Cervical Spine Manipulation Research Articles

Assessment of in vivo 3D kinematics of cervical spine manipulation: Influence of practitioner experience and occurrence of cavitation noise

Investigations on 3D kinematics during spinal manipulation are widely reported for assessing motion data, task reliability and clinical effects. However the link between cavitation occurrence and specific kinematics remains questionable. This paper investigates the 3D head-trunk kinematics during high velocity low amplitude (HVLA) manipulation for different practitioners with respect to the occurrence of cavitation. Head-trunk 3D motions were sampled during HVLA manipulation in twenty asymptomatic volunteers manipulated by four practitioners with different seniority (years of experience). Four target levels were selected, C3 and C5 on each side, and were randomly allocated to the different practitioners. The data was recorded before, during and after each set of trial in each anatomical plane. The number of trials with cavitation occurrence was collected for each practitioner. The manipulation task was performed using extension, ipsilateral side bending and contra-lateral axial rotation independent of side or target level. The displayed angular motion magnitudes did not exceed normal active ROM. Regardless cavitation occurrence, wide variations were observed between practitioners, especially in terms of velocity and acceleration. Cavitation occurrence was related to several kinematics features (i.e. frontal ROM and velocity, sagittal acceleration) and practitioner experience. In addition, multilevel cavitation was observed regularly. Kinematics of cervical manipulation is dependent on practitioner and years of experience. Cavitation occurrence could be related to particular kinematics features. These aspects should be further investigated in order to improve teaching and learning of cervical manipulation technique.

Gastroesophageal Reflux Disease

a Private practic b Private practic Submit reques De Veentjes 21-03 (e-mail: annakjona Paper submitted 0161-4754/$32. Copyright D 20 doi:10.1016/j.jm Objective: To present the diagnosis and management of gastroesophageal reflux disease found in a pediatric patient, to discuss the importance of a detailed case history, and to bring forward some of the most important clues, both verbal and nonverbal, that can lead to the diagnosis. Clinical Features: An 8-year-old boy was brought to a chiropractic clinic by his mother complaining of headache and neck pain. Based on the history and physical examination, a diagnosis of cervicogenic headache was made. Intervention and Outcome: Treatment consisted of chiropractic manipulation of the upper cervical spine in combination with cranial treatment was applied in addition to dietary advice. The headache returned and the patient was then referred to a colleague for a second opinion. Based on a detailed history, gastroesophageal reflux disease was diagnosed and the patient was referred to a specialist for suitable treatment. Conclusion: Because of the position as first-line health practitioners, it is inevitable that doctors of chiropractic will be faced with complaints of a nonbiomechanical nature. It is important to recognize conditions, such as gastroesophageal reflux, at an early stage and to refer appropriately. (J Manipulative Physiol Ther 2006;29:245-247) Key Indexing Terms: Gastroesophageal Reflux; Children; Abdominal Pain; Headache G astroesophageal reflux (GER) is a condition whereby the gastric contents regurgitate into the esophagus. In adults it is not an uncommon presentation and the diagnosis is predominantly straightforward, recognized as a bburning sensationQ high in the chest, often in combination with having eaten and/or with laying in a recumbent position. There is also a high incidence in babies younger than 1 year (approximately 40%-65%). The presentation in this age category is mainly excessive reflux of milk. With a broader array of symptoms such as angina, abdominal pain, reflux, nausea and vomiting, GER is a regular complaint in children. The recovery of GER is mostly spontaneous or it is easily treated with conservative methods. On the other hand, gastroesophageal reflux disease (GERD) is a pathological process that is typified by gastrointestinal and respiratory symptoms as a result of aspiration of gastric contents. In children the incidence is approximately 1 in 300. If left untreated, there is an increased chance of e, Doetinchem, The Netherlands. e, Borger, The Netherlands. ts for reprints to: Anna Jonasson, MSc, , 7001 DL Doetinchem, The Netherlands sson@hotmail.com). April 14, 2005. 00 06 by National University of Health Sciences. pt.2006.01.004 developing other diseases such as esophageal cancer. In the case of GERD, medical intervention is inevitable. The goal of this case presentation is to underline that an undiagnosed case of GERD can present in a chiropractic practice, which can be correctly identified with a detailed history and recognition of the red flags.

Spinal manipulation does not affect pressure pain thresholds in the absence of neuromodulators: a randomized controlled trial

Background: Measurement of pressure pain threshold (PPT) is a way to determine one of the many potential treatment effects of spinal manipulative therapy.Objective: To determine how multiple spinal manipulations administered in a single-session affected PPTs at local and distal sites in asymptomatic individuals.Methods: Participants were randomly assigned into one of three groups: Group one (n = 18) received a lumbar manipulation followed by a cervical manipulation. Group two (n = 17) received a cervical manipulation followed by a lumbar manipulation. The control group (n = 19) received two bouts of five minutes of rest. At baseline and after each intervention or rest period, each participant’s PPTs were obtained using a handheld algometer. The PPTs were tested bilaterally over the lateral epicondyles of the humerus and over the mid-bellies of the upper trapezius, lumbar paraspinal, and the tibialis anterior muscles. This study was registered with ClinicalTrials.gov, and its Identifier is NCT02828501.Results: Repeated-measures ANOVAs and Kruskal–Wallis tests showed no significant within- or between-group differences in PPT. Within-group effect sizes in the changes of PPT ranged from −.48 at the left paraspinal muscles to .24 at the left lateral humeral epicondyle. Statistical power to detect significant differences at α of 0.05 was calculated to be 0.94.Conclusions: This study suggests that in young adults who do not have current or recent symptoms of spinal pain, multiple within-session treatments of cervical and lumbar spinal manipulation fail to influence PPTs. Changes in PPT that are observed in symptomatic individuals are likely to be primarily influenced by pain-related neuromodulators rather than by an isolated, mechanical effect of spinal manipulation.

Adverse events after cervical spinal manipulative therapy: Consensus based classification and definitions

Cervical spinal manipulations (CSM) are frequently employed techniques to alleviate neck pain and headache. Minor and major complications following CSM have been described, though clear consensus on definition and the classification of the complications had not yet been achieved. As a result, incidence rates may be underestimated. The aim of this study was to develop a consensus-based classification of adverse events following cervical spinal manipulations which has good feasibility in clinical practice and research. Design: A three round Delphi-study. Medical specialists, manual therapists, and patients (n=30) participated in an online survey. In Round 1, participants were invited to select a classification system of adverse events. Potential complications were inventoried and detailed in accordance with the ICF and the ICD-10. In Round 2, panel members categorized the potential complications in their selected classification. During the third round, it was inquired of the participants whether they concurred with the answer of the majority of participants. Results: Thirty four complications were defined. Consensus was achieved for 29 complications for all durations [hours, days, weeks]. For the remaining five complications, consensus was reached for two of the three durations [hours, days, weeks]. Conclusions: A consensus-based classification system of adverse events after cervical spinal manipulation was developed which comprises patients’ and clinicians’ perspectives and has only a small number of categories. The classification system includes a precise description of potential adverse events and is based on international accepted classifications (ICD-10 and ICF). This classification system may be useful for utilization in both clinical practice and research.

The art and science of mitigating risk: A qualitative study of the teaching and learning of cervical spine manipulation

The art and science of mitigating risk: A qualitative study of the teaching and learning of cervical spine manipulation

Mobilization and Manipulation of the Cervical Spine in Patients with Cervicogenic Headache: Any Scientific Evidence?

Cervical mobilization and manipulation are frequently used to treat patients diagnosed with cervicogenic headache (CEH); however, there is conflicting evidence on the efficacy of these manual therapy techniques. The purpose of this review is to investigate the effects of cervical mobilization and manipulation on pain intensity and headache frequency, compared to traditional physical therapy interventions in patients diagnosed with CEH. A total of 66 relevant studies were originally identified through a review of the literature, and the 25 most suitable articles were fully evaluated via a careful review of the text. Ultimately, 10 studies met the inclusion criteria: (1) randomized controlled trial (RCT) or open RCT; the study contained at least two separate groups of subjects that were randomly assigned either to a cervical spine mobilization or manipulation or a group that served as a comparison; (2) subjects must have had a diagnosis of CEH; (3) the treatment group received either spinal mobilization or spinal manipulation, while the control group received another physical therapy intervention or placebo control; and (4) the study included headache pain and frequency as outcome measurements. Seven of the 10 studies had statistically significant findings that subjects who received mobilization or manipulation interventions experienced improved outcomes or reported fewer symptoms than control subjects. These results suggest that mobilization or manipulation of the cervical spine may be beneficial for individuals who suffer from CEH, although heterogeneity of the studies makes it difficult to generalize the findings.

Abstract WP197: Spinal Manipulation Therapy and Risk of Cerebrovascular Events: Evidence Map and Meta-analysis

Introduction: Cervical spinal manipulation therapy (SMT) has been associated with cerebrovascular events, including arterial dissection and stroke. We constructed an evidence map of the published literature and systematically reviewed epidemiological studies on the association between SMT and cerebrovascular events. Methods: We searched MEDLINE, EMBASE, Cochrane, the ISI database, and reference lists through 7/14 to identify studies with data, evidence, or opinions on stroke or dissection occurring after SMT. Descriptive statistics were used to summarize the study design and publication date of studies. Summary ORs with 95% confidence intervals (CI) were estimated using random effects inverse variance analyses. Results: Among 311 studies meeting eligibility criteria, most were case reports (105, 34%), editorials/letters (n=81, 26%) and case series (n=51, 16%). Six eligible analytic epidemiologic studies (in 5 publications) were found: 5 case control studies included a median of 53 cases (range 47-818; total 1546) and 100 controls (range 43-3164; total 5671) and one case-crossover study used 818 cases from one of the case control studies. SMT exposure within 30 days of the index date was not statistically significantly associated with stroke/dissection risk (OR = 1.79, 95% CI 0.88-3.64, p=0.11; I2 = 63%, p for heterogeneity = 0.03). Three studies used more reliable case definitions (imaging-confirmed dissection), and found that SMT was associated with a significantly increased risk (OR=4.31, 95% CI 1.32-14.07, p=0.015). Conclusion: Most studies published on the relation between SMT and cerebrovascular events cannot provide robust information on causal inference, but the few available epidemiologic studies indicate possible harm associated with SMT. More well-powered studies with better case ascertainment are needed to guide inference about SMT safety.

Influence of the cervical spine manipulation in the neck disability index in patients with chronic neck pain: A preliminary study

Introduction: Neck pain is one of the major problems managed by chiropractors, therefore its common the use of spinal manipulationto manage this problem. Objective: To evaluate the influence of Cervical Spine Manipulation (CSM) in the Neck Disability Index (NDI) ofpatients with chronic neck pain compared to a manipulative sham group. Method: 15 patients with chronic neck pain, were randomlyassigned into one of two groups. Experimental Group (EG), with 8 patients, mean age of 30.6(13.7) years and Sham Group (SG), with 7patients, mean age of 38.9(17.0) years. All the patients signed a Voluntary Informed Consent Document, approved by the university’sresearch ethics committee (n°555.015). The NDI was used to evaluate the outcome. The EG intervention was the CSM, performed 4times, along a mean of 39.2 days. The SG was subjected to a similar cervical manipulative sensory experience, also performed 4 times,along a mean of 30.6 days. Paired and unpaired Student’s t-test was used to assess intra and inter group differences, respectively.Results: Statistically significant differences (p=0.000) were found for NDI between the pre and post-treatment evaluations of both theEG (26.3(5.0) % pre; 10.9(7.1) % post) and the SG (30.1(3.7) % pre; 18.4(5.3) % post). There were no significant differences for NDI inthe pre-treatment between groups (p=0.122), however statistically significant differences were found in the post-treatment betweenthe EG and the SG (p=0.039). Conclusion: The result shows that after the treatment period both groups showed improvement for NDI,however the CSM in the EG resulted in an improved outcome in the treatment of patients with chronic neck pain.

Does cervical lordosis change after spinal manipulation for non-specific neck pain? A prospective cohort study

BackgroundThe association between cervical lordosis (sagittal alignment) and neck pain is controversial. Further, it is unclear whether spinal manipulative therapy can change cervical lordosis. This study aimed to determine whether cervical lordosis changes after a course of spinal manipulation for non-specific neck pain.MethodsPosterior tangents of C2 and C6 were drawn on the lateral cervical fluoroscopic images of 29 patients with subacute/chronic non-specific neck pain and 30 healthy volunteers matched for age and gender, recruited August 2011 to April 2013. The resultant angle was measured using ‘Image J’ digital geometric software. The intra-observer repeatability (measurement error and reliability) and intra-subject repeatability (minimum detectable change (MDC) over 4 weeks) were determined in healthy volunteers. A comparison of cervical lordosis was made between patients and healthy volunteers at baseline. Change in lordosis between baseline and 4-week follow-up was determined in patients receiving spinal manipulation.ResultsIntra-observer measurement error for cervical lordosis was acceptable (SEM 3.6°) and reliability was substantial ICC 0.98, 95 % CI 0.962–0991). The intra-subject MDC however, was large (13.5°). There was no significant difference between lordotic angles in patients and healthy volunteers (p = 0.16). The mean cervical lordotic increase over 4 weeks in patients was 2.1° (9.2) which was not significant (p = 0.12).ConclusionsThis study found no difference in cervical lordosis (sagittal alignment) between patients with mild non-specific neck pain and matched healthy volunteers. Furthermore, there was no significant change in cervical lordosis in patients after 4 weeks of cervical spinal manipulation.

The simulated early learning of cervical spine manipulation technique utilising mannequins.

BackgroundTrivial pain or minor soreness commonly follows neck manipulation and has been estimated at one in three treatments. In addition, rare catastrophic events can occur. Some of these incidents have been ascribed to poor technique where the neck is rotated too far. The aims of this study were to design an instrument to measure competency of neck manipulation in beginning students when using a simulation mannequin, and then examine the suitability of using a simulation mannequin to teach the early psychomotor skills for neck chiropractic manipulative therapy.MethodsWe developed an initial set of questionnaire items and then used an expert panel to assess an instrument for neck manipulation competency among chiropractic students. The study sample comprised all 41 fourth year 2014 chiropractic students at Murdoch University. Students were randomly allocated into either a usual learning or mannequin group. All participants crossed over to undertake the alternative learning method after four weeks. A chi-square test was used to examine differences between groups in the proportion of students achieving an overall pass mark at baseline, four weeks, and eight weeks.ResultsThis study was conducted between January and March 2014. We successfully developed an instrument of measurement to assess neck manipulation competency in chiropractic students. We then randomised 41 participants to first undertake either “usual learning” (n = 19) or “mannequin learning” (n = 22) for early neck manipulation training. There were no significant differences between groups in the overall pass rate at baseline (χ2 = 0.10, p = 0.75), four weeks (χ2 = 0.40, p = 0.53), and eight weeks (χ2 = 0.07, p = 0.79).ConclusionsThis study demonstrates that the use of a mannequin does not affect the manipulation competency grades of early learning students at short term follow up. Our findings have potentially important safety implications as the results indicate that students could initially gain competence in neck manipulation by using mannequins before proceeding to perform neck manipulation on each other.

Head-Trunk Kinematics During High-Velocity–Low-Amplitude Manipulation of the Cervical Spine in Asymptomatic Subjects: Helical Axis Computation and Anatomic Motion Modeling

ObjectiveThis study aimed to analyze the in vivo 3-dimensional kinematics of the head during cervical manipulation including helical axis (HA) computation and anatomic motion representation. MethodsTwelve asymptomatic volunteers were included in this study. An osteopathic practitioner performed 1 to 3 manipulations (high-velocity and low-amplitude [HVLA] multiple component technique) of the cervical spine (between C2 and C5) with the patient in the sitting position. During manipulation, head motion was collected using an optoelectronic system and expressed relative to the thorax. Motion data were processed to analyze primary and coupled motions and HA parameters. Anatomic motion representation including HA was obtained. ResultsDuring manipulation, average maximal range of motion was 39° (SD, 6°), 21° (SD, 7°), and 8° (SD, 5°) for lateral bending (LB), axial rotation (AR), and flexion extension, respectively. For the impulse period, magnitude averaged of 8° (SD, 2°), 5° (SD, 2°), and 3° (SD, 2°), for LB, AR, and flexion extension, respectively. Mean impulse velocity was 139°/s (SD, 39°/s). Concerning AR/LB ratios, an average of 0.6 (SD, 0.3) was observed for global motion, premanipulation positioning, and impulse. Mean HA was mostly located ipsilateral to the impulse side and displayed an oblique orientation. ConclusionThis study demonstrated limited range of AR during cervical spine manipulation and provided new perspectives for the development of visualization tools, which might be helpful for practitioners and for the analysis of cervical manipulation using HA computation and anatomic representation of motion.

Advances in Biomechanical Examination of Cervical Spine Manipulation

Advances in Biomechanical Examination of Cervical Spine Manipulation

Correction: The Quality of Reports on Cervical Arterial Dissection following Cervical Spinal Manipulation

The authors have found that some of the data contained in this manuscript are categorized inappropriately. Many of the cases included from two case-control studies (Rothwell et al. and Stevinson et al.) should be omitted from the paper’s calculations as they were reported originally as cervical artery dissection cases in general, but not cervical artery dissection cases that occurred prior to cervical manipulation. The total number of cases where cervical manipulation was reported to have occurred prior to the onset of cervical artery dissection should be reduced from 902 to 322. With this adjustment, the time to onset of symptoms can now be reported to be a smaller percentage of cases (89%) compared to the original paper (93%). Similarly, the percentage of cases that named the involved vessel increased from 71% to 77%. Finally, the percentage of cases reporting the profession of the involved clinician performing the manipulation decreased from 99% to 80%. Excluding these three variables, the other 15 variables in the paper remain unchanged. This reclassification of cases does not alter the conclusions of the paper.

Does cervical spine manipulation reduce pain in people with degenerative cervical radiculopathy? A systematic review of the evidence, and a meta-analysis

Objective: To access the effectiveness and safety of cervical spine manipulation for cervical radiculopathy. Data sources: PubMed, the Cochrane Central Registry of Controlled Trials (CENTRAL) in the Cochrane Library, EMBASE, Chinese Biomedical Literature Database (CBM), Chinese National Knowledge Infrastructure (CNKI), Chinese Scientific Journal Database (VIP), Wanfang data, the website of Chinese clinical trial registry and international clinical trial registry by US National Institutes of Health. Review methods: Randomized controlled trials that investigated the effects of cervical manipulation compared with no treatment, placebo or conventional therapies on pain measurement in patients with degenerative cervical radiculopathy were searched. Two authors independently evaluated the quality of the trials according to the risk of bias assessment provided by the PEDro (physiotherapy evidence database) scale. RevMan V.5.2.0 software was employed for data analysis. The GRADE approach was used to evaluate the overall quality of the evidence. Results: Three trials with 502 participants were included. Meta-analysis suggested that cervical spine manipulation (mean difference 1.28, 95% confidence interval 0.80 to 1.75; P < 0.00001; heterogeneity: Chi2 = 8.57, P = 0.01, I2 = 77%) improving visual analogue scale for pain showed superior immediate effects compared with cervical computer traction. The overall strength of evidence was judged to be moderate quality. One out of three trials reported the adverse events and none with a small sample size. Conclusion: There was moderate level evidence to support the immediate effectiveness of cervical spine manipulation in treating people with cervical radiculopathy. The safety of cervical manipulation cannot be taken as an exact conclusion so far.

A cross-sectional postal survey of musculoskeletal physiotherapists’ opinions towards the published theory of cervical spine manipulation

AbstractPurposeSurvey the opinions of physiotherapists on the published theory of cervical spine manipulation, to assist the physiotherapist in achieving informed consent in advance of planned orthopaedic manual therapy interventions.MethodA self-administered postal survey was validated, and then sent to 325 physiotherapists working in musculoskeletal practices in Dorset and Hampshire, United Kingdom.ResultsFour articles presenting theories of cervical manipulation were found in the search of literature published during 2008–2011. Nine theories from the literature are presented within the survey: four theories are accepted by more than 50% of the sample.ConclusionsWhen a patient asks how manipulation works, before any of the theories are offered to the patient, it can be elucidated that the theoretical base underpinning every aspect of cervical manipulation is still underdeveloped. This study finds popular theory accepted by over 70% of physiotherapists, namely that spinal manipulation activates mechanore...

Complementary and Alternative Medicine for the Management of Cervical Radiculopathy: An Overview of Systematic Reviews.

Background. Complementary and alternative medicine (CAM) is widely applied in the clinical practice of neck pain owing to cervical radiculopathy (CR). While many systematic reviews exist in CAM to improve CR, research is distributed across population, intervention, comparison, and setting. Objective. This overview aims to summarize the characteristics and evaluate critically the evidence from systematic reviews. Methods. A comprehensive literature search was performed in the six databases without language restrictions on February 24, 2015. We had identified relevant systematic reviews that examined the subjects with neck pain due to cervical radiculopathy undergoing CAM. Two authors independently appraised the methodological quality using the revised assessment of multiple systematic reviews instrument. Results. We had included eight systematic reviews. The effectiveness and safety of acupotomy, acupuncture, Jingfukang granule, manual therapies, and cervical spine manipulation were investigated. Based on available evidence, the systematic reviews supported various forms of CAM for CR. Nevertheless, the methodological quality for most of systematic reviews was low or moderate. In addition, adverse reactions of primary studies were infrequent. Conclusions. Current systematic reviews showed potential advantages to CAM for CR. Due to the frequently poor methodological quality of primary studies, the conclusions should be treated with caution for clinical practice.

The Effect of Cervical Spine Manipulation on Postural Sway in Patients With Nonspecific Neck Pain

ObjectiveThis crossover study aimed to determine whether a single high-velocity, low-amplitude manipulation of the cervical spine would affect postural sway in adults with nonspecific neck pain. MethodsTen participants received, in random order, 7 days apart, a high-velocity, low-amplitude manipulation applied to a dysfunctional spinal segment and a passive head-movement control. Four parameters of postural sway were measured before, immediately after, and at 5 and 10 minutes after each procedure. ResultsResults showed no differences between interventions in change in any of the parameters. When changes before and immediately after each procedure were analyzed separately, only the control showed a significant change in the length of center of pressure path (an increase from median, 118 mm; interquartlie range, 93-137 mm to an increase to 132 mm; 112-147; P = .02). ConclusionThis study failed to show evidence that single manipulation of the cervical spine influenced postural sway. Given the ability of the postural control system to reweight the hierarchy of sensory information to compensate for inadequacies in any 1 component, it is possible that any improvements in the mechanisms controlling postural sway elicited by the manipulative intervention may have been concealed.

Real-Time Monitoring of Stresses and Displacements in Cervical Nuclei Pulposi During Cervical Spine Manipulation: A Finite Element Model Analysis

ObjectiveThe objective of this study was to research the distribution of stresses and displacements in cervical nuclei pulposi during simulated cervical spine manipulation (CSM). MethodsA 3-dimensional finite element model of C3/4~C6/7 was established. The detailed mechanical parameters of CSM were analyzed and simulated. During the process, the changes in stresses and displacements of cervical nuclei pulposi within the model were displayed simultaneously and dynamically. ResultsCervical spine manipulation with right rotation was targeted at the C4 spinous process of the model. During traction, levels of stresses and displacements of the nuclei pulposi exhibited an initial decrease followed by an increase. The major stresses and displacements affected the C3/4 nucleus pulposus during rotation in CSM, when its morphology gradually changed from circular to elliptical. The highest stress (48.53 kPa) occurred at its right superior edge, on rotating 40° to the right. It protruded toward the right superior, creating a gap in its left inferior aspect. The highest displacement, also at 40° right, occurred at its left superior edge and measured 0.7966 mm. Dimensions of stresses and displacements reduced quickly on rapid return to neutral position. ConclusionThe morphology of the C3/4 nucleus pulposus changed during CSM with right rotation, and it created a gap in its left inferior aspect. Biomechanically, it is more safe and rational to rotate toward the healthy side than the prolapsed side of the intervertebral disk during CSM. Upon ensuring due safety, the closer the application force is to the diseased intervertebral disk, the better is the effect of CSM.

Inertial sensor real-time feedback enhances the learning of cervical spine manipulation: a prospective study.

BackgroundCervical Spinal Manipulation (CSM) is considered a high-level skill of the central nervous system because it requires bimanual coordinated rhythmical movements therefore necessitating training to achieve proficiency. The objective of the present study was to investigate the effect of real-time feedback on the performance of CSM.MethodsSix postgraduate physiotherapy students attending a training workshop on Cervical Spine Manipulation Technique (CSMT) using inertial sensor derived real-time feedback participated in this study. The key variables were pre-manipulative position, angular displacement of the thrust and angular velocity of the thrust. Differences between variables before and after training were investigated using t-tests.ResultsThere were no significant differences after training for the pre-manipulative position (rotation p = 0.549; side bending p = 0.312) or for thrust displacement (rotation p = 0.247; side bending p = 0.314). Thrust angular velocity demonstrated a significant difference following training for rotation (pre-training mean (sd) 48.9°/s (35.1); post-training mean (sd) 96.9°/s (53.9); p = 0.027) but not for side bending (p = 0.521).ConclusionReal-time feedback using an inertial sensor may be valuable in the development of specific manipulative skill. Future studies investigating manipulation could consider a randomized controlled trial using inertial sensor real time feedback compared to traditional training.

Elongated Styloid Processes and Calcified Stylohyoid Ligaments in a Patient With Neck Pain: Implications for Manual Therapy Practice

ObjectiveThe purpose of this paper is to present a case of a patient with neck pain, tinnitus, and headache in the setting of bilateral elongated styloid processes (ESP) and calcified stylohyoid ligaments (CSL), how knowledge of this anatomical variation and symptomatic presentation affected the rehabilitation management plan for this patient, and to discuss the potential relevance of ESPs and CSLs to carotid artery dissection. Clinical featuresA 29-year-old male military helicopter mechanic presented for chiropractic care for chronic pain in the right side of his neck and upper back, tinnitus, and dizziness with a past history of right side parietal headaches and tonsillitis. Conventional radiographs showed C6 and C7 spinous process fractures, degenerative disc disease at C6/7, and an elongated right styloid process with associated calcification of the left stylohyoid ligament. Volumetric computerized tomography demonstrated calcification of the stylohyoid ligaments bilaterally. Intervention and outcomeGiven the proximity of the calcified stylohyoid apparatus to the carotid arteries, spinal manipulation techniques were modified to minimize rotation of the neck. Rehabilitation also included soft tissue mobilization and stretching, corrective postural exercises, and acupuncture. An otolaryngologist felt that the symptoms were not consistent with Eagle syndrome and the tinnitus was associated with symmetric high frequency hearing loss, likely due to occupational noise exposure. Initially, the patient's symptoms improved but plateaued by the fifth visit. ConclusionNeck pain in the presence of ESPs and CSLs can be associated with Eagle syndrome, which can include ipsilateral head and neck pain, odynophagia, dysphagia, and cerebrovascular symptoms. This case, initially thought to be Eagle syndrome, highlights proper diagnostic workup for this condition and presents potential contraindications to consider with regard to cervical spine manipulation in such patients. Manual therapy precautions pertaining to cervical spine manipulation may be appropriate in cases involving ESPs and calcified stylohyoid ligaments.