality found strong reliability (ĸ =0.80) for assessing flexion of C4/5, by video-fluoroscopy, as the increase in spinolaminar distance between segments. Higher concordance was found for radiologists more experienced in fluoroscopic interpretation[225].

lesion site based on systems of analysis. Two of those systems, full spine radiography listings and Gonstead, use full spine x-rays, although the Gonstead approach adds information from skin temperature readings.

No details of the system analyses were included and comparison of systems in this fashion has little meaning.

The extensive work of Jackson et al. [84,226] attempted to evaluate the reliability of various measures of alignment in lateral x-rays of the spine, including anterior head translation, atlas plane to horizontal, Ruth Jackson's cervical stress lines, and five relative intersegmental rotation angles for the neck. Inter-rater reliabilities were substantial to near perfect in the cervical spine (0.74 ≤ ĸ ≤ 0.99). Phillips et al. [227] evaluated 56 radiographic variables demonstrating a high inter-observer reliability for interpretations by chiropractors, but not for medical physicians. Most notably, findings related to disc space narrowing were the few statistically associated with back or leg complaints (P = 0.025).

Integrated P.A.R.T.S. Studies [Quality scores: Validity 0 low, 0 moderate, 1 high; Reliability 3 low, 7 moderate ,1 high].

Lumbar patterns of vertebral displacement on lateral bending films, following the definitions attributed to Grice [228], measuring lateral tilt combined with rotation have been studied for reliability. In this low quality study, inter-rater concordance for lateral tilt was moderate (0.49 < ĸ < 0.65) for L1 to L4 but fair (0.23 < ĸ < 0.24) for L5.

Reliability for rotation was varied over a broader range (0.19 < ĸ < 0.60) for all spinal levels depending on pairing of examiners. The ability to predict aberrant lateral bending of a vertebral segment from x-rays taken in the neutral orientation of the segment was studied by Haas and Petersen [229]. Healthy and low back pain subjects were examined. In this high quality study, a moderate negative correlation (−0.39 < r < −0.16) was found between the amount of neutral lateral tilt of the vertebrae and its tendency to increase that tilt when lateral bending to the opposite side. Both symptomatic and asymptomatic subjects revealed the same behaviour.

Olson et al. [230] hypothesized a difference in motion in lateral bending of the upper cervical spine based on different standardized starting postures: neutral or minimally flexed.

However, in this low quality reliability study, no difference was observed (p > 0.05).

Rhudy et al. [231] examined agreement on the decision of

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Recommendation: Evidence of high quality supports the use of static and motion studies to identify hypermobile segments but not hypomobile segments. Thus, in terms of validity, the high quality evidence available at this time is unfavourable for use of x-rays to determine the site of care.

Several reports have utilized a montage or large panel of examination techniques in order to localize the target of care to a region or within a narrow anatomical limit, such as an individual articulation. Ten of these studies [48,68,136,201,232234] attempted to combine results into a form of summary score to guide the decision to provide care. Two studies [33,71] evaluated neurological tests designed to localize pathology according to sclerotome or dermatome, and orthopedic tests localizing to specific regions/articulations. Results from separate tests were not analyzed statistically to determine their individual contributions to a global decision to treat. Where in fact integrated P.A.R.T.S studies did analyze the individual contributions of specific tests, these results have been discussed within the appropriate preceding sections.

Leboeuf-Yde et al. [48], in a high quality study, asked examiners to categorize subjects into groups of “low back pain today” and “low back pain never” after using a panel of tests for posture, motion and pain provocation. The accuracy rates were 78% and 67%, respectively.

An early study by Rhudy et al. [231] focused on the tools used to identify the site of care. The inter-examiner agreement findings of three examiners who analyzed full spine x-ray films were compared with their motion palpation findings and each of these were also compared with their Gonstead style analysis of neurocalometer readings on a small sample of fourteen symptomatic patients. The investigators reported almost perfect/substantial correlation only 19% of time, fair/moderate correlation 21% of time and poor/ nil correlation 60% of the time. Hawk et al.[232], bundled assessment of segmental hypomobility/hypermobility, tissue texture, palpable temperature, and tenderness elicited on palpation to identify the site of treatment. Agreement was

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slight, at best.

An inter-examiner reliability study by Keating et al. [235] attempted to correlate eight different tools common in chiropractic practice: i) palpatory pain over osseous structures and ii) paraspinal soft tissues, iii) temperature differences between adjacent segments as measured by the dermothermograph, iv) visual inspection for segmental abnormality, v) active and vi) passive motion palpation, vii) muscle tension palpation, and viii) misalignment palpation. Scores were combined to form a composite joint abnormality index, with osseous pain and soft tissue pain, temperature and visual observation giving the strongest correlations (0.34 < r < 0.65). In a follow-up study that was also rated as moderate quality, Boline et al. [55] assessed the composite from visual inspection, palpation for pain over osseous and soft tissue structures, surface EMG and the dermothermograph. Reliability of the combined scores was mixed (−0.3 < ĸ < 0.56) and judged unacceptable for clinical application. They again reported that palpation for pain over osseous and soft tissue structures and visual observation of posture produced good to excellent inter-examiner agreement. Results from visual postural analysis, pain description by the patient, plain static erect x-ray films, leg length discrepancy, neurological tests, motion palpation, static palpation and orthopedic tests were evaluated by French et al. [68]. Overall, the measures were not reproducible and the decision to treat, either by different examiners on the same occasion or the same examiner on different occasions, was not reproducible.

Petersen et al. [71] linked a systematic partitioning of patients according to suspected pathoanatomical site of pain production based on pain distribution, response to postural movements and orthopedic maneuver. Inter-rater kappa scores ranged from 0.44 ≤ ĸ ≤ 1.00 for assignment of patients in groups for discogenic, radicular, zygapophyseal, sacroiliac and myofascial categories.

Qvistgaard et al. [136] focused on identifying abnormal spinal segments (± 1 segment) as the most pronounced dysfunction in the lumbar spine. Testing combined standing (trunk side bending, flexion, ‘stork test’), supine pelvic girdle clockwise/ counter clockwise rotation, prone lumbar springing, and side-lying multifidus tension manoeuvres. Kappa values were: segmental diagnosis, 0.57; multifidus test, 0.48; side flexion, 0.45; and ventral flexion 0.44. A similar approach to the thoracic spine was used by Potter et al.[233].

Combining inspection of posture, voluntary movement, passive movement and static palpation, identification of a dysfunctional joint in the thoracic spine showed moderate

A selection of published research by CMCC faculty

to poor reliability (ICC = 0.70, C.I. 0.27–0.90). For the lumbar spine, the results were better: ICC = 0.96 (95% CI, 0.87 to 0.99). Toussaint et al. [236] examined the sacroiliac joint with a combination of the standing flexion test, spine test (Gillet), and iliac springing test. Agreement on side, based on a positive result combined for any two tests, was moderate to substantial (0.483 ≤ ĸ ≤ 0.677).

Degenhardt et al. [201,234] evaluated a consensus training method to enhance the inter-rater reliability of a panel of tests. After training intervention [234] for 12 groups of 3 examiners, agreement on tenderness rose from ĸ =0.32 to ĸ =0.68 and that for tissue texture improved from ĸ =0.12 to ĸ =0.45. In the separate study [201], training was able to produce increased agreement in static palpation asymmetry (ĸ =0.18 to 0.59), tissue texture (ĸ = −0.01 to 0.45), anterior springing (ĸ =0.29 to 0.44) and palpatory tenderness (ĸ = 0.32 to 0.65). Retention of the improved skill has not been reported.

Recommendation: Unclear, based on moderate quality evidence, for examination montages contributing any more than their component elements to the decision to localize treatment.

Discussion The work of this report represents the most comprehensive review of the literature, to date, in relation to the diagnostic methods used for locating the site of care at which to apply manipulation treatment methods. Despite a number of studies addressing the questions of validity and reliability over the years, the research community’s sense of what constitutes a good study of diagnostic accuracy appears to be evolving. Guidelines for evaluating the strength of evidence are relatively recent in comparison to guidelines for studies of treatment. The first broadly accepted sets of standards for the design of studies of diagnostic accuracy, Standards for Reporting of Diagnostic Accuracy (STARD) and the Quality Assessment of Diagnostic Accuracy Studies (QUADAS), were published in 2003 [25,26,237,238]. The Quality Appraisal tool for Studies of Diagnostic Reliability (QAREL) only appeared in 2010 [27].Applying these tools to the literature found high quality evidence for the majority of the P.A.R.T.S. constructs. Constrained by the current understandings of manipulation treatment methods and the patients to whom they are applied, better practices, if not best, for practitioners are evident and summarized in Table 3. Very few methods can be used in isolation. Taken as a whole, the literature continues to support the fundamental principles of clinical differential diagnosis [10]. The physical examination should be contextualized by the patient’s history and presenting complaint to progressively narrow the

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focus of attention, first to region then local site and, sometimes, tissue. The body of evidence seems to support more direct, mechanical methods of assessing and identifying the site of care, and in general is not supportive of less direct methods such as manual muscle testing for non-pathological states, thermography, surface electromyography and measures of electrodermal activity.

Fixed examination montages are no more helpful than information derived from the individual components.

Manoeuvres that replicate the patient’s familiar pain may be the most consistent sources for diagnostic information.

A number of assessment methods were judged to be useful for patient screening or for narrowing the topographical focus of examination. These included postural assessment, orthopedic testing in general, and range of motion testing, as well as assessment of leg length inequality. While there is favourable evidence for a number of palpation methods, there are significant limitations. The inability to locate anatomical landmarks likely is a common underlying feature. When the error in accuracy is taken into account by enfolding those errors (e.g. ± one vertebral segment) into the decision criteria, inter-rater reliability increases substantially.

Examining this error construct in light of more recent work may be instructive. Is the error a result of limitations in communicating what is being perceived by the examiner? May it be a result of the variation in clinical presentations in patients that are believed to respond to manipulation treatments? Future diagnostic studies are likely to benefit from studies on mechanisms of the examination and of the underlying clinical state.

For example, the work of Degenhardt et al. [201,234] strives to understand the elements of examiner perceptions and to train examiners to reliably locate them and convey their interpretations. Fritz and colleagues [74,89,90,221] are attempting to tease apart the objective static and dynamic features of spinal function in relation to examination findings and responses to treatment.

The ambiguity of the clinical state of the underlying lesion or lesions treated with manipulation is a constraint on the literature and this constraint cannot be effectively controlled by research methodologies. At present, there is no ideal gold standard of comparison. In response, a pragmatic approach has been taken in this, consistent with the practitioner’s experience, and accepts forms of concurrent, construct and face validity for the necessity of care as derived from the patient’s clinical presentation.

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Limitations •

Although every effort was made to perform an exhaustive and complete search, the abundance of relevant literature, coupled with the fact that some authors did not choose useful indexing terms, guarantees that some literature was missed.

•

A number of studies used examiners of doubtful ability– commonly students–and this seems incongruous when investigating what may be complex psychomotor skills, as suggested by the work of Degenhardt et al. [201,234].

•

Rules that are used to rate the strength of evidence are by definition arbitrary and thus subject to discussion.

•

A number of authors utilized suboptimal methods of data analysis (e.g. correlation analysis) particularly for addressing inter-rater reliability. Found usually in the lower ranked articles, correlation analysis may yield a high value for correlation between measures where the accuracy may be meaningfully in question.

This review, having examined the evidence on the reliability and validity of research on the site of care, by design did not address the larger question as to the clinical value of identifying a putative appropriate site of care. We cannot rule out the possibility that the clinical consequences of the manipulation treatment are to some extent site independent.

While it is generally recognized that using checklists to generate summary quality scores may be problematic (for example, see Whiting et al. [25,26,238], especially when the weighting of items is arbitrary, the method which we used– employing item response theory to weight items based on the inverse of their prevalence with a set of papers, has been used previously for STARD [239] and validated for the CONSORT statement for papers within manual medicine [28].

Systematic use of QUADAS and QAREL independently address only metrics of validity and reliability within the context of each study. It is important to bear in mind that neither characteristic necessarily implies the other. That is, an assessment may be valid but unreliable, and the obverse, reliable but not valid. The implication of either alone or both together is insufficient to define clinical utility.

An important deficiency in the literature is the absence of significant discussion on the clinical utility of the various assessment methods.

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The broad search which was conducted has likely resulted in a corpus of literature which is generally representative of the current state of research in this area. Thus, where high levels of evidence were available and collective findings coherent–either favourable or unfavourable towards the use of a particular method–individual new studies are unlikely to affect the results presented herein. On the other hand, where the level of available evidence was relatively low or the findings of different studies incoherent, then new studies may well lead to new conclusions. Furthermore, the technologies themselves evolve. Thus, for example, while this review found coherent, moderate or high quality

A selection of published research by CMCC faculty

evidence which was not supportive of the use of methods that indirectly assess the tissues, technical improvements could see the future clinical validation of such methods.

Finally, while there is a need for more and better research into the underlying functional and/or pathological states that respond to manipulation, future diagnostic studies ought to focus beyond the metrics of accuracy. As posited

by Bossuyt et al. [240], the value of diagnostic tests/ maneuvers ought to rely on their clinical utility and capacity to change health outcomes.

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202. Paulet T, Fryer G: Inter-examiner reliability of palpation for tissue texture abnormality in the thoracic paraspinal region.

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205. Imoto K, Takebayashi T, Kanaya K, Kawaguchi S, Katahira G, Yamashita T: Quantitative analysis of sensory functions after lumbar discectomy using current perception threshold testing.

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measurements of segmental paraspinal skin surface

response and spinal palpation findings in pain-free males. J

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207. Plaugher G, Haas M, Doble RW Jr, Lopes MA, Cremata EE, Lantz C: The interexaminer reliability of a galvanic skin response instrument.

J Manipulative Physiol Ther 1993, 16:453–459.

220. Bierma-Zeinstra SM, van Gool JJ, Bernsen RM, Njoo KH: Measuring the sacral inclination angle in clinical practice: is there an alternative to radiographs? J Manipulative Physiol Ther 2001, 24:505–508.

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221. Abbott JH, Fritz JM, McCane B, Shultz B, Herbison P, Lyons B, et al:

et al:A metaanalytic review of surface electromyography among

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211. Dankaerts W, O'Sullivan P, Burnett A, Straker L: Altered patterns of superficial trunk muscle activation during sitting in nonspecific chronic low back pain patients: importance of subclassification.

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212. Fryer G, Bird M, Robbins B, Fossum C, Johnson JC: Resting

B: Repeatability over time of posture, radiograph positioning, and radiograph line drawing: an analysis of six control groups. J Manipulative Physiol Ther 2003, 26:87–98.

223. Plaugher G, Hendricks AH: The inter- and intraexaminer reliability of the gonstead pelvic marking system. J Manipulative Physiol Ther 1991, 14:503–508.

224. Antos JC, Robinson K, Keating JC, Jacobs GE: Interrater reliability of fluoroscopic detection of fixation in the Mid cervical spine.

Chiropract Tech 1990, 2:53–55.

225. Croft AC, Krage JS, Pate D, Young DN: Videofluoroscopy in cervical

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213. Lehman GJ: Clinical considerations in the use of surface electromyography: three experimental studies. J Manipulative Physiol Ther 2002, 25:293–299.

214. Leach RA, Owens EF Jr, Giesen JM: Correlates of myoelectric asymmetry detected in low back pain patients using hand-held poststyle surface electromyography. J Manipulative Physiol Ther 1993, 16:140–149.

215. Harrison DD, Cailliet R, Janik TJ, Troyanovich SJ, Harrison DE, Holland B: Elliptical modeling of the sagittal lumbar lordosis and segmental rotation angles as a method to discriminate between normal and low back pain subjects. J Spinal Disord 1998, 11:430– 439.

216. Harrison DD, Harrison DE, Janik TJ, Cailliet R, Ferrantelli JR, Haas

226. Jackson BL, Harrison DD, Robertson GA, Barker WF: Chiropractic biophysics lateral cervical film analysis reliability. J Manipulative Physiol Ther 1993, 16:384–391.

227. Phillips RB, Frymoyer JW, Mac Pherson BV, Newburg AH: Low back pain: a radiographic enigma. J Manipulative Physiol Ther 1986, 9:183–187.

228. Haas M, Nyiendo J, Peterson C, Thiel H, Sellers T, Cassidy D, et al: Interrater reliability of roentgenological evaluation of the lumbar spine in lateral bending. J Manipulative Physiol Ther 1990, 13:179–189.

229. Haas M, Peterson D: A roentgenological evaluation of the relationship between segmental motion and malalignment in lateral bending. J Manipulative Physiol Ther 1992, 15:350–360.

230. Olson KA, Paris SV, Spohr C: Radiographic assessment and

JW, et al: Modeling of the sagittal cervical spine as a method to

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reliability in spinal subluxation assessment: a multifactorial

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mensuration analysis of the anteroposterior lumbopelvic view: a

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219. Plaugher G, Hendricks AH, Doble RW Jr, Bachman TR, Araghi HJ,

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Manipulative Physiol Ther 1999, 22:382–389.

233. Potter L, McCarthy C, Oldham J: Intraexaminer reliability of identifying a dysfunctional segment in the thoracic and lumbar spine. J Manipulative Physiol Ther 2006, 29:203–207.

234. Degenhardt BF, Snider KT, Snider EJ, Johnson JC: Interobserver

Hoffart VM: The reliability of patient positioning for evaluating static

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Triano JJ et al

A selection of published research by CMCC faculty

235. Keating JC Jr, Bergmann TF, Jacobs GE, Finer BA, Larson K: Interexaminerreliability of eight evaluative dimensions of lumbar segmental abnormality. J Manipulative Physiol Ther 1990, 13:463–470.

236. Toussaint R, Gawlik CS, Rehder U, Ruther W: Sacroiliac joint diagnostics in the Hamburg construction workers study. J Manipulative Physiol Ther 1999, 22:139–143.

237. Bossuyt PM, Reitsma JB, Bruns DE, Gatsonis CA, Glasziou PP, Irwig LM, et al: The STARD statement for reporting studies of diagnostic accuracy: explanation and elaboration. Ann Intern Med 2003, 138:W1–W12.

238. Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, et al: QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 2011, 155:529–536.

239. Budgell B: The use of surface electromyography in the assessment of functional biomechanical disorders of the spine. Victoria, Australia: Chiropractors Registration Board of Victoria; 2007.

240. Bossuyt PM, Reitsma JB, Linnet K, Moons KG: Beyond diagnostic accuracy: the clinical utility of diagnostic tests. Clin Chem 2012, 58:1636–1643.

Originally published in Chiropractic and Manual Therapies, 2013 Oct 21;21(1):36. Open Access Article distributed under the terms of the Creative Commons Attribution License .

Access Online: http://dx.doi.org/10.1186/2045-709X-21-36

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Retention of Blinding at Follow-up in a Randomized Clinical Study Using a Sham-Control Cervical Manipulation Procedure for Neck Pain: Secondary Analyses From a Randomized Clinical Study Vernon H, Triano JJ, Soave D, Dinulos M, Ross K, Tran S Canadian Memorial Chiropractic College

Abstract Objective Participants in clinical trials of spinal manipulation have not been rigorously blinded to group assignment. This study reports on secondary analyses of the retention of participant blinding beyond the immediate post-treatment time frame following a single-session, randomized clinical study. A novel control cervical manipulation procedure that has previously been shown to be therapeutically inert was contrasted with a typical manipulation procedure.

Methods A randomized clinical study of a single session of typical vs sham-control manipulation in patients with chronic neck pain was conducted. Findings of self-reported group registration at 24 to 48 hours post-treatment were computed. The Blinding Index (BI) of Bang et al was then applied to both the immediate and post-24- to 48-hour results.

Results Twenty-four to 48 hours after treatment, 94% and 22% of participants in the typical and control groups, respectively, with the BI of Bang et al, the immediate post-treatment

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correctly identified their group assignment. When analyzed BI for the group receiving a typical manipulation was 0.22 (95% confidence interval [CI], -0.03 to 0.47); for the group receiving a control manipulation, it was 0.19 (95% CI, -0.06 to 0.43). The BI at post-24 hours was as follows: typical = 0.75 (95% CI, 0.59-0.91) and control = -0.34 (95% CI, -0.58 to -0.11).

Conclusions This study found that the novel sham-control cervical manipulation procedure may be effective in blinding sham group allocation up to 48 hours post-treatment. It appears that, at 48 hours post-treatment, the modified form of the typical cervical manipulation was not. The sham-control procedure appears to be a promising procedure for future clinical trials.

Originally published in the Journal of Manipulative and Physiological Therapeutics 2013 Oct;36(8):522-6. Epub 2013 Sep 5. Reproduced with permission from Elsevier.

Access Online: http://dx.doi.org/10.1016/j.jmpt.2013.06.005

A selection of published research by CMCC faculty

Immediate Changes in Temporomandibular Joint Opening and Pain Following Vibration Therapy: A Feasibility Pilot Study Muir B, Brown C, Brown T, Tatlow D, Buhay J Canadian Memorial Chiropractic College

Abstract Objective The purpose of this pilot study was to determine the scientific and process feasibility in an effort to direct future larger trials.

Methods Scientific Feasibility: Twelve subjects were randomly allocated to an intervention and a control group. The intervention protocol consisted of intraoral vibration therapy on the muscles of mastication bilaterally for a period of 1 minute per muscle. Process Feasibility: Several feasibility outcomes were examined including recruitment and retention rates and consent.

Conclusions Scientific Feasibility: The scientific results should be interpreted with caution due to the small sample sizes employed. The study seems to support the scientific feasibility of a future larger single treatment trial.

Process Feasibility: Recruitment and retention rates and ratios seem to support future studies. Utilizing the feasibility results of the current study to direct a future larger multiple treatment trial consistent with other comparable TMD studies however is limited.

Originally published in the Journal of the Canadian Chiropractic Association, 2014 Dec; 58(4): 467â&#x20AC;&#x201C;480.

Reproduced with permission.

Results Scientific Feasibility: Large effect sizes were generated for both mouth opening and VAS in favour of the intervention group. Process Feasibility: a recruitment ratio of 2.3 respondents to 1 participant was determined, along with a retention to loss ratio of 13:1 and a consent to loss ratio of 12:0.

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Is Low Back Pain Associated With Worse Health-Related Quality of Life 6 Months Later?

Nolet PS, Kristman VL, Côté P, Carroll LJ, Cassidy JD Canadian Memorial Chiropractic College

Abstract Purpose The purpose of this study was to investigate the impact of low back pain (LBP) on future health-related quality of life (HRQoL). Current evidence suggests that individuals with LBP have poorer HRQoL than those without LBP. However, most of the evidence comes from cross-sectional studies where LBP and HRQoL are determined at the same time.

One prospective study examined the association between days with LBP and HRQoL but did not account for the intensity of LBP. Therefore, this association needs to be tested in a large prospective population-based sample with a valid measure of LBP and adequate control of known confounders.

Methods We formed a cohort of 1,110 randomly sampled Saskatchewan adults in September 1995. LBP at baseline was measured with the chronic pain questionnaire. The SF-36 questionnaire was used to measure physical and mental HRQoL at 6 months follow-up. Multivariable linear regression was used to estimate the association between graded LBP at baseline and HRQoL at 6 months while controlling for the effects of confounding.

Results The 6-month follow-up rate was 70.7 % (785/1,110). LBP had a dose-response relationship with worsening physical HRQoL at 6 months, after controlling for age, income, arthritis, neck pain, and kidney disorders: grade III-IV LBP (ß= -10.23; 95 % CI -12.46, -7.99), grade II LBP (ß= -6.72, 95 % CI -8.79, -4.65), and grade I LBP (ß = -1.77; 95 % CI -3.18, -0.36). There was no dose-response relationship between LBP and mental HRQoL at 6 months.

Results The 6-month follow-up rate was 70.7 % (785/1,110). LBP had a dose-response relationship with worsening physical HRQoL at 6 months, after controlling for age, income, arthritis, neck pain, and kidney disorders: grade III-IV LBP (ß = -10.23; 95 % CI -12.46, -7.99), grade II LBP (ß= -6.72, 95 % CI -8.79, -4.65), and grade I LBP (ß = -1.77; 95 % CI -3.18, -0.36). There was no dose-response relationship between LBP and mental HRQoL at 6 months.

Conclusions Low back pain has an impact on future physical HRQoL. Strategies for reducing the effects of LBP on HRQoL should be an important focus for clinicians, researchers, and health policy makers.

Originally published in European Spine Journal 2015 Mar;24(3):458-66. Epub 2014 Nov 13. Reproduced with permission from Springer Science+Business Media.

Access Online: http://dx.doi.org/10.1007/s00586-014-3649-4

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A selection of published research by CMCC faculty

Informed Consent for Chiropractic Care: Comparing Patients' Perceptions to the Legal Perspective Winterbottom M1, Boon H1, Mior S2 , Facey M1 University of Toronto, 2Canadian Memorial Chiropractic College

1

Abstract Purpose This study explored chiropractic patients' perceptions of exchanging risk information during informed consent and compared them with the legal perspective of the informed consent process.

Methods Interviews were conducted with 26 participants, recruited from chiropractic clinics. Transcripts were analysed using a constant comparative method of analysis.

Findings Participants experienced informed consent as an on-going process where risk information informed their decisions to receive treatment throughout four distinct stages. In the first stage, information acquired prior to arriving at the clinic for treatment shaped perceptions of risk. In stage two, participants assessed the perceived competence of their

practitioners. Participants then signed the consent form and discussed the risks with their practitioners. Finally, they communicated with their practitioners during treatment to ensure their pain threshold was not crossed.

Conclusion These findings suggest that chiropractic patients perceive informed consent as a process involving communication with their practitioners, and that it is possible to educate patients about the risks associated with treatment while satisfying the legal requirements of informed consent.

Originally published in Manual Therapy, 2015 Jun;20(3): 463-8. Epub 2014 Nov 26. Reproduced with permission from Elsevier.

Access Online: http://dx.doi.org/10.1016/j.math.2014.11.009

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Development and Validation of Providers' and Patients' Measurement Instruments to Evaluate Adverse Events After Spinal Manipulation Therapy Pohlman KA1, O'Beirne M2, Thiel H3, Cassidy JD4,5, Mior S6 , Hurwitz EL7, Westawa M8,9, Ishaque S1, Yager JY9, Vohra S1 University of Alberta, 2University of Calgary, 3Anglo-European College of Chiropractic, 4University of Toronto, 5University Health Network,

1 6

Canadian Memorial Chiropractic College, 7University of Hawaii, 8LifeMark Health, 9McMaster University

Abstract Introduction Spinal manipulation therapy (SMT) is used throughout the world by chiropractors, osteopaths, physiotherapists and other manual therapists, yet there are no systematic data collection mechanisms in place to monitor and evaluate adverse events (AE) that occur after SMT. We established a reporting and learning system (“SafetyNet”) to fill this void and to address several aims, one of which is a prospective population-based active surveillance study to (a) document AE after SMT, (b) identify potential risk factors, and (c) develop potential strategies to mitigate risk. The purpose of this paper is to describe the development and validation of provider and patient measurement instruments to identify potential SMT AE in provider offices.

Methods Instrument development and validation occurred in a step-wise fashion: (1) definition of terms (e.g. adverse event, seriousness); (2) identification and development of key domains, items, and sub-items; and (3) assessment of relevant measurement properties.

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Results Two provider short instruments, a provider long instrument, and a pre and post treatment patient comment instruments were developed, refined, and pilot tested with 12 providers and 300 patients.

Conclusion The development and validation of instruments to evaluate SMT AEs may benefit the SMT research community as well as clinicians and their patients by providing rigorous prospective assessment of potential SMT-related AEs and their risk factors, thus enhancing patient safety and the promotion of a safety culture. Placing the instruments in providers’ offices for use on consecutive patients is next on the SafetyNet research agenda.

Originally published in the European Journal of Integrative Medicine, 2014 Aug 1;6(4):467-72.Eur J Integr Med. 2014 Aug 1;6(4):467-72. Reproduced with permission from Elsevier.

Access Online: http://dx.doi.org/10.1016/j.eujim.2014.01.002

A selection of published research by CMCC faculty

Policy

The Effectiveness of Exercise on Recovery and Clinical Outcomes of Soft Tissue Injuries of the Leg, Ankle, & Foot A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration Woitzik E1, Jacobs C1,2 , Wong JJ1,2 , Côté P1,2,3 , Shearer HM1,2 , Randhawa K 2 , Sutton D2 , Southerst D2 , Varatharajan S2 , Brison RJ4, Yu H2 , van der Velde G5, Stern PJ1, Taylor-Vaisey A 2, Stupar M2 , Mior S1, Carroll LJ1,7 Canadian Memorial Chiropractic College, 2UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College, 3University of Ontario Institute of Technology (UOIT), 4Queen's University at Kingston, 5University of Toronto, 6Institute for Work and Health, 7University of Alberta 1

Abstract Introduction Soft tissue injuries of the leg, ankle, or foot are common and often treated by exercise. The purpose of this study was to determine the effectiveness of exercise for the management of soft tissue injuries of the leg, ankle, or foot.

Methods A systematic review of the literature was conducted. We searched five databases from 1990 to 2015. Relevant articles were critically appraised using Scottish Intercollegiate Guidelines Network (SIGN) criteria. The evidence from studies with low risk of bias was synthesized using the best evidence synthesis methodology.

Results We screened 7,946 articles. We critically appraised ten randomized trials and six had a low risk of bias. The evidence suggests that for recent lateral ankle sprain: 1) rehabilitation exercises initiated immediately post-injury are as effective as a similar program initiated one week post-injury; and 2) supervised progressive exercise plus

education/advice and home exercise lead to similar outcomes as education/advice and home exercise. Eccentric exercises may be more effective than an AirHeel brace but less effective than acupuncture for Achilles tendinopathy of more than two months duration. Finally, for plantar heel pain, static stretching of the calf muscles and sham ultrasound lead to similar outcomes, while static plantar fascia stretching provides short-term benefits compared to shockwave therapy.

Conclusion We found little evidence to support the use of early or supervised exercise interventions for lateral ankle sprains. Eccentric exercises may provide short-term benefits over a brace for persistent Achilles tendinopathy and plantar fascia stretching provides short-term benefits for plantar heel pain.

Originally published in Manual Therapy, 2015 Oct;20(5): 633-45. Epub 2015 Mar 28. Reproduced with permission from Elsevier.

Access Online: http://dx.doi.org/10.1016/j.math.2015.03.012

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Systematic Review of Prognosis and Return to Play After Sport Concussion: Results of the International Collaboration on Mild Traumatic Brain injury Prognosis Cancelliere C1, Hincapié CA1, Keightley M1, Godbolt AK3, Côté P1,4,5,6 , Kristman VL1, Stålnacke BM5, Carroll LJ6,7, Hung R1, Borg J2, Nygren-de Boussard C2, Coronado VG7, Donovan J1, Cassidy JD1,6,8 University of Toronto, 2Karolinska Institutet, Stockholm, Sweden, 3Umeå University, Umeå, Sweden, 4University of Ontario Institute of Technology, 5UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, 6Canadian Memorial Chiropractic College, 7University of Alberta, 8Centers for Disease Control and Prevention, 9University of Southern Denmark 1

Abstract Objective To synthesize the best available evidence on prognosis after sport concussion.

Data Sources MEDLINE and other databases were searched (2001-2012) with terms including "craniocerebral trauma" and "sports."

Reference lists of eligible articles were also searched.

Study Selection Randomized controlled trials and cohort and case-control studies were selected according to predefined criteria.

Studies had to have a minimum of 30 concussion cases.

Data Extraction Eligible studies were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers independently reviewed and extracted data from accepted studies into evidence tables.

Data Synthesis Evidence was synthesized qualitatively according to modified SIGN criteria, and studies were categorized as exploratory or confirmatory based on the strength of their design and evidence. After 77,914 records were screened, 52 articles were eligible for this review, and 24 articles (representing

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19 studies) with a low risk of bias were accepted. Our findings are based on exploratory studies of predominantly male football players at the high school, collegiate, and professional levels. Most athletes recover within days to a few weeks, and American and Australian professional football players return to play quickly after mild traumatic brain injury. Delayed recovery appears more likely in high school athletes, in those with a history of previous concussion, and in those with a higher number and duration of postconcussion symptoms.

Conclusions The evidence concerning sports concussion course and prognosis is very preliminary, and there is no evidence on the effect of return-to-play guidelines on prognosis.

Our findings have implications for further research. Welldesigned, confirmatory studies are urgently needed to understand the consequences of sport concussion, including recurrent concussion, across different athletic populations and sports.

Originally published in Archives of Physical Medicine and Rehabilitation, 2014 Mar;95(3 Suppl):S210-29. Reproduced with permission from Elsevier.

Access Online: http://dx.doi.org/10.1016/j.apmr.2013.06.035

A selection of published research by CMCC faculty

Differentiating Intraprofessional Attitudes Towards Paradigms in Health Care Delivery Among Chiropractic Factions: Results From A Randomly Sampled Survey McGregor M, Puhl AA, Reinhart C, Injeyan HS, Soave D Canadian Memorial Chiropractic College

Abstract Background As health care has increased in complexity and health care teams have been offered as a solution, so too is there an increased need for stronger interprofessional collaboration. However the intraprofessional factions that exist within every profession challenge interprofessional communication through contrary paradigms. As a contender in the conservative spinal health care market, factions within chiropractic that result in unorthodox practice behaviours may compromise interprofessional relations and that profession’s progress toward institutionalization. The purpose of this investigation was to quantify the professional stratification among Canadian chiropractic practitioners and evaluate the practice perceptions of those factions.

Methods A stratified random sample of 740 Canadian chiropractors was surveyed to determine faction membership and how professional stratification could be related to views that could be considered unorthodox to current evidence-based care and guidelines. Stratification in practice behaviours is a stated concern of mainstream medicine when considering interprofessional referrals.

Results Of 740 deliverable questionnaires, 503 were returned for a response rate of 68%. Less than 20% of chiropractors (18.8%) were aligned with a predefined unorthodox perspective of the conditions they treat. Prediction models suggest that unorthodox perceptions of health practice related to treatment choices, x-ray use and vaccinations were strongly associated with unorthodox group membership (Χ 2 =13.4, p = 0.0002).

Conclusion Chiropractors holding unorthodox views may be identified based on response to specific beliefs that appear to align with unorthodox health practices. Despite continued concerns by mainstream medicine, only a minority of the profession has retained a perspective in contrast to current scientific paradigms. Understanding the profession’s factions is important to the anticipation of care delivery when considering inter-professional referral.

Originally published in BMC Complementary and Alternative Medicine. 2014 Feb 10;14:51.

This is an Open Access Article distributed under the terms of the Creative Commons Attribution License.

Access Online: http://dx.doi.org/10.1186/1472-6882-14-51

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Examination of the Relationship Between Theory-Driven Policies and Allowed Lost-Time Back Claims in Workers' Compensation: A System Dynamics Model Wong JJ1,2 , McGregor M2 , Mior SA 2 , Loisel P2,3 UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and the Canadian Memorial Chiropractic College (CMCC), 2Canadian Memorial Chiropractic College, 3University of Toronto 1

Abstract Objective The purpose of this study was to develop a model that evaluates the impact of policy changes on the number of workers' compensation lost-time back claims in Ontario, Canada, over a 30-year timeframe. The model was used to test the hypothesis that a theory- and policy-driven model would be sufficient in reproducing historical claims data in a robust manner and that policy changes would have a major impact on modeled data.

Methods The model was developed using system dynamics methods in the Vensim simulation program. The theoretical effects of policies for compensation benefit levels and experience rating fees were modeled. The model was built and validated using historical claims data from 1980 to 2009. Sensitivity analysis was used to evaluate the modeled data at extreme end points of variable input and timeframes. The degree of predictive value of the modeled data was measured by the coefficient of determination, root mean square error, and Theil's inequality coefficients.

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Results Correlation between modeled data and actual data was found to be meaningful (R2 = 0.934), and the modeled data were stable at extreme end points. Among the effects explored, policy changes were found to be relatively minor drivers of back claims data, accounting for a 13% improvement in error. Simulation results suggested that unemployment, number of no-lost-time claims, number of injuries per worker, and recovery rate from back injuries outside of claims management to be sensitive drivers of back claims data.

Conclusion A robust systems-based model was developed and tested for use in future policy research in Ontario's workers' compensation. The study findings suggest that certain areas within and outside the workers' compensation system need to be considered when evaluating and changing policies around back claims.

Originally published in the Journal of Manipulative and Physiological Therapeutics, 2014 Jan;37(1):7-21. Epub 2013 Nov 12. Reproduced with permission from Elsevier.

Access Online: http://dx.doi.org/10.1016/j.jmpt.2013.07.009

A selection of published research by CMCC faculty

Is Exercise Effective for the Management of Subacromial Impingement Syndrome and Other Soft Tissue Injuries of the Shoulder?

A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration Abdulla SY1, Southerst D1,2 , C么t茅 P1,2 , Shearer HM2 , et al Canadian Memorial Chiropractic College, 2UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology and Canadian Memorial Chiropractic College, 3New York University, 4University of Ontario Institute of Technology, 5 University of Alberta, 6University of Toronto 1

Abstract Background Exercise is a key component of rehabilitation for soft tissue injuries of the shoulder; however its effectiveness remains unclear.

Objective Determine the effectiveness of exercise for shoulder pain.

Methods We searched seven databases from 1990 to 2015 for randomized controlled trials (RCTs), cohort and case control studies comparing exercise to other interventions for shoulder pain. We critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network (SIGN) criteria. We synthesized findings from scientifically admissible studies using best-evidence synthesis methodology.

Results We retrieved 4853 articles. Eleven RCTs were appraised and five had a low risk of bias. Four studies addressed subacromial impingement syndrome. One study addressed nonspecific shoulder pain. For variable duration subacromial impingement syndrome: 1) supervised strengthening leads

to greater short-term improvement in pain and disability over wait listing; and 2) supervised and home-based strengthening and stretching leads to greater shortterm improvement in pain and disability compared to no treatment. For persistent subacromial impingement syndrome: 1) supervised and home-based strengthening leads to similar outcomes as surgery; and 2) home-based heavy load eccentric training does not add benefits to home-based rotator cuff strengthening and physiotherapy.

For variable duration low-grade nonspecific shoulder pain, supervised strengthening and stretching leads to similar short-term outcomes as corticosteroid injections or multimodal care.

Conclusions The evidence suggests that supervised and home-based progressive shoulder strengthening and stretching are effective for the management of subacromial impingement syndrome. For low-grade nonspecific shoulder pain, supervised strengthening and stretching are equally effective to corticosteroid injections or multimodal care.

Originally published in Manual Therapy, 2015 Oct;20(5): 646-56. Epub 2015 Apr 1. Reproduced with permission from Elsevier.

Access Online: http://dx.doi.org/10.1016/j.math.2015.03.013

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Policy Feature Article

Is Multimodal Care Effective for the Management of Patients With Whiplash-Associated Disorders or Neck Pain and Associated Disorders?

A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration Sutton DA 1,2 , Côté P1,2,3,4 , Wong JJ1,2 , Varatharajan S1,2 , Randhawa KA1,2 , Yu H1,2 , Southerst D1,2 , Shearer HM1,2 , van der Velde GM4,5, Nordin MC 2,6 , Carroll LJ1,7, Mior SA 2,3 , Taylor-Vaisey AL1, Stupar M1,2 UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College, 2Canadian Memorial Chiropractic, 3University of Ontario Institute of Technology (UOIT),4University of Toronto, 5 Institute for Work and Health, 6NYU School of Medicine, 7University of Alberta 1

Abstract Background Context Little is known about the effectiveness of multimodal care for individuals with whiplash-associated disorders (WAD) and neck pain and associated disorders (NAD).

Purpose To update findings of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders and evaluate the effectiveness of multimodal care for the management of patients with WAD or NAD. Study setting Systematic review and best-evidence synthesis.

Patient sample We included randomized controlled trials (RCTs), cohort studies, and case control studies.

Outcome Measures Self-rated recovery, functional recovery (eg, disability, return to activities, work, or school), pain intensity, health-related quality of life, psychological outcomes (eg, depression, fear), or adverse events.

Methods We systematically searched five electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials) from 2000 to 2013.

RCTs, cohort, and case-control studies meeting our selection criteria were eligible for critical appraisal.

Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines

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Network criteria. Scientifically admissible studies were summarized using evidence tables and synthesized following best-evidence synthesis principles.

Results We retrieved 2,187 articles, and 23 articles were eligible for critical appraisal. Of those, 18 articles from 14 different RCTs were scientifically admissible. There were a total of 31 treatment arms, including 27 unique multimodal programs of care. Overall, the evidence suggests that multimodal care that includes manual therapy, education, and exercise may benefit patients with grades I and II WAD and NAD. General practitioner care that includes reassurance, advice to stay active, and resumption of regular activities may be an option for the early management of WAD grades I and II. Our synthesis suggests that patients receiving high-intensity health care tend to experience poorer outcomes than those who receive fewer treatments for WAD and NAD. Conclusions Multimodal care can benefit patients with WAD and NAD with early or persistent symptoms. The evidence does not indicate that one multimodal care package is superior to another. Clinicians should avoid high utilization of care for patients with WAD and NAD.

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Sutton DA et al

Introduction Most people experience neck pain during their lifetime [1,2].

Neck pain is a public health problem and a leading cause of disability [1,3–5]. Nonspecific neck pain results in significant health-care utilization, work absenteeism, and lost productivity [1,6–9].

Neck pain is a complex biopsychosocial disorder and is associated with physical and psychological symptoms, and its consequences range from transient limitations of daily activities to prolonged work absenteeism [10–15]. The clinical management of neck pain can be complex and may involve combining multiple interventions (multimodal care) to address its symptoms and consequences.

Although understanding the effectiveness of multimodal care is challenging, it is necessary to guide clinical practice.

Clinicians manage patients according to their training, beliefs, preferences, and understanding of the evidence and are likely to combine various interventions in a multimodal program of care. Randomized controlled trials (RCTs) can examine the effectiveness of single interventions [16].

However, examining combinations of interventions as delivered in multimodal care affords greater insight into routine practice [17–20].

Few systematic reviews have evaluated the effectiveness of multimodal care for the management of neck pain [16,17,21].

Past reviews have combined trials of multimodal care with trials of specific interventions [22]. Methodologically, this approach is problematic because it may lead to biased conclusions about the effectiveness of a specific intervention. This is because the effectiveness (or ineffectiveness) of an intervention embedded within a multimodal program of care cannot easily be extracted from the effect of other interventions included in the multimodal approach.

In 2008, the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders (NPTF) reported on the effectiveness of noninvasive combined approaches, or multimodal care, for the management of neck pain and associated disorders (NAD), whiplash-associated disorders (WAD), and cervicobrachial pain [23]. The NPTF described multimodal care as combinations of single treatments, rehabilitation programs, or packages of care. The NPTF found evidence from one Quebec cohort study that a coordinated multidisciplinary management approach was associated with faster claim closure in individuals with WAD[5]. This finding was not supported by a Saskatchewan cohort study that found referrals to community-based inpatient or outpatient rehabilitation programs were

associated with delayed self-rated recovery from WAD[24].

Similarly, the NPTF found inconsistent evidence that multimodal care was more effective than other interventions for the management of individuals with persistent NAD or cervicobrachial pain[23].

The objective of our systematic review was to update the review of the NPTF on the effectiveness of multimodal care for the management of NAD and WAD. Specifically, we evaluated the effectiveness of multimodal care in improving self-rated recovery, functional recovery, or clinical outcomes in adults or children with WAD (grades I–III), and NAD (grades I–III).

Method Registration This review protocol was registered with the International Prospective Register of Systematic Reviews on July 3, 2013 (CRD42013004999).

Eligibility criteria Population Studies of adults and children diagnosed with WAD grades I to III or NAD grades I to III were included in our review. We excluded studies of neck pain because of major structural pathology (eg, fractures, dislocations, spinal cord injury, or neoplasms). WAD was defined using the Quebec Task Force classification (Table 1) [3]. We defined NAD according to the definition proposed by the NPTF (Table 2) [25].

Intervention We defined multimodal care as a treatment approach that includes at least two distinct therapeutic modalities (Table 3), provided by one or more health-care disciplines[16,22].

We excluded studies where the effectiveness of one intervention could be isolated.

Comparison Groups Studies that compared multimodal care to other interventions, placebo/sham interventions, or no intervention were considered.

Outcomes Eligible studies included self-rated recovery, functional recovery (eg, return to activities at work or school), disability, pain intensity, health-related quality of life, psychological outcomes (eg, depression, fear), or adverse events.

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Table 1 The Québec Task Force classification of grades of whiplash associated disorders

Table 2 The Neck Pain Task Force classification of grades of neck pain associated disorders

Study characteristics Eligible studies met the following criteria: English language; published between January 1, 2000 and May 16, 2013 and not reviewed by the NPTF; RCTs, cohort studies, or case-control studies; and included an inception cohort of at least 30 participants per treatment arm with the condition for RCTs or 100 subjects per group with the condition in cohort studies or case-control studies. Study exclusion criteria included: letters, editorials, commentaries, unpublished manuscripts, dissertations, government reports, books and book chapters, conference proceedings, meeting abstracts, lectures and addresses, consensus development statements, or guideline statements; pilot studies, cross-sectional studies, case reports, case series, qualitative studies, narrative reviews, systematic reviews, clinical practice guidelines, biomechanical studies, or laboratory studies; or cadaveric or animal studies.

Information Sources Our search strategy was developed with a health sciences librarian (Appendix I). A second librarian reviewed the search for completeness and accuracy using the Peer Review of Electronic Search Strategies Checklist [26,27].

The following databases were searched: MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from January 1, 2000 to May 16, 2013. We reviewed the reference list of the NPTF to identify additional eligible studies [22].

The search strategy was first developed in MEDLINE and subsequently adapted to the other databases. The search terms included subject headings specific to each database and free-text words relevant to multimodal care, NAD grades I to III, and WAD grades I to III. Databases containing the results of the searches were created using EndNote X6 (http://endnote.com/if/online-user-manual).

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Study selection Eligible studies from the NPTF were included in our synthesis. New eligible studies were selected through a two-phase screening process. In Phase 1, two randomly paired reviewers independently screened titles and abstracts to determine eligibility. Studies were classified as relevant, possibly relevant, or irrelevant. In Phase 2, the same reviewers independently reviewed manuscripts of possibly relevant studies to make a final determination of eligibility. Reviewers met to resolve disagreements and reach consensus in both phases. We involved a third independent reviewer if consensus could not be reached.

Assessment of risk bias Independent reviewer pairs critically appraised the internal validity of eligible studies using the Scottish Intercollegiate Guidelines Network (SIGN) criteria for RCTs, cohort studies, and case-control studies (Table 4) [28]. The SIGN criteria assist with the evaluation of the impact of selection bias, information bias, and confounding on the results of a study.

We did not use a quantitative score or a cut-off point to determine the internal validity of studies [29]. Rather, the SIGN criteria were used to assist reviewers in making an informed overall judgment on the internal validity of studies.

This methodology has been previously described [30–34].

Specifically, we critically appraised the following methodological aspects of a study: clarity of the research question, randomization method, concealment of treatment allocation, blinding of treatment and outcomes, similarity of baseline characteristics between treatment arms, co-intervention/ contamination, validity and reliability of outcome measures, attrition, intention-to-treat analysis, and comparability of results across study sites (where applicable). All reviewers were trained in the evaluation of studies using the SIGN criteria. Consensus between

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Table 3 Therapeutic modalities: definitions and examples

Table 4 Risk for bias for accepted randomized controlled trials based on the SIGN Criteria {32}

CS, cannot say; DC, chiropractor; GP, general practitioner; HEA, home exercise with advice; MD, medical doctor; MIN, minimal intervention; MPT, multimodal physical therapy; N, no; NA, not applicable; PASS, Pain and Stress Self-Management Group; PT, physical therapy; SMP, self-management program; SIGN, Scottish Intercollegiate Guidelines Network; STT, soft-tissue therapy; TENS, transcutaneous eletrical nerve stimulation; Y, yes.

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reviewers was reached through discussion. An independent third reviewer was used to resolve disagreements if consensus could not be reached. We contacted authors when additional information was needed to complete the critical appraisal. Studies with adequate internal validity were included in our synthesis [35].

Data extraction and synthesis of results The lead author extracted data from scientifically admissible studies and built evidence tables (Table 5). A second reviewer independently checked the extracted data.

Meta-analysis was not performed because of heterogeneity of scientifically admissible studies. A qualitative synthesis of the scientifically admissible studies was performed according to principles of best-evidence synthesis [35].

We stratified our synthesis according to disorder type (ie, WAD or NAD) and duration of the disorder (eg, recent 3 months], persistent [3 months], variable [all duration]).

We further stratified the multimodal programs of care according to their effectiveness to determine the components of intervention that are associated with superior outcomes: superior (associated with a minimal clinically important change compared with its comparator [36], equivalent (no clinically important differences between groups), and inferior (associated with worse outcomes than its comparator). The following minimal clinically important change thresholds were employed: 10 mm on the 100 mm Visual Analog Scale, 2 points on the 11 point Numeric Rating Scale, 25/100 difference on the Northwick Neck Pain Questionnaire (NPQ), and 5 points on the 50 point Neck Disability Index [37–44]. We estimated the intensity of care in each outcome group by computing the mean number of visits for each category.

Statistical Analysis The interrater agreement for article screening was computed using the kappa coefficient (k) and 95% confidence intervals (CIs) [45,46]. The percentage agreement for critical appraisal was calculated for admissible/ inadmissible results. Similarly, we computed the difference in mean change between groups and its 95% CI to quantify effect sizes. The computation of the 95% CI for the difference in mean change assumed that the preintervention and post intervention outcomes were highly correlated (r50.8) [47,48].

Reporting The systematic review was organized and reported based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement [49].

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Results Study Selection Our search yielded 2,187 articles. We removed 570 duplicates and screened 1,618 articles (Figure 1). A total of 1,543 articles did not meet our selection criteria leaving 23 articles eligible for critical appraisal. Nine studies (11 articles) published from 2007 to 2013 were deemed scientifically admissible and included in our synthesis [50–59].

A further six studies (seven articles) from 2000 to 2006 were included in the NPTF [60–66]. Of these, five studies were not included in the NPTF evidence of multimodal care.

We therefore included these five studies in our evidence synthesis of multimodal care [61–66]. The interrater agreement for the screening of articles was k50.80 (95% CI 0.70–0.89).

We achieved 90% agreement (10/11) for the critical appraisal of studies.

Study characteristics All 14 scientifically admissible studies (18 articles) were RCTs. Three studies addressed recent neck pain [50,57,66], two addressed persistent neck pain [53,54,60], and six targeted neck pain of variable duration [51,52,58,59,61,62,64,65]. Two studies investigated NAD Grade III [51,57], two addressed recent WAD [55,56,63], and one addressed persistent WAD Grade II [67].

The multimodal programs included a range of interventions: education, exercise, manipulation, mobilization, traction, soft-tissue therapy, acupuncture, heat and/or cold, electrotherapy, prescribed medication, and psychological interventions (Table 6). The most commonly used interventions were exercise (13/14), manual therapy (12/14), and education (12/14). Five health-care professions delivered multimodal care: physical therapists, physicians (MD, GP, osteopathic physician), naprapaths, nurses, and chiropractors (DC). One study included more than one health-care provider in a single treatment arm [58,64].

Risk of bias within studies All admissible RCTs used appropriate randomization procedures, concealment of treatment allocation, blinding (where possible), appropriate outcome measures, and performed an intention-to-treat analysis (Table 4).

Some studies had limitations: differences in baseline characteristics[51–54,67] and cointervention information unavailable. The follow-up rate for most RCTs was more than 75% [51–56,58,64,67], except two RCTs with follow-up rates more than 60% [50,53,54]. Twenty-three percent (5/22) of critically appraised studies had poor internal validity [68–72] . The methodological weakness of the excluded RCTs include inadequate methods of randomization (2/4), concealment (2/4), and blinding (2/4) [70,71]. All four RCTs

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Table 5 Evidence table for accepted RCTs on multi-modal care for WAD and NAD

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Table 5 (Continued)

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Table 5 (Continued)

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Table 5 (Continued)

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Table 6 Combinations of interventions in multi-modal care reported in scientifically admissible randomized control trials 2000-2013

DC, chiropractor; GP, general practitioner; MD, medical doctor; PT, physical therapist; UK, unknown.

Note: Empty cells indicate that the intervention component was not provided in the treat arm. Table includes only modalities reported in scientifically admissible studies. * Equivalent multi-modal programs of care † Inferior multi-modal programs of care ‡ Superior multi-modal programs of care

had important differences in baseline characteristics and high attrition[68,70–72] and three trials did not address cointerventions [68,71,72]. Intention-to-treat analyses could not be confirmed in two trials [68,72]. The inadmissible cohort study did not describe the source population or sampling frame; it had high attrition (60%) and the validity and reliability of the outcome could not be established [69].

Summary of evidence Recent whiplash-associated disorders Grades I to III Evidence from one RCT suggests that multimodal care by a physiotherapist is more effective than one education session for the management of patients with recent WAD grades I to III (Table 5) [55,56]. In the RCT by Lamb et al. [55,56], patients with symptoms persisting 3 weeks after attending an emergency department were randomized to multimodal care or an education intervention. Multimodal care (up to 6 visits per 8 weeks) could include manual therapy, heat or cold, exercise (eg, range of motion, proprioceptive training), and psychological strategies (eg, relaxation, coping strategies). Compared with education, multimodal care led to statistically but nonclinically important improvement in self-rated disability (mean change difference 3.7/ 100 [95% CI 6.1 to 1.3]). Multimodal care was also associated with greater self-perceived benefit (OR52.19 [95% CI 1.54–3.11])

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and reduced workdays lost (mean change difference 4 [95% CI 7.9 to 1.1]) at 4 months.

A second RCT suggests that education from a general practitioner (GP) leads to superior outcomes compared to multimodal care by a physiotherapist. Scholten-Peeters et al. [63] reported no statistically significant difference in neck pain intensity, headache intensity, and activities of daily living between participants randomized to education by a GP and those allocated to multimodal care (education and advice, exercise) (Table 5). However, those who received the GP intervention were more likely to report self-perceived functional recovery (relative risk [RR]52.3 [95% CI 1.0–5.0]) at the 1-year follow-up. The intensity of care was lower for GP care (mean 53.9/18.8 weeks) than multimodal care (mean 512.7/ 19.9 weeks).

Persistent whiplash-associated disorder Grade II Evidence from one RCT suggests that multimodal care provided by physiotherapists (exercise, mobilization, education, and ergonomic advice) provides similar outcomes to a self-management program based on an educational booklet (mechanism of whiplash, reassurance of recovery, stay active, ergonomic advice, exercise) for the management of persistent WAD Grade II [67]. Both interventions were

Sutton DA et al provided over a 10-week period. The multimodal care intervention led to a statistically but not clinically important reduction in self-rated neck pain and disability (mean change from baseline 10.4% [standard deviation {SD}614]), compared with the self-management program (4.6% [SD68.8]).

Clinically important differences in secondary outcomes were not observed.

Recent neck pain and associated disorders Grades I to III Evidence from one RCT suggests that multimodal care by chiropractors (manipulation, mobilization, soft-tissue massage, hot/cold packs, and advice), multimodal care by an MD (pain medication and advice to stay active or modify activity), or a program of home exercise (self-mobilization of neck/shoulders) and education by a physiotherapist provide equivalent outcomes for the management of recent NAD grades I to II (Table 5) [50]. All interventions were provided over a 12-week period. The mean number of visits was lowest for the home exercise group (2 visits), followed by multimodal care by MDs (4.8 visits) and last multimodal care by chiropractors (15.3 visits).

Evidence from an RCT suggests that multimodal care (manipulation, mobilization, coordination and stabilization exercises, and advice) by manual therapists and a behavioral graded activity program by physiotherapists provide equivalent outcomes for the management of recent NAD grades I to III (Table 5) [57]. Pool et al. [57] reported no differences in global perceived effect or neck pain intensity.

The mean number of visits for behavioral graded activity (8.2 visits) was greater than multimodal care (5.2 visits).

Evidence from one RCT suggests that one session of multimodal care (manipulation, soft-tissue techniques) provided by an osteopath and an intramuscular injection of ketorolac by a nurse provide equivalent outcomes for recent NAD grades I–II (Table 5) [66]. The interventions were delivered on presentation to the emergency department, and the outcome was assessed 1 hour later. The multimodal care intervention led to a statistically but not clinically important reduction in pain intensity (mean change difference 1.1/10 [95% CI 0.36–1.85]) compared with the intramuscular ketorolac group. No difference in self-perceived pain relief was found.

Persistent neck pain and associated disorder Grades I–II Evidence from one RCT suggests that a physiotherapist provided group-based pain and stress self-management program (relaxation, balance and body awareness exercise, pain and stress self-management lectures and discussion) offers equivalent outcomes to individualized multimodal care (manual therapy, massage, acupuncture, heat,

A selection of published research by CMCC faculty

transcutaneous electrical nerve stimulation, exercise, and ultrasound) by physiotherapists for persistent neck pain (Table 5) [53,54].

Compared with individualized care, there were small statistically but not clinically important changes in favor of the self-management group for all outcomes.

The mean intensity of care was 7 visits per 20 weeks for the self-management group compared with 11 visits per 20 weeks for the individualized multimodal physiotherapy group.

Evidence from one RCT suggests that a multimodal program of care that emphasizes proprioceptive training leads to similar outcomes as multimodal care that combines education and instruction about neck exercises. In their RCT, Taimela et al. [60] randomized participants to multimodal care (cervicothoracic stabilization, relaxation, behavioral support, eye fixation, seated wobble board), a home multimodal exercise and education program [60] or a home and work exercise program. Individuals randomized to the clinic-based multimodal care reported greater improvement in sagittal ROM at 3 months but not at 12 months (Table 5).

It should be noted that important baseline differences in pain intensity were reported in this trial; however, they were not controlled in the analyses. Therefore, we cannot comment on the impact of these treatments on pain intensity. It is important to consider this source of bias when synthesizing the evidence.

Evidence from one RCT suggests that multimodal care (mobilization and home exercise) by manual therapists is superior to continued GP care (pain medication and advice) and multimodal physiotherapy care (exercises, traction, soft-tissue techniques, and passive electromodalities) by physiotherapists for the management of recent NAD grades I to II (Table 5) [61,62]. All interventions were provided over a 6-week period. Multimodal care was more effective than continued GP care in improving self-perceived recovery (recovered or much improved 32.4% [95% CI 15.8–49.0] at 7 weeks, 29.5% [95% CI 12.9–46.1] at 13 weeks) and pain (mean change difference: bother-someness 1.5/10 [95% CI 0.4–2.5], most severe 1.4/10 [95% CI 0.4–2.4]) in the short term. Furthermore, multimodal care was more effective than multimodal physiotherapy care in improving self-perceived recovery (recovered or much improved: 17.5% [95% CI 0.1–34.8]) and pain (mean change difference: most severe 1.2/10 [95% CI 0.2–2.3]) in the short term. Patients allocated to continued GP care had fewer visits (median52) than those in the multimodal manual therapy (median56) and multimodal physiotherapy (median59).

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Evidence from one RCT suggests that multimodal care (mobilization, muscle energy techniques, and home strengthening and range-of-motion exercises) is superior to multimodal minimal intervention (postural advice, range-of-motion exercise, sub-therapeutic ultrasound, and direction to continue prescribed medication) by physiotherapists, for the management of NAD grades I to II (Table 5) [59]. Each group received two treatments per week over a 3-week period by physiotherapists. Participants randomized to multimodal care receiving mobilization, exercise, and muscle energy techniques reported long-term statistically and clinically important improvement in neck disability (mean change difference: 52 weeks 5.1/50 [95% CI 8.1 to 2.1]) compared with those in the control group. However, only short-term statistically and clinically important differences in neck pain were found favoring multimodal care receiving mobilization, exercise, and muscle energy techniques (mean change difference: 6 weeks 14.2/100 [95% CI 22.7 to 5.6]). Finally, a greater proportion of participants in the minimal intervention group required health-care services postintervention [59].

incidence of reporting improvement at 6 months: RR52.2 (95% CI 1.6–3.1) (Table 5) [51].

Evidence from a fourth RCT suggests that multimodal care (manipulation, mobilization, massage, stretching, and advice regarding physical activity and ergonomics) provided by a naprapath plus medication prescribed by a physician is superior to MD care (two sessions of education and prescribed medication) for the management of workers with NAD grades I and II (Table 5) [73,74]. Skillgate et al. [58,64] reported small statistically significant (but nonclinically important) differences in neck pain favoring multimodal care by naprapaths. Naprapath care was more effective than MD care in promoting functional recovery (RR 4.3 [95% CI 2.6–6.9]).

Evidence from one RCT suggests that one education session by a physiotherapist provides similar outcomes to multimodal care (electrotherapy, mobilization, education, exercise, acupuncture, massage, relaxation, collar, heat/ cold) provided by a physiotherapist for NAD grades I and II of at least 2 weeks duration (Table 5) [65]. Klaber Moffett et al.

[65] reported small statistically significant (but nonclinically important) differences in neck pain disability favoring education at 12 months. Small and clinically nonimportant differences in health-related quality of life favored multimodal care.

Evidence from a sixth RCT suggests that a multimodal program focused on soft-tissue therapy (neuromuscular technique, post-isometric stretching, spray, and stretching) provides similar outcomes to transcutaneous electrical nerve stimulation in patients with subacute and chronic NAD grades I and II during 10 visits over 3 weeks (Table 5)[52].

Both groups received verbal and written information during the first two sessions on postural skills, isometric exercises, and neck exercises to perform at home. The authors reported no statistically or clinically significant differences between groups in pain intensity, physical disability, or general health state.

Figure 1. Identification and selection of articles.

Evidence from another RCT suggests that adding two sessions of thoracic spine manipulation and neck range-of motion exercise to a multimodal care program (strengthening and flexibility exercises, advice, and stretching) by physiotherapists does not lead to clinically important improvements in neck pain and neck disability.

However, adding manipulation is associated with a higher

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Components of multimodal program of care The multimodal treatment arms associated with superior outcomes included exercise (67%), manual therapy (83%), and education (67%) [51,55,56,58,59,61–64], whereas programs with equivalent outcomes included education (77%) and exercise (61%) [50,52–54,57,60,65–67] (Table 6). Among all treatment arms, the number of visits ranged from 1 to 15.3 (except one trial that reported 52 visits [53,54], with treatment duration ranging from 1 minute to 20 weeks. On average, multimodal care included six visits per 8 weeks of care. The inferior treatment arms

Sutton DA et al had an average five visits per 7 weeks [51,55,56,58,59,61â&#x20AC;&#x201C;64], whereas superior treatment arms included an average six visits per 8 weeks [51,55,56,58,59,61â&#x20AC;&#x201C;64] (Table 6).

Adverse events Nine admissible RCTs reported adverse events [50,52,55,56,58,60â&#x20AC;&#x201C;66].

No RCT reported serious adverse events. Most adverse events were minor (eg, headache, increased neck pain, tingling in upper extremities, dizziness). The proportion of adverse events in participants enrolled in a multimodal program of care ranged from 3% after one multimodal osteopathic treatment [66] to 63% after a multimodal program of care.

Discussion Summary of evidence Our systematic review suggests that there is a role for multimodal care in the management of patients with NAD and WAD. These patients may benefit from a multimodal program of care that includes manual therapy, education, and exercise. The relative effectiveness of the reviewed programs of care does not appear to be related to a specific provider type.

Our review suggests that the intensity of multimodal care is a determinant of outcome. The evidence suggests that patients with recent WAD and NAD who receive more than six visits per 8 weeks do not report better outcomes than those who receive fewer treatments [50,63]. This finding agrees with the results of two Canadian population based cohort studies that investigated the association between type and intensity of health care received in the first 30 days post-collision and time to recovery from WAD (both studies were reviewed and deemed admissible by the NPTF) [9,75].

In both studies, whiplash patients were stratified into GP low utilization (one or two visits), GP high utilization (more than two visits), DC low utilization (one to six visits), DC high utilization (more than six visits), GP and DC low utilization (one to six visits), GP and DC high utilization (one to six visits), GP and specialists, and general medical groups. Both cohorts provide consistent evidence that the rate of recovery was faster for individuals receiving low-utilization GP care than for those in the high-utilization chiropractic care (DC), GP plus DC care, or care provided by GP plus specialists.

The association between type and intensity of care was strongest during the first 6 months post collision.

Update of the NPTF Our review is a significant update of the NPTF. Based on the evidence available up to 2007, the NPTF found inconsistent evidence that multimodal care was more effective than other noninvasive interventions for the management of

A selection of published research by CMCC faculty

individuals with NAD and WAD [23]. Our results update the work of the NPTF from two perspectives. First, we refined the methodology to systematically review the evidence on multimodal care by expanding the definition of multimodal care to include at least two distinct therapeutic modalities, provided by one or more health-care disciplines.

We clearly specified the distinct therapeutic modalities under consideration. Second, we combined the evidence used by the NPTF with the more recent evidence from high-quality RCTs.

Other systematic reviews Systematic reviews dedicated exclusively to multimodal care are uncommon. However, studies that include multimodal care have been considered within the context of systematic reviews of single interventions. There are differences in our results compared with those reported by previous systematic reviews. Karjalainen et al.[21] reported that multidisciplinary biopsychosocial rehabilitation did not demonstrate better pain and disability outcomes than a coaching model of care provided by a single health-care provider or traditional rehabilitation for neck and shoulder pain. Leaver et al. [76] reported that multimodal physical therapy, that excluded manual therapy, did not provide better disability outcomes or pain relief than minimal treatment.

Binder et al. [77] reported that cognitive behavioral therapy plus physiotherapy may be superior to education and advice but equal to cognitive behavioral therapy alone at reducing the risk of being off work. Finally, Yadla et al. [78] reported that acute WAD patients receiving early and frequent active cervical rotation exercise experienced reduced pain intensity and sick leave compared with a multimodal treatment consisting of rest, soft-collar, and gradual self-mobilization.

However, these reviews had important limitations: conclusions based on studies with small sample sizes [21,76] and did not stratify results for neck pain only [21,77].

Strengths and limitations Our review has strengths. First, we searched five databases, and the search strategy was peer reviewed by a second librarian to minimize errors. Second, we used clear inclusion and exclusion criteria for study selection, only considering studies with a clearly defined inception cohort of individuals with neck pain. Third, the critical appraisal process was standardized using the SIGN criteria. Fourth, we provide a unique method of qualitatively summarizing the results allowing for a clustering of effective therapies.

Finally, our conclusions are based on the best-evidence synthesis method to minimize the risk of bias associated with using low-quality studies.

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Some limitations are noted in our review. First, we restricted our search to include articles in the English language, which may have excluded some relevant studies. However, other systematic reviews of clinical trials have also limited their search to the English language and this did not lead to biased results [79]. Other systematic reviews reported similar results when studying the effect of language restrictions in conventional medicine [80–83].

suggests that multimodal care including education, exercise, and manual therapy can benefit patients with WAD and NAD. However, our systematic review also suggests that there is no additional benefit to providing frequent sessions of multimodal care to patients with WAD and NAD over an extended time period. Furthermore, our systematic review highlights the need for additional quality explanatory randomized controlled trials.

We did not review qualitative studies exploring the lived experience of patients receiving multimodal care. We are therefore unable to comment on how patients valued and experienced their exposure to multimodal interventions.

Although this is not a source of bias in our review, it is recommended that future systematic reviews consider examining qualitative studies to gain insight into the patients’ perspective of multimodal care. Furthermore, our systematic review included clinically heterogeneous samples with different diagnoses and heterogeneous multimodal programs of care. This level of clinical heterogeneity did not allow for the pooling of results through meta-analysis.

Acknowledgements

Conclusions

The authors acknowledge the invaluable contributions to this review from Angela Verven, Arthur Ameis, Carlo Ammendolia, David Cassidy, Doug Gross, Gail Lindsay, John Stapleton, Mike Paulden, Murray Krahn, Robert Brison, Roger Salhany, Shawn Marshall, and Poonam Cardoso. The authors also thank Trish Johns-Wilson at the University of Ontario Institute of Technology for her review of the search strategy. Funding: This study was funded by the Ontario Ministry of Finance and the Financial Services Commission of Ontario (RFP#: No.: OSS_00267175). The funding agency was not involved in the collection of data, data analysis, data interpretation, or drafting of the article. This research was undertaken, in part, thanks to funding from the Canada Research Chairs program.

Multimodal care reflects the combination of therapeutic interventions that are used by health-care providers to manage patients with neck pain. Overall, our review

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Originally published in The Spine Journal, Spine J. 2014 Jul 8. pii: S1529-9430(14)00650-0. [Epub ahead of print].

Reproduced with permission from Elsevier.

Access online: http://dx.doi.org/10.1016/j.spinee.2014.06.019

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Does Structured Patient Education Improve the Recovery and Clinical Outcomes of Patients with Neck Pain?

A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration Yu H1,2, Côté P1,2 , Southerst D1,2 , Wong JJ1,2 , Varatharajan S1,2 , Shearer HM1,2 , et al UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 2Canadian Memorial Chiropractic College 1

Abstract Background context In 2008, the Bone and Joint Decade 2000 to 2010 Task Force on Neck Pain and Its Associated Disorders recommended patient education for the management of neck pain.

However, the effectiveness of education interventions has recently been challenged.

Purpose To update the findings of the Bone and Joint Decade 2000 to 2010 Task Force on Neck Pain and Its Associated Disorders and evaluate the effectiveness of structured patient education for the management of patients with whiplash associated disorders (WAD) or neck pain and associated disorders (NAD).

Study design/setting Systematic review of the literature and best-evidence synthesis.

Patient sample Randomized controlled trials that compared structured patient education with other conservative interventions.

Outcome measures Self-rated recovery, functional recovery (eg, disability, return to activities, work, or school), pain intensity, health-related quality of life, psychological outcomes such as depression or fear, or adverse effects.

Methods We systematically searched eight electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Central Register of Controlled Trials, DARE, PubMed, and ICL) from 2000 to 2012. Randomized controlled trials, cohort studies, and case-control studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Scientifically admissible studies were summarized

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in evidence tables and synthesized following best-evidence synthesis principles.

Results We retrieved 4,477 articles. Of those, nine were eligible for critical appraisal and six were scientifically admissible.

Four admissible articles investigated patients with WAD and two targeted patients with NAD. All structured patient education interventions included advice on activation or exercises delivered orally combined with written information or as written information alone. Overall, as a therapeutic intervention structured patient education was equal or less effective than other conservative treatments including massage, supervised exercise, and physiotherapy. However, structured patient education may provide small benefits when combined with physiotherapy. Either mode of delivery (eg, oral or written education) provides similar results in patients with recent WAD. Conclusions This review adds to the Bone and Joint Decade 2000 to 2010 Task Force on Neck Pain and Its Associated Disorders by defining more specifically the role of structured patient education in the management of WAD and NAD. Results suggest that structured patient education alone cannot be expected to yield large benefits in clinical effectiveness compared with other conservative interventions for patients with WAD or NAD. Moreover, structured patient education may be of benefit during the recovery of patients with WAD when used as an adjunct therapy to physiotherapy or emergency room care. These benefits are small and short lived.

Originally published in Spine Journal, 2014;(14):10, [Epub ahead of print] Reproduced with permission from Elsevier.

Access Online: http://dx.doi.org/10.1016/j.spinee.2014.03.039

A selection of published research by CMCC faculty

Can Functional Capacity Tests Predict Future Work Capacity in Patients With Whiplash-Associated Disorders?

Trippolini MA1, Dijkstra PU1, Côté P2,3 , Scholz-Odermatt SM5, Geertzen JH6, Reneman MF1 University of Groningen, The Netherlands, 2University of Toronto, 3University of Ontario Institute of Technology, 4Canadian Memorial Chiropractic College, 5Central Office for Statistics in Accident Insurance, Lucerne, Switzerland 1

Abstract Objective To determine whether functional capacity evaluation (FCE) tests predict future work capacity (WC) of patients with whiplash-associated disorders (WADs) grades I and II who did not regain full WC 6 to 12 weeks after injury.

Design Prospective cohort study.

Setting Rehabilitation center.

Participants Workers (N=267) listed on workers' compensation with grade I or II WADs 6 to 12 weeks after injury.

Interventions Patients performed 8 work-related FCE tests.

Main Outcome Measures WC (0-100%) measured at baseline and 1, 3, 6, and 12 months after testing. Correlation coefficients between FCE tests and WC were calculated. A linear mixed-model analysis was used to assess the association between FCE and future WC.

and WC ranged from r=.06 (lifting low at 12-mo follow-up) to r=.39 (walking speed at 3mo). Strength of the correlations decreased over time. FCE tests did not predict WC at followup. The predictors of WC were in (time) (β=23.74), mother language (β=5.49), WC at baseline (β=1.01), and selfreported disability (ĸ=-.20). Two interaction terms, in (time) × WC (β=-.19) and ln (time) × self-reported disability (β=-.21), were significant predictors of WC. Conclusions FCE tests performed within 6 to 12 weeks after WADs injury grades I and II are associated with WC at baseline but do not predict future WC, whereas time course, mother language, WC at baseline, and self-reported disability do predict future WC. Additionally, the interaction between time course WC at baseline and self-reported disability predicted future WC.

Originally published in Archives of Physical Medicine and Rehabilitation, 2014 Dec;95(12):2357-66. Epub 2014 Aug 13.

This is an Open Access Article reproduced under the terms of the Creative Commons Attribution License.

Access Online: http://dx.doi.org/10.1016/j.apmr.2014.07.406

Results Mean ± SD WC increased over time from 20.8%±27.6% at baseline to 32.3%±38.4%, 51.3%±42.8%, 65.6%±42.2%, and 83.2%±35.0% at the 1-, 3-, 6-, and 12-month follow-ups, respectively. Correlation coefficients between FCE tests

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Assessing the Change in Attitudes, Knowledge, and Perspectives of Medical Students Towards Chiropractic After an Educational Intervention Wong JJ, Di Loreto L, Kara A, Yu K, Mattia A, Soave D, Weyman K, Kopansky-Giles D Canadian Memorial Chiropractic College

Abstract Objective We assessed the change in attitudes, knowledge, and perspectives of medical students towards chiropractic after a 1-hour educational intervention.

Methods A mixed-methods approach was used with a 52-item crosssectional paper survey and 1 focus group of third-year medical students. The views of these medical students towards chiropractic were assessed previously in their second-year of medical school. ANOVA and the Wilcoxon rank-sum test were used to assess between-group differences between the medical students' views before and after the educational intervention. The constant comparative method for analyzing qualitative data was used to identify emergent themes from the focus group transcript.

Results Of 112 third-year medical students, 58 completed the survey (51.7% response rate). The focus group consisted of 6 medical students. Self-reported understanding of chiropractic and number of attitude-positive responses

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were significantly higher in the group after the educational session. The average number of correct responses assessing knowledge on chiropractic also was significantly higher. Focus group themes were that medical students wanted exposure to chiropractic in clinical settings, had negative attitudes towards chiropractic formed from hidden curriculum, had concerns regarding evidence and safety of chiropractic, and thought that timing of the session on chiropractic was too late in the curriculum.

Conclusions The attitudes and knowledge of medical students towards chiropractic improved immediately after a 1-hour educational intervention. Formally educating medical students on chiropractic may help minimize hidden curriculum issues regarding chiropractic, as identified by the medical students, and facilitate collaboration between medical and chiropractic providers.

Originally published in the Journal of Chiropractic Education, 2014 Oct;28(2):112-22. Epub 2014 Sep 19.

Reproduced with permission.

Access Online: http://dx.doi.org/10.7899/JCE-14-16

A selection of published research by CMCC faculty

Conference Proceedings 2013-2015 Howard L. Teacher education: Shifting teacher thinking? 13 Jun 3; Victoria, BC:

history and prognosis for pediatric MTBI: Results of the International Collaboration

Canadian Association for Studies in Adult Education (CASAE) 2013 Conference.

on MTBI Prognosis (ICoMP). 14 Mar 19; San Francisco, CA: Tenth World Congress on Brain Injury.

Vernon H. The neck disability index from 1991 until today. 13 Aug 15; Helsinki, Finland: 14th Physiatric Summer School Neck Pain – New Perspectives.

Chow N, Wong JJ, Lee S, Hayes K, Moore D, Kopansky-Giles D, Weyman K. Assessing the change in attitudes, knowledge, and perspectives of medical

Vernon H. What’s new in non-organic signs and malingering in whiplash? 13 Sep 8;

students to chiropractic after a core clerkship rotation in family medicine. 14 Mar

Hamilton, ON: The Canadian Academy of Pain Management, Pain Course, Hamilton

21; Orlando FL: ACC RAC Conference 2014.

General Hospital.

Wong JJ, Di Loretto L, Kara A, Yu K, Mattia A, Soave D, Weyman K, Kopansky-Giles Chang Y, Kopansky-Giles D, Peranson J, Glazier R. PAASSPORT: Primary care

D. Assessing the change in attitudes, knowledge, and perspectives of medical

Advanced Access Study - Spreading the Practice and Optimizing Interprofessional

students to chiropractic after an educational intervention. 14 Mar 21; Orlando FL:

Resources and Treatment. 13 Oct 22; Toronto, ON: Association of Family Health

ACC RAC Conference 2014.

Teams of Ontario (AFHTO) 2013 Conference.

Triano JJ, Grondin D, Tran S. The effect of foot orthotics on lower extremity joint Kopansky-Giles D. Enhancing Primary Health Care Delivery in the Inner City

coupling during a functional task. 14 Mar 21; Orlando FL: ACC RAC Conference

through Interprofessional Team-based Care. 13 Oct 29; Chicago IL: International

2014.

Congress for Clinicians in Complementary and Integrative Medicine (ICC-CIM) 2013.

Dougherty P, Taylor J, Triano JJ. Chiropractic Care in the Complex Older Adult. (workshop) 14 Mar 21; Orlando FL: ACC RAC Conference 2014.

Chang PYL, Kopansky-Giles D. Primary care Advanced Access Study - Spreading Practice & Optimizing Interprofessional Resources. 13 Nov 6; Vancouver, BC:

Rosner AL, Haneline M, Giuliano D. Vertebral Artery Incidents: Assessing the Risk

Family Medicine Forum 2013 Pre-Conference Day.

of Vascular Complications associated with Spinal Manipulation. (workshop) 14 Mar 21; Orlando FL: ACC RAC Conference 2014.

Peranson J, Kopansky-Giles D. Making IPE Work: Opportunities and challenges in the ambulatory primary care setting. 13 Nov 6; Vancouver, BC: Family Medicine

Howarth SJ. Creep induced adaptations to motor control of spine posture and joint

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stiffness. 14 Mar 21; Orlando FL: ACC RAC Conference 2014.

Busse J. The challenge of identifying best practices. 13 Nov 18; Washington, DC:

Inoue N, Senoo I, Espinoza Oras A, An H, Andersson G, Triano JJ. In vivo

Bone and Joint Initiative USA Musculoskeletal Summit Best Practices in

three-dimensional morphometric analysis of the lumbar neural foramen. 14 Mar

Patient-Centered Musculoskeletal Care.

21; Orlando FL: ACC RAC Conference 2014.

Chang PYL, Kopansky-Giles D. Primary care advance access study – spreading the

Azad A, Howard L. Leading curricular change by restructuring a female care

practice and optimizing interprofessional resources and treatment. 13 Nov 24; St.

course at a chiropractic college: Where evidence-based clinical practice and

John’s NL: Primary Healthcare Partnerships Forum.

evidence-based teaching meet. 14 Mar 21; Orlando FL: ACC RAC Conference 2014.

Kopansky-Giles D, Leung F-K, Horner K. Enhancing Primary Health Care Delivery

Weis CA, McDonald T, Soye M, Scott L, Dennison-Taylor S. The most common

in the Inner City Through Interprofessional Teamwork. 14 Jan 16; National Webinar

exercises prescribed by chiropractors to reduce low back and pelvic girdle pain in

#360: Canadian Human Health Resources CHNET.

pregnant patients. 14 Mar 21; Orlando FL: ACC RAC Conference 2014.

Triano JJ. Clinical Fundamentals : Advances in Mechanobiology Informing

Ammendolia C. Clinical outcomes using the boot camp for lumbar spinal stenosis

Chiropractic and Management of the Complex Spine. 14 Feb 2; Norway: Norwegian

program: A retrospective study. 14 Mar 21; Orlando FL: ACC RAC Conference 2014.

Chiropractic Association’s Vinterkurs.

Mastragostino P, Kopansky-Giles D, Vernon H, Huff H. Assessing attitudes, Cancelliere C, Kristman VL, Cassidy JD, Hincapié CA, Côté P, Boyle E, Carroll LJ,

knowledge and perceptions towards spinal manipulation: Development and

Stålnacke BM, Nygren-de Boussard C, Borg J. Systematic review of return to work

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after mild traumatic brain injury: Results of the International Collaboration on

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Chung C, Johnson R, Jager A. A survey analysis of the public’s perception of the chiropractic profession. 14 Mar 21; Orlando FL: ACC RAC Conference 2014.

Rumney PG, Hung R, McAdam L, Ameis A, Lacerte M, Côté P, Cassidy D, Boyle E, Greenspoon D. Exploring the King’s outcome scale for childhood head

Duquette S, McDonald M, Moran B, Wilson P, Starmer D, Giuliano D. Effects of

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whole body vibration on patients with cerebral palsy – A literature review. 14 Mar

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Stålnacke BM, Cassidy JD. A systematic review of the clinical course, natural

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97

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Kazemi M, Ong M, Pacis A, Tseng K. A profile of 2012 Olympic games taekwondo

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athlete. (poster) 14 Mar 21; Orlando FL: ACC RAC Conference 2014.

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Lee A, Yu A, Young S, Battaglia P, Ho J. Omohyoid Muscle Syndrome In A

Chang YL, Kopansky-Giles D. PAASSPORT: Primary care Advanced Access Study

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affairs. 14 Jun 8; Saint Mary's University in Halifax, NS: Canadian Association of

Bridging the Gap between Knowledge Transfer and Knowledge Utilization.

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Howard L, Taylor R. Transforming Teaching and Learning through Reflective Ricohermoso R, Larocque C, Malik F, Ruff M, Gleberzon B. Do chiropractors choose

Practice. 14 Jun 17; Kingston, ON: Society for Teaching and Learning in Higher

certain spinal manipulative therapies depending on various clinical scenarios?

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Howarth SJ, Kingston DC, Brown SHM, Graham RB. Merging in vivo estimates of Statz R, Pym M, Gleberzon B. Sexual harassment of female chiropractors by

passive tissue changes with local dynamic stability of spine movement during

patients in a clinical setting: an exploratory survey (poster) 14 Mar 21; Orlando FL:

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Callaghan JP, Drake JDM, Howarth SJ. Joint Loading History and the Influence on Facet Joint Mechanics. 14 Jul 10; Boston, MA: 7th World Congress of

Sukhera SA, Percival J, Mior SA, Rutherford S. Demonstrating the use of PAJMA in

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Fehlings M, Tetreault L, Alshafai N, Kopjar B, Côté P, Delfino H, Kale S, Barbagallo G, Bartels R, Zhou Q, Arnold P, Zileli M, Tan G, Yukawa Y, Moraes O, Scerrati M,

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Tanaka M, Toyone T, Bolger C, Alvarado M. Clinical and Surgical Predictors of

Knowledge Translation Research in Chiropractic Practice: Developing

Perioperative Complications in patients with degenerative cervical myelopathy:

Implementation Interventions to Improve the Uptake of Research into Clinical

Results from the multicenter, prospective AOSpine International study on 479

Practice. (workshop) 14 Mar 21; Orlando FL: ACC RAC Conference 2014.

patients. 14 Jul 16; Valencia Spain: International Meeting on Advanced Spine Techniques.

Starmer D, Stainsby B, Graf M, DeMarco L, Pownall L. Simulation in Chiropractic Education: The Essentials of Simulation. (workshop) 14 Mar 21; Orlando FL: ACC

Engell S, Triano JJ. Paraspinal Soft Tissue Layer Differential Movement from SMT

RAC Conference 2014.

preload. 14 Sep 26; Buffalo, NY: ACES symposium.

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Approaches to Discipline. (workshop) 14 Mar 21; Orlando FL: ACC RAC Conference

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2014.

Regional Health Authority.

Goyeche L, Mior S. Recruitment and Retention of Doctors of Chiropractic in Rural

Stupar M, Côté P, Cassidy JD, Brison RJ, Boyle E. Development and evaluation of a

Communities in Newfoundland and Labrador from 1991 to 2010. (poster) 14 Apr 8;

clinical prediction rule to screen for patients at higher risk for developing chronic

Ottawa: Chronic Disease Prevention Alliance of Canada's 5th Pan Canadian

whiplash-related symptoms Poster presentation. Presented by M Stupar. 14 Sep

Conference: New partnerships and New Approaches for Chronic Disease

30; Campos do Jordão, Brazil: XIII International Low Back Pain Forum.

Prevention.

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JD, Boyle E. Feasibility study of the King's Outcome Scale for Childhood Head Injury

inter-professionalism within health care: a call for solidarity among the

in children attending a rehabilitation hospital. Archives of Physical Medicine and

professions. 14 May 8; Chicago IL: Academy for Professionalism in Health Care.

Rehabilitation. 2014 Oct; 95(10): e56. 14 Oct 09; Toronto, ON: The American Congress of Rehabilitation Medicine 91st Annual Conference.

Goyeche L, Mior SA. Recruitment and Retention of Doctors of Chiropractic in Rural Communities in Newfoundland and Labrador from 1991 to 2010. (poster) 14 May 9;

Lillian R, Kopansky-Giles D. Building an Effective National Action Network. 14 Oct

McMaster University, Hamilton: Canadian Society of Epidemiology and

11; London, England: Bone and Joint Decade - World Network Meeting. (workshop)

Biostatistics, National Student Conference.

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Oct 22; Quebec City, QC: International Society for the Scholarship of Teaching and

Care: The Patient’s Experience. (poster) 14 May 13; Miami FL: International

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Research Congress on Integrative Medicine and Health.

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Table Technology (FSTT). 14 Oct 22; Quebec City, QC: International Society for the

I’m Not in Pieces, But Need Help to Get My Life Back. 14 May 21; University of

Scholarship of Teaching and Learning.

Illinois at Urbana-Champaign, IL: The Tenth International Congress of Qualitative Inquiry: Qualitative Inquiry and the Politics of Research.

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A selection of published research by CMCC faculty

Pierre E, Howard L. 14 Oct 22; Quebec City, QC: International Society for the

Engell S, Triano JJ. Paraspinal soft tissue layer differential movement from SMT

Scholarship of Teaching and Learning.

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Kopansky-Giles D, Peranson J. Teaching an Inter-professional Approach to

Erwin WM, DeSouza L, Zia Karim M, Wang S. Molecular probing of the

Managing Low Back Pain in the Primary Care Setting. 14 Oct 30; Miami, FL:

intervertebral disc: Quantitative iTRAQ proteomic analysis of the nucleus pulposus

WFC-ACC Education Conference.

in health and spontaneous degeneration. 15 Mar 19; Las Vegas, NV: ACC-RAC 2015.

Kopansky-Giles D, DeMarco L. Incorporating Interprofessional Education in a Curriculum – Benefits, Methods, Challenges. 14 Oct 30; Miami, FL: WFC-ACC

Guist B, Starmer D, Tuff T, Warren S, Williams M. Changes in manipulative peak

Education Conference. (workshop)

force modulation and time to peak thrust among first-year chiropractic students following a 12-week detraining period: a pilot study. 15 Mar 19; Las Vegas, NV:

Moreau B, Johnson V, Kilgore D, Tipton J, McCarty RA, Vinjamury S, Kopansky-

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Howard L, Triano JJ, McGregor M, Giuliano D. Education technology and psycho-motor skill development: teacher thinking versus student thinking. 15 Mar

Peranson J, Kopansky-Giles D. Incorporating Interprofessional Education in Health

19; Las Vegas, NV: ACC-RAC 2015.

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Howarth SJ, D'Angelo K, Triano JJ. A new model to derive patient low back loads

Chang YL, Kopansky-Giles D, Peranson J. When it works, it works well: Staff

during high-velocity low-amplitude spinal manipulation. 15 Mar 19; Las Vegas, NV:

Experiences with Advanced Access Scheduling at an Academic Family Medicine

ACC-RAC 2015.

Centre. 14 Nov 12; Quebec City, QC: Family Medicine Forum.

Kim PSY, Parish D, Tibbles A, Illes J. Assessing the Quality of Clinical Teachers Kopansky-Giles D, Newton C. Redefining the Collaborator Role Competencies for

Through Instrument Evaluations. 15 Mar 19; Las Vegas, NV: ACC-RAC 2015.

Family Medicine. 14 Nov 12; Quebec City, QC: Family Medicine Forum. (workshop) Kinsinger S. Patient sexual abuse: comparing the rate of discipline for chiropractic, Chow N, Wong JJ, Lee S, Hayes K, Moore D, Kopansky-Giles D, Weyman K, Soave D.

massage therapy, medicine and physical therapy professions. 15 Mar 19; Las

Attitudes and knowledge of medical students toward chiropractic from second to

Vegas, NV: ACC-RAC 2015.

fourth year of school. 14 Nov 12; Quebec City, QC: Family Medicine Forum.

Korpela AP, Erwin WM. The regenerative potential of notochordal cell conditioned Kopansky-Giles D, Newton C. The Collaborator Role Competency Working

media in ligament injury. 15 Mar 19; Las Vegas, NV: ACC-RAC 2015.

Group - an Update on Activities. 14 Nov 12; Quebec City, QC: CFPC – Family Medicine Forum: Section of Teachers Council meeting.

McFadden R, Starmer D, Klerer D. Are the peak forces taught in the curriculum at a chiropractic institution for a prone thoracic spinal manipulation effective in

Tetreault L, Kopjar B, Côté P, Arnold P, Fehlings M. A Clinical Prediction Rule for

producing a cavitation in asymptomatic chiropractic students with a thoracic joint

Clinical Outcomes in Patients Undergoing Surgery for Degenerative Cervical

restriction? A pilot study. 15 Mar 19; Las Vegas, NV: ACC-RAC 2015.

Myelopathy: Analysis of an International AOSpine Prospective Multicenter Dataset of 757 Subjects. 14 Nov 12; San Francisco, CA: North American Spine Society.

Mior S, Randhawa K, Shearer H, Côté P. The effectiveness of manual therapy in patients diagnosed with neck pain and whiplash associated disorders: a systematic

Tetreault L, Côté P, Kopjar B, Delfino H, Kale S, Barbagallo G, Arnold P, Zileli M,

review. 15 Mar 19; Las Vegas, NV: ACC-RAC 2015.

Tan G, Yukawa Y, Moraes O, Scerrati M, Tanaka, Toyone T, Bolger C, Fehlings M, Clinical and Surgical Predictors of Perioperative Complications in Patients with

Moss JA. Leadership – Decision making in a complex world. 15 Mar 19; Las Vegas,

Degenerative Cervical Myelopathy: Results from the Multicenter, Prospective

NV: ACC-RAC 2015. (workshop)

AOSpine International Study on 479 Patients. 14 Nov 12; San Francisco, CA: North American Spine Society.

Olesen K, Howard P, Xing S, Leung FH, Kopansky-Giles D. Health professional perspectives regarding the use of patient-reported outcome measures in an

McGregor M. Caregiver Stress: Challenges and a New Paradigm. 14 Nov 21;

integrated primary care health centre: A pilot project. 15 Mar 19; Las Vegas, NV:

Toronto, ON: Toronto ABI Network Conference.

ACC-RAC 2015.

Weis CA. Oh Momma! Pregnancy Aches and Pains Presentation. 14 Nov 28;

Singh J, Matta A, Erwin WM. Evaluation of molecular phenotype of intervertebral

Toronto, ON: 52nd Annual Scientific Assembly.

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Azad A, Killinger LZ, Howard L. Collaborative Learning Strategies to Develop

Stainsby B, Egonia J, Clarke M. Learning spinal manipulation: a best-evidence

Interprofessional Collaboration: Process and Product. 15 Mar 19; Las Vegas, NV:

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requirements with individuals of varying body mass index: A pilot study. 15 Mar 19;

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Triano JJ, Giuliano D, McGregor M, Howard L. Effects of reflective practice on

Starmer D, Ross JK, Boudreau PA, DiCarlo A, Marshall E, Bradshaw J. The effects

learning of defined manipulation performance parameters. 15 Mar 19; Las Vegas,

of a pre-adjustment communication on satisfaction ratings of a chiropractic

NV: ACC-RAC 2015.

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Chow N, Weyman K, Kopansky-Giles D. Attitudes and Knowledge of Medical

Stern P, Chung C, Triano JJ. Training leaders in chiropractic: A survey of Canadian

Students towards Chiropractic from Second Year to Fourth Year of Their Medical

Memorial Chiropractic College (CMCC) residency graduates. 15 May 13; Athens,

Program. 15 Apr 25; Vancouver, BC: Canadian Conference on Medical Education.

Greece: WFC Biennial Conference.

Howitt S. 15 May 13; Athens, Greece: Fédération Internationale de Chiropratique du Sport.

Stupar M, Côté P, Carroll L, Brison R, Boyle E, Cassidy JD. Predicting outcomes in whiplash-associated disorders: prediction models developed and validated in two

Jacobs CL, Cassidy JD, Côté P, Boyle E, Ramel E, Hartvigsen J, Schwartz I,

Canadian provinces. 15 May 13; Athens, Greece: WFC Biennial Conference.

Ammendolia C. Prevalence and Associated Factors of Musculoskeletal Pain and Injury in Professional Dancers, an International Cross Sectional Study. 15 May 13;

Sukhera SA, Percival J, Mior SA. Shifting the focus to patient-centered

Athens, Greece: Fédération Internationale de Chiropratique du Sport.

improvement: A Canadian chiropractic case study. 15 May 13; Athens, Greece: WFC Biennial Conference.

Chang YL, Peranson J, Kopansky-Giles D. "When it works": academic family medicine staff experiences with advanced access scheduling. 15 May 13; Athens,

Teodorczyk-Injeyan J, Injeyan HS, Triano JJ, McGregor M. Divergent inflammatory

Greece: WFC Biennial Conference

profiles in acute and chronic low back pain patients: A single blind pilot clinical trial. 15 May 13; Athens, Greece: WFC Biennial Conference.

Giuliano D, Howard L, Taylor R, McGregor M, Statz R, Bagnell C, Linka M. Manikin-based simulation: online orientation and student anxiety. 15 May 13;

Tibbles A. Clinical Grand Rounds. 15 May 13; Athens, Greece: WFC Biennial

Athens, Greece: WFC Biennial Conference.

Conference.

Giuliano D, McGregor M. Manikin-based simulation: learning and learning retention. 15 May 13; Athens, Greece: WFC Biennial Conference.

Injeyan HS, Teodorczyk-Injeyan J, Triano JJ, McGregor M. Alterations of inflammatory cytokine profiles following spinal manipulative treatment (SMT) of low back patients: A single blind pilot clinical trial 15 May 13; Athens, Greece: WFC Biennial Conference.

Kazemi M, Hua G, Ingar A, Jaffery A, Huang G. Injuries in elite Taekwondo Poomsea athletes. 15 May 13; Athens, Greece: WFC Biennial Conference.

Kitchen L, Kivisto A, Dowgialo A, Wong JJ. Practice profiles, satisfaction, and perceptions towards chiropractic education in Canada among recent chiropractic graduates: A cross-sectional survey. 15 May 13; Athens, Greece: WFC Biennial Conference.

Mior SA, Boon H, Rozmovits L. Where's the middle? The challenge of defining the continuum of adverse events in spinal manipulation therapy.15 May 13; Athens, Greece: WFC Biennial Conference.

Mior SA, McGregor M. Assessing the predictors of chiropractic service utilization in patients with musculoskeletal pain presenting to an interdisciplinary primary care clinic.15 May 13; Athens, Greece: WFC Biennial Conference.

Olesen K, Howard P, Xing S, Leung FH, Kopansky-Giles D. Health professional perspectives regarding the use of patient-reported outcome measures in an integrated primary care health center: A pilot project. 15 May 13; Athens, Greece: WFC Biennial Conference.

Rezai M, Côté P, Cassidy JD, Carroll L, Kristman VL, Ibrahim S. Defining work ability: a scoping review of the literature. 15 May 13; Athens, Greece: WFC Biennial Conference.

Shearer H, Côté P, Boyle E, Hayden JA, Frank JW, Johnson WG. Who will have sustainable employment after a back injury? The development of a clinical predication model in a cohort of injured workers. 15 May 13; Athens, Greece: WFC Biennial Conference.

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The CMCC Research Report 2014-2015 is produced by the Division of Marketing and Communications.

Director: Mara Bartolucci Designer: Wendy Tabor Contributors: Mark Fillery, Margaret McCallen To request a copy, contact the Division of Marketing and Communications at: Phone: 416 482 2340 Fax: 416 482 3629 Email: communications@cmcc.ca Canadian Memorial Chiropractic College 6100 Leslie Street, Toronto, ON, M2H 3J1 www.cmcc.ca CopyrightŠ 2016 Canadian Memorial Chiropractic College

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