Cervicogenic Dizziness: A Case Report Illustrating Orthopaedic Manual and Vestibular Physical Therapy Comanagement

Abstract

The diagnosis and treatment of patients with dizziness of a cervical origin may pose a challenge for orthopaedic and vestibular physical therapy specialists. A thorough examination, which consists of a screening examination to rule out pathologies not amenable to sole physical therapy management and, if indicated, a physical therapy differential diagnostic process incorporating both cervical spine and vestibular tests and measures, may indicate an appropriate course of management. The treatment progression is then based on patient signs, symptoms, and response to physical therapy interventions. This case study describes the diagnosis, treatment, and outcomes of a patient with cervicogenic dizziness co-managed by a vestibular and an orthopaedic manual physical therapist.     

Dizziness in Orthopaedic Physical Therapy Practice: History and Physical Examination

Abstract

Physical therapy (PT) differential diagnosis of patients complaining of dizziness centers on distinguishing those patients who might benefit from sole management by the physical therapist from those patients who require referral for medical-surgical differential diagnosis and (co) management. There is emerging evidence that PT management may suffice for patients with benign paroxysmal positional vertigo, cervicogenic dizziness, and musculoskeletal impairments leading to dysequilibrium. This article provides information on the history taking and physical examination relevant to patients with a main complaint of dizziness. The intention of the article is to enable the therapist to distinguish between patients complaining of dizziness due to these three conditions amenable to sole PT management and those patients who likely require referral. Where available, we have provided data on reliability and validity of the history items and physical tests described to help the clinician establish a level of research-based confidence with which to interpret history and physical examination findings. The decision to refer the patient for a medical-surgical evaluation is based on our findings, the interpretation of such findings in light of data on reliability and validity of history items and physical tests, an analysis of the risk of harm to the patient, and the response to seemingly appropriate intervention.     

Use of Translatoric Mobilization in a Patient with Cervicogenic Dizziness and Motion Restriction: A Case Report

Abstract

Some physical therapists consider the report of dizziness at end-range cervical extension when coupled with side-bending and rotation to the same side (coupled lower cervical rotation in extension) to be a positive sign of vertebral artery compromise. However, degenerative changes and associated movement abnormalities in cervical motion segments may also produce dizziness. The use of mid-line translatoric joint mobilization in the presence of limited active cervical motion that is accompanied by dizziness during cervical extension, rotation, and coupled rotation in extension has not been addressed in the current literature. This case report describes the examination, evaluation, diagnosis, intervention, and outcomes for a 64-year-old woman who presented with limited cervical mobility and the complaint of dizziness during performance of these movements. Examination included a clinical differentiation process to determine the cause of the movement-related dizziness. Examination findings included increased translatoric joint play, tenderness, and reproduction of dizziness at the C4-C6 segments and decreased translatoric joint play at the C1-C4 and C7-T4 motion segments. Intervention included movement re-education and application of translatoric joint mobilization to the hypomobile segments. After 8 visits, there was complete resolution of dizziness during all active cervical movements and improved cervical mobility, as documented with the CROM. This case report demonstrates that clinical symptoms consistent with cervicogenic dizziness and limited cervical mobility may be treated safely and effectively using translatoric joint mobilization techniques. Confirmatory diagnostic ultrasound analysis of the vertebral artery revealed no compromise in flow velocity during the application of these translatoric mobilization techniques.     

Physical therapy and migraine: musculoskeletal and balance dysfunctions and their relevance for clinical practice

BackgroundMigraine is a primary headache with high levels of associated disability that can be related to a variety of symptoms and comorbidities. The role of physical therapy in the management of migraine is largely unknown. Therefore, the aim of this review is to highlight and critically discuss the current literature and evidence for physical therapy interventions in individuals with migraines.MethodsA narrative review of the literature was performed.ResultsPhysical therapists assessing and treating patients with migraine should focus on two primary aspects: (1) musculoskeletal dysfunctions, and (2) vestibular symptoms/postural control impairment. Signs and symptoms of musculoskeletal and/or vestibular dysfunctions are prevalent among individuals with migraines and different disability levels can be observed depending on the presence of aura or increment of the migraine attacks.ConclusionA proper physical examination and interview of the patients will lead to a tailored treatment plan. The primary aim regarding musculoskeletal dysfunctions is to reduce pain and sensitization, and physical therapy interventions may include a combination of manual therapy, exercise therapy, and education. The aim regarding postural control impairment is to optimize function and reduce vestibular symptoms, and interventions should include balance exercises and vestibular rehabilitation. However, consistent evidence of benefits is still lacking due to the lack of and therefore need for tailored and pragmatic clinical trials with high methodological quality.     

高频超声诊断小腿疾病的应用进展

随着高频超声的问世及超声宽景成像技术的迅速发展,超声医学在骨科和运动医学疾病的诊断中发挥着越来越大的作用。以往骨骼肌肉系统疾病的影像学诊断方法包括X线、CT和MRI,与之相比,高频超声检查具有实时、便捷、无创、无辐射的优点,在功能状态下能够良好显示肌肉、肌腱、神经、血管等结构,因而成为骨骼肌肉系统疾病首选的影像学诊断方法。本文就高频超声在小腿疾病诊断中的应用进展进行综述。     

Patients report being satisfied with private musculoskeletal physical therapy when therapists educate effectively and facilitate shared decision making

BackgroundOverall satisfaction with physical therapy care can improve patient adherence and active involvement in their management. However, which individual factors most influence satisfaction with private practice physical therapy care is not well established.ObjectiveTo identify which aspects of the private practice musculoskeletal physical therapy experience best delineated “completely satisfied” and “dissatisfied patients”.MethodsThe MedRisk Instrument for Measuring Patient Satisfaction with Physical Therapy Care (MRPS) was used in a cross-sectional design within 18 Australian private musculoskeletal physical therapy practices. The area under the curve (AUC) of receiver operator characteristic curves (ROC) was used to quantify the ability of the individual patient experience questions to classify the global impressions of satisfaction and likelihood to recommend to others.Results1712 patients completed the survey (out of 7320 survey recipients - response rate 23%). High scores were identified for overall satisfaction (4.8/5 ± 0.61) and likelihood to recommend (4.78/5 ± 0.67). Individual items relating to education (AUC = 0.839 and 0.838) and shared decision making (AUC = 0.832 and 0.811) were the most accurate indicators of satisfaction and likelihood to recommend to others, respectively.ConclusionIndividual questionnaire items relating to education and shared decision making were the most accurate indicators of satisfaction and likelihood to recommend in patients attending private practice musculoskeletal physical therapy in Australia. Clinicians and educators should focus on developing these skills to encourage an effective therapeutic alliance and promote greater levels of patient satisfaction.     

Effect of Patient Use of Physical Therapy After Referral for Musculoskeletal Conditions on Future Medical Utilization: A Retrospective Cohort Analysis

ObjectiveThe purpose of this study was to evaluate whether physical therapy use influenced subsequent use of musculoskeletal-related surgeries, injections, magnetic resonance imaging (MRI), and other imaging.MethodsWe conducted a retrospective cohort study of patients aged 18 to 64 years who had an ambulatory care visit at the University of Utah system, after implementation of the 10th revision of the International Statistical Classification of Diseases and Related Health Problems with adequate data collection in the system at the time of the data pull, between October 1, 2015, and September 30, 2018. We identified patients (n = 85 186) who received care for a musculoskeletal condition (lower back pain, cervical, knee, shoulder, hip, elbow, ankle, wrist/hand, thoracic, and arthritis diagnoses). Regression analyses were used to evaluate the association between physical therapy use and medical care use while controlling for relevant factors.ResultsIn patients referred to physical therapy (n = 15 870), physical therapy use (n = 3812) was associated with increased MRI use (incidence rate ratio, 1.24; 95% confidence interval, 1.15-1.33; P < .001) and surgery use (incidence rate ratio, 1.11; 95% confidence interval, 1.00-1.23; P < .001). Several other factors were also associated with increased health care use, including being referred by an orthopedic provider, obesity, non–lower back pain diagnoses, and having 1 or more comorbidities.ConclusionOutpatient physical therapy use for musculoskeletal conditions in adult patients younger than 65 years at the University of Utah system, a mountain west United States academic health care system, was associated with increased rates of MRI and surgery. This finding is contrary to prior research suggesting that physical therapy improves outcomes in some diagnosis groups. A referral from an orthopedic provider, non–lower back pain diagnoses, and obesity were also associated with increased medical care utilization.     

Interpretation of trial-based economic evaluations of musculoskeletal physical therapy interventions

BackgroundAs resources for healthcare are scarce, decision-makers increasingly rely on economic evaluations when making reimbursement decisions about new health technologies, such as drugs, procedures, devices, and equipment. Economic evaluations compare the costs and effects of two or more interventions. Musculoskeletal disorders have a high prevalence and result in high levels of disability and high costs worldwide. Because physical therapy interventions are usually the first line of treatment for musculoskeletal disorders, economic evaluations of such interventions are becoming increasingly important for stakeholders in the field of physical therapy, including physical therapists, decision-makers, and reseachers. However, economic evaluations are relatively difficult to interpret for the majority of stakeholders.ObjectiveTo support physical therapists, decision-makers, and researchers in the field of physical therapy interpreting trial-based economic evaluations and translating the results of such studies to clinical practice.MethodsThe design, analysis, and interpretation of economic evaluations performed alongside randomized controlled trials are discussed. To further illustrate and explain these concepts, we use a case study assessing the cost-effectiveness of exercise therapy compared to standard advice in patients with musculoskeletal disorders.ConclusionsEconomic evaluations are increasingly being used in healthcare decision-making. Therefore, it is of utmost importance that their design, conduct, and analysis are state-of-the-art and that their interpretation is adequate. This masterclass will help physical therapists, decision-makers, and researchers in the field of physical therapy to critically appraise the quality and results of trial-based economic evaluations and to apply the results of such studies to their own clinical practice and setting.     

Funding is related to the quality,conduct, and reporting of trial reports in musculoskeletal physical therapy: A survey of 210 published trials

Background: The relationship between trial funding and methodological quality, the conduct and reporting of trials has been investigated in several medical disciplines, but remains unclear in musculoskeletal physical therapy trials. The aim of this study was to determine the association between funding and research team composition, sample size, quality, and journal impact factor of randomized controlled trial reports in musculoskeletal physical therapy. Methods: A survey of 210 trial reports in musculoskeletal physical therapy, which were randomly selected from those published in 2011–2013 and indexed on the Physiotherapy Evidence Database (PEDro), is performed. Total PEDro score and citation details of the trial reports were downloaded from PEDro. Pairs of assessors independently extracted information about funding, sample size, and composition of the research team. Journal impact factor was downloaded by one reviewer. Results: Trial funding was associated with having multiple departments in the research team (odds ratio: 1.89, 95% confidence interval: 1.03–3.49), larger sample size (median: n = 72 versus n = 50), higher quality (mean PEDro score: 6.06 versus 5.11), and publication in journals with higher impact factors (median: 2.12 versus 1.78). Conclusion: Trial funding was positively associated with having multiple departments represented in the research team, larger sample size, higher quality, and publication in higher impact factor journals.     

The effectiveness of vestibular rehabilitation therapy vs conservative treatment on dizziness: a systematic review and meta-analysis

Abstract

Background: Dizziness is a common condition which may lead to loss of function and disability. Vestibular Rehabilitation Therapy (VRT) may be utilized to affect the vestibular system and reduce dizziness. However, controversy exists regarding the most effective interventions to treat dizziness.

Objectives: To examine the effectiveness of VRT compared to other conservative treatments in reducing dizziness and disability.

Methods: A literature search was performed using different combinations of the terms: dizziness, physical therapy, vertigo, vestibular, cervicogenic dizziness to identify randomized clinical trials comparing VRT to conservative treatments. The Cochrane Risk of Bias Tool was used to assess the quality of each included study. Additionally, a meta-analysis and qualitative analysis of the evidence was performed.

Results: Ten studies were included in the systematic review. Only four studies were included in the meta-analysis due to lack of adequate data reported for continuous outcomes. Eight studies scored less than a 69% on the Cochrane risk of bias tool indicating a low to moderate risk of bias. The meta-analysis revealed that VRT was found to be more effective than conservative treatment for short term outcomes (0–3?weeks) but not long-term outcomes (4 or more weeks). The results from the studies excluded from the meta-analysis but included in the systematic review are inconclusive.

Conclusions: VRT was only found to be more effective than other conservative treatments in the short term.     

Systematic Review of Efficacy for Manual Lymphatic Drainage Techniques in Sports Medicine and Rehabilitation: An Evidence-Based Practice Approach

Abstract

Manual therapists question integrating manual lymphatic drainage techniques (MLDTs) into conventional treatments for athletic injuries due to the scarcity of literature concerning musculoskeletal applications and established orthopaedic clinical practice guidelines. e purpose of this systematic review is to provide manual therapy clinicians with pertinent information regarding progression of MLDTs as well as to critique the evidence for e cacy of this method in sports medicine. We surveyed English-language publications from 1998 to 2008 by searching PubMed, PEDro, CINAHL, the Cochrane Library, and SPORTDiscus databases using the terms lymphatic system, lymph drainage, lymphatic therapy, manual lymph drainage, and lymphatic pump techniques. We selected articles investigating the effects of MLDTs on orthopaedic and athletic injury outcomes. Nine arti- cles met inclusion criteria, of which 3 were randomized controlled trials (RCTs). We evaluated the 3 RCTs using a validity score (PEDro scale). Due to di erences in experimental design, data could not be collapsed for meta-analysis. Animal model experiments reinforce theoretical principles for application of MLDTs. When combined with concomitant musculoskeletal therapy, pilot and case studies demonstrate MLDT e ectiveness. e best evidence suggests that the efficacy of MLDT in sports medicine and rehabilitation is specific to resolution of enzyme serum levels associated with acute skeletal muscle cell damage as well as reduction of edema following acute ankle joint sprain and radial wrist fracture. Currently, there is limited high-ranking evidence available. Well-designed RCTs assessing outcome variables following implementation of MLDTs in treating athletic injuries may provide conclusive evidence for establishing applicable clinical practice guidelines in sports medicine and rehabilitation.     

Cervicogenic dizziness – musculoskeletal findings before and after treatment and long-term outcome

Purpose. To explore musculoskeletal findings in patients with cervicogenic dizziness and how these findings relate to pain and dizziness. To study treatment effects and long-term symptom progress.

Method. Twenty-two patients (20 women, 2 men; mean age 37 years) with suspected cervicogenic dizziness underwent a structured physical examination before and after physiotherapy guided by the musculoskeletal findings. Questionnaires were sent to the patients six months and two years after treatment.

Results. Dorsal neck muscle tenderness and tightness was found in a majority of the patients. Zygapophyseal joint tenderness was found at all cervical levels. Cervical range of motion was equal to or larger than expected age and gender matched values. The cervico-thoracic region was often hypomobile. Most patients had postural imbalance. Dynamic stabilization capacity was reduced. Suboccipital muscles tightness correlated with posture imbalance and poor neck stability. The treatment resulted in reduced tenderness in levator scapula, high and middle paraspinal and temporalis muscles and zygapophyseal joints at C4-C7 and increased cervico-thoracic mobility. Reduction of middle paraspinal muscle tenderness correlated with neck pain relief. Postural alignment improved, as did dynamic stabilization in trunk, neck and shoulders. After 6 months, 13 of the 17 patients had still no or less neck pain and 14 had no or less dizziness. After 2 years, 7 patients had no or less neck pain and 11 no or less dizziness.

Conclusion. Patients with suspected cervicogenic dizziness have some musculoskeletal findings in common. Treatment based on these findings reduces neck pain as well as dizziness long-term but some patients might need a maintenance strategy.     

Imaging in conjunction with physical therapy in management of a patient with history of thoracic tumour

Abstract

Background:

Physical therapy care for musculoskeletal conditions includes an ongoing process that systematically considers and prioritises diagnostic hypotheses. These diagnostic hypotheses include those that are typical for common musculoskeletal conditions, and must also include more rare conditions that would require care outside the scope of practice of the physical therapist. When additional screening is required, physical therapists collaborate with other providers or directly order the appropriate tests to rule out suspected pathology.     

Preliminary results of patient-defined success criteria for individuals with musculoskeletal pain in outpatient physical therapy settings

Zeppieri G Jr, Lentz TA, Atchison JW, Indelicato PA, Moser MW, Vincent KR, George SZ. Preliminary results of patient-defined success criteria for individuals with musculoskeletal pain in outpatient physical therapy settings.Objectives(1) To investigate patient-defined parameters of treatment success in an outpatient physical therapy setting with musculoskeletal pain, (2) to determine whether patient-defined treatment success was influenced by selected demographic and clinical factors, and (3) to examine whether patient subgroups existed for ratings of importance for each treatment outcome domain.DesignCross-sectional study.SettingOutpatient physical therapy clinic.ParticipantsConsecutive patients (N=110) with complaints of musculoskeletal pain.InterventionsNot applicable.Main Outcome MeasureWe reported patient-defined treatment success targets for pain, fatigue, emotional distress, and interference with daily activities using the Patient-Centered Outcomes Questionnaire (PCOQ). We also investigated whether patient subgroups existed based on perceived importance of improvement for these same outcome domains.ResultsPatient-defined criteria for treatment success included mean reductions (from baseline scores) in pain of 3.0 points, in fatigue of 2.3 points, in emotional distress of 1.4 points, and in interference with daily activities of 3.4 points. There were no differences in patient-defined criteria for treatment success based on sex, age, postoperative rehabilitation, prior physical therapy, other prior health care interventions, duration of symptoms, and anatomical location of symptoms (P>.01). Cluster analysis of the PCOQ importance ratings indicated a 2-cluster solution. The multifocused subgroup demonstrated higher importance for improvement ratings in each treatment outcome domain when compared with the pain-focused subgroup (P>.05).ConclusionsThese data indicate that patient-defined criteria for treatment success required greater reductions in the studied outcome domains to be considered successful. These data suggest the potential existence of patient subgroups that either rate improvement in all outcome domains as important or rate pain relief as the most important outcome.     

Lumbar Spinal Stenosis: A Literature Review

Abstract

This paper describes the etiology and clinical manifestations of lumbar spinal stenosis (LSS); discusses diagnosis, prognosis, and intervention; and addresses outcome studies and their implications in managing patients with lumbar spinal stenosis. LSS is a condition involving narrowing of the central spinal canal, lateral recesses, or intervertebral foramina; it is the most commonly diagnosed degenerative process associated with aging. Neurogenic intermittent claudication is a common clinical manifestation of LSS that must be differentiated from vascular claudication of the lower extremities. Although surgery is commonly performed in treating LSS, some evidence exists to support the use of a conservative approach such as orthopaedic manual physical therapy. However, controlled clinical trials with large sample sizes are lacking to offer strong support for either conservative or surgical measures. This paper provides a rationale for a manual physical therapy and exercise approach in treating LSS. Future studies need to include comparative research involving different conservative approaches, and indications for surgical versus nonsurgical management of LSS need to be more clearly defined and studied through randomized, controlled clinical trials.     

Evidence-Based Approach to the Physical Therapy Diagnosis and Management of Neck and Upper Extremity Pain using Cervical and Thoracic Spine Thrust Manipulation: A Case Report

Abstract

Neck and upper extremity pain are common medical diagnoses for patients seeking physical therapy care. The purpose of this case report is to describe an evidence-based approach to the physical therapy diagnosis and management of a 46-year-old female reporting insidious onset neck pain and bilateral upper extremity paraesthesiae of two years duration. Evaluation of examination data, based on research data with regard to diagnostic accuracy of the tests and measures used, indicated a diagnosis of cervical radiculopathy. Management was based on a treatment-based classification approach and focused on restoring mobility by way of thrust manipulations directed at the thoracic and cervical spine. At the completion of the physical therapy plan of care (8 visits), the patient rated her perceived improvement on the Global Rating of Change Scale as "a very great deal better." The Numerical Pain Rating Score improved from 6/10 to 0/10. Patient-perceived disability, as measured by the Neck Disability Index, improved from 26% to 0%, and the patient's score on the modified Oswestry Disability Index improved from 30% to 0%. Bilateral upper extremity paraesthesiae also had completely resolved. These clinically meaningful improvements in pain and perceived disability were maintained six weeks after discharge. While a cause-and-effect relationship cannot be inferred from a case report, it is plausible that an orthopaedic manual physical therapy approach in the management of patients with both neck and upper extremity pain may result in decreased pain and improved function. Further clinical trials are needed to test this hypothesis.     

The management of shoulder impingement and related disorders: A systematic review on diagnostic accuracy of physical tests and manual therapy efficacy

BackgroundDiagnostic accuracy of physical tests and effectiveness of musculoskeletal rehabilitation of shoulder disorders are still debated.ObjectivesTo investigate diagnostic accuracy of physical tests, efficacy of physiotherapy and coherence between target of assessment and intervention for shoulder impingement and related disorders like bursitis, rotator cuff and long head biceps tendinopathy and labral lesions.MethodsA systematic search of four databases was conducted, including RCTs and cross-sectional studies. Cochrane Risk of Bias and QUADAS-2 were adopted for critical appraisal and a narrative synthesis was undertaken.Results6 RCTs and 2 cross-sectional studies were appraised. Studies presented low to moderate risk of bias. There is a lack of evidence to support the mechanical construct guiding the choice of physical tests for diagnosis of impingement. Manual techniques appear to yield better results than placebo and ultrasounds, but not better than exercise therapy alone. Discrepancy between the goal of assessment strategies and the relative proposed treatments were present together with high heterogeneity in terms of selection of patients, type of endpoints and follow-ups.ConclusionsMusculoskeletal physiotherapy seems to be an effective treatment for patients with shoulder pain although it is still based on weak diagnostic clinical instruments. The adoption of more functional and prognostic assessment strategies is advisable to improve coherence between evaluation and treatment.