Pickard CM, Sullivan PE, Allison GT, Singer KP (2002) Is there a difference in hip joint position sense between young and older groups? Submitted

Abstract

Background: Joint position sense in the knee has been shown by many authors to decline with age. It has been speculated this decrease contributes to abnormal joint mechanics during load-bearing activities and putatively result in joint degeneration. Surprisingly little research has been conducted on the human hip to determine benchmarks for normal joint position sense.

Method: Fifty-nine community dwelling subjects, 30 young (mean age 21.7 years) and 29 older (mean age 75 years) were recruited to determine normal reference ranges for the effect of age on hip joint position sense. Active and passive repositioning tasks were performed in inner and outer ranges of the hip abduction plane of movement. An electromagnetic tracking system was used to obtain accurate error measurements of the angular displacement.

Results: Results indicated no difference in hip joint position sense between the young and older subjects (F1,57 = 0.011, p = 0.917). However it was found that for both age groups, accurate reproduction of position at the hip joint occurred in the inner range (F1,57 = 13.760, p < 0.001). For both groups, active repositioning was more accurate than passive (F1,57 = 9.265, p = 0.004).

Conclusion: These results could be due to several factors including the influence of the joint receptors and the range in which the muscles are functioning. The influence of the level of physical activity on joint position sense appears to be advantageous.

Singer BJ, Dunne J,. Singer KP, Jegasothy GM, .Allison GT (2002) Ankle contracture following moderate to severe acquired brain injury: incidence and physical therapy management.

Abstract

Secondary musculoskeletal impairments, such as reduced dorsiflexion range, are common following acquired brain injury. The purpose of this study was to examine the incidence and physical therapy management of ankle contracture in a cohort of patients undergoing inpatient rehabilitation following moderate to severe acquired brain injury.

Methods

Age, gender, diagnosis, severity of injury, maximal passive ankle dorsiflexion with the knee extended and plantarflexor/invertor muscle tone were collected for 105 patients. Subjects were allocated retrospectively into one of four 'ankle outcome'categories according to ankle range and response to physical therapy intervention. The association between the type and severity of abnormal muscle activity and ankle outcome category was examined.

Results

No ankle abnormalities were identified in 65 patients (62%) (category 1). In twenty-three patients (22%) reduced dorsiflexion range resolved with standard physical therapy treatment (category 2). Seventeen patients (16%) had contracture which persisted or worsened despite standard physical therapy treatment. Ten of these underwent specific treatment including serial casting and, in some cases, adjunctive injection of botulinum toxin type A (category 3). Invasive management was not considered an appropriate priority in seven subjects due to the severity of their overall disability (category 4). Dystonic muscle overactivity was strongly associated with contracture. No subject in categories 3 or 4 presented with normal tone or spasticity in the affected limb. Two case studies illustrate the interaction between muscle overactivity and rheologic changes within the musculo-tendinous unit.

Conclusion

The incidence of ankle contracture in this cohort was much lower than previously reported. Effective treatment for this complex impairment depends on accurate evaluation and appropriate remediation. Peripheral manifestations of upper motor neurone damage can be influenced by rheologic properties such as muscle length and stiffness and, conversely, chronic muscle overactivity can lead to adaptive shortening and altered joint mechanics.

Allison GT and Henry S (2002) The influence of fatigue on trunk muscle responses to sudden arm movements, a pilot study. Submitted

Abstract

Objective: To examine fatigue induced changes in trunk muscle latencies following trunk muscle fatigue Design A repeated measures within subject design.

Background: Trunk muscles in response to sudden arm movements is an area of interest in clinical biomechanics and motor control.

Methods: Electromyographic profiles were recorded from Transversus Abdominis (finewire) , Internal Oblique, Rectus Abdominis and External Oblique and Longissimus at the level of the 3rd lumbar vertebrae bilaterally. Four asymptomatic subjects performed arm-raising task using a visual cue before and after an isometric fatiguing trunk extension task.

Results: Feed forward responses were not detected in all muscles for every trial. In general, following fatigue trunk muscle onset latencies occur earlier (left , z = -3.149, p = .0016 ; right , z = -1.982, p = .0475).

Conclusions: Trunk muscle fatigue causes a change in the motor control strategy for anticipatory postural adjustments in normal subjects. It remains unclear if there is a pattern for specific muscles changes between individuals and if these are reflected in individuals with low back pain.

Relevance: Trunk muscle fatigue and altered trunk muscles latencies to movement perturbations have been associated with low back pain. These findings suggest that there may be a link between centrally mediated response to isometric muscle fatigue and anticipatory motor control strategies.

Allison GT, Nagy B, Hall T (2001) A randomised clinical trial of manual therapy for cervicobrachial pain syndrome - pain and disability outcomes. Manual Therapy. Accepted for publication

Abstract

Study Design

A single blind randomised placebo controlled trial.

Objectives

To determine the clinical effect of a specific and non-specific manual therapy techniques on individuals with chronic cervicobrachial pain syndrome.

Summary of Background Data

Cervicobrachial pain syndrome is an upper quarter pain condition in which mechanosensitive neural tissue is a primary feature.

Methods

Thirty subjects with cervicobrachial pain syndrome (twenty females) were randomly allocated to one of three groups - specific manipulative therapy, placebo physiotherapy or the control group. Specific manipulative therapy consisted of passive techniques aimed at mobilising neural tissue structures the placebo manipulative physiotherapy involved genuine manual therapy techniques that tended to focus on arthrokinetic components. The control group received no additional treatment. The treatment period lasted eight weeks in total. Following the eight week control period, the subjects in the control group were crossed over into the specific manipulative therapy group and received the eight week specific manipulative therapy treatment. Pain and functional disability assessments (Short-form McGill pain questionnaire, visual analogue scale and Northwick Park neck pain questionnaire) were recorded before, midway and after an 8 week treatment period.

Results

The findings of this study suggest that both specific and placebo manipulative physiotherapy are equally effective in improving pain intensity, pain quality scores and functional disability levels.

Conclusions

The two manual therapy interventions had clinical focus on neurogenic and arthrokinetic aspects. It was demonstrated that they have an overlap in their therapeutic benefit. This may be a manifestation of the techniques or the heterogeneity of the cervicobrachial syndrome subjects.

Boyle JJW, Milne N and Singer KP (2001) Influence of age on cervicothoracic spinal curvature: Postural implications. Submitted

Abstract

Objectives

To define cervicothoracic spinal curvature relative to age.

Method

172 lateral spinal radiographs (114 males, 59 females) were analysed using two procedures: 1] Cobb angles were derived for thoracic [T1 to T12], cervical [C2 to C7] and cervicothoracic junctional regions [C6 to T4]; and 2] the cervicothoracic curvatures were digitised (C2 to T12), to derive the apex of both curves and the inflexion point.

Results

A significantly increasing thoracic spinal curvature was determined for both genders, with the mean apex location close to T6. The cervical lordosis tended to flatten with increasing age, particularly in males, with the cervical apex location moving from C6 to C4. The cervicothoracic curve inflexion point moved cranially with increasing age from T3 towards C7-T1.

Conclusion

The cervicothoracic spinal curvature undergoes progressive alteration through the lifespan with subsequent cranial migration of the inflexion point between the thoracic kyphosis and cervical lordosis. This characteristic provides a sensitive method of assessing the effects of aging, mechanical deformation or trauma on cervicothoracic spinal alignment.

Haynes MJ, Edmondston SE (2001) Accuracy and reliability of a new protractor - based neck goniometer. Journal of Manipulative and Physiological Therapeutics. Accepted for publication

Abstract

Objective: To assess the reliability of the SpinT, a new protractor-based device, for measuring active cervical spine ranges of motion. To compare the accuracy of CROM and SpinT measurements of rotation about the Y axis with and without tilt; the former motion occurring during natural rotation of the head.

Methods: Two examiners measured twice each of the individual cervical ranges of motion of 23 individuals; 15 men and 8 women, aged 21-42. The participants were asked to move their necks to the end ranges while they sat upright. The accuracy of the CROM and SpinT goniometers was assessed using a testing instrument capable of rotating and/or tilting to pre-set angles, and which either device could be positioned on.

Results: There was excellent agreement between the SpinT measurements of rotation about the Y axis compared to the readings from the testing platform regardless of the angle of tilt, while the CROM displayed poor concordance when the tilt exceeded 50. The reliability trials generally yielded close agreement between the examiners, especially regarding measurements of rotation left and right and flexion, and revealed higher concordance regarding intra-examiner results.

Conclusion: This study indicates that SpinT measurements of active cervical ranges of motion are reliable, and that the SpinT is accurate in measuring rotation with associated tilt.

Relevance

Measuring the natural movements of the neck can provide an indication of the clinically related, functional status of the cervical spine. This study suggests that the SpinT examination technique is accurate and reliable when making such measurements.

Key Words: Cervical vertebrae; Spine; Tests and measurements; Range of motion.

Tan C, Dunn S, Kent GN, Randall AG, Edmondston SJ, Singer KP (2001) The effect of formalin-fixation on collagen and elastin crosslinks in human spinal discs and ligamentum flavum. Journal of Musculoskeletal Research

Abstract

Due to the restricted access to fresh un-preserved tissue samples, the effect of formalin-fixation on the distribution and extent of collagen and elastin crosslinks in the matrix of human spinal discs was evaluated. Five lumbar discs and ligamentum flavum samples were harvested from two fresh cadaveric spines after routine post-mortem procedures. Anular (n=76), nuclear (n=28) and liagmentum flavum (n=58) samples were selectively removed from the spine and divided into two halves. One half was stored in 10% buffered formalin and the other half was stored in a freezer at -20°C. Samples from each half were dried, hydrolysed and assayed for collagen and elastin crosslinks using HPLC. Subsequently, samples were assayed initially at weekly intervals until the 5th week, and thereafter at varied weekly intervals until the 30th week.

There were no significant differences in the collagen content and the extent of pyridinoline, deoxypyridinoline, isodesmosine and desmosine crosslinks between fresh and formalin-fixed disc and ligament samples. There were also no significant trends in the collagen content or extent of collagen and elastin crosslinks after 30 weeks of formalin fixation, compared with baseline data.

Formalin-fixation does not significantly alter the collagen content or the extent of non-reducible collagen [pyridinoline, deoxypyridinoline], and elastin [desmosine and isodesmosine] crosslinks.

Tan CI, Kent GN, Randall AG, Edmondston SJ, Singer KP (2001) Collagen and elastin crosslinks in human intervertebral discs and ligamentum flavum: age, gender and spinal level influences. Journal of Musculoskeletal Research

Abstract

The collagen and elastin content and extent of collagen crosslinks were determined in human formalin-fixed and unfixed intervertebral discs and ligamentum flava. Tissue samples from cadaveric spinal discs (n= 77) and ligamentum flava (n= 364) were obtained from 24 formalin-fixed and 2 fresh spines.

The mean age of all cases was 57 ± 26 years. Spinal ligament and disc samples were harvested and analysed for collagen, and crosslinks of pyridinoline, deoxypyridinoline, and elastin crosslinks isodesmosine and desmosine. Collagen and elastin crosslinks were extracted from hydrolysed samples by cellulose partition chromatography, and analysed by reverse-phase HPLC.

Elastin crosslinks were only detected in 4 lumbar discs (mean 0.04 ± 0.01 nmol/mg dry wt) but yielded results for all ligamentum flavum samples (mean 20.2 ± 6.4 nmol/mg dry wt). For ligamentum flavum, the collagen and collagen crosslinks increased significantly with age (p< 0.05), whereas elastin content decreased significantly with age but only for the lumbar region (p< 0.05). Collagen and elastin content were significantly higher in females (p< 0.01) and collagen, pyridinoline and isodesmosine were significantly higher in the lumbar region (p< 0.01).

Elastin detected in lumbar discs was significantly less than that found in ligamentum flavum. The collagen and elastin content and extent of collagen crosslinks in ligamentum matrix varied significantly depending on the age, gender and spinal region.

Singer B, Jegasothy G, Singer KP, Allison G (2002) Evaluation of serial casting to correct equino-varus deformity of the ankle following acquired brain injury in adults. Clinical Biomechanics. 17: 152-161

Abstract

Objective: To determine the efficacy of a regime of serial plaster casting to ameliorate equino-varus deformity in subjects with acquired brain injury secondary to trauma or intra-cerebral haemorrhage.

Design: Prospective uncontrolled interventional trial

Setting: Inpatient Neurosurgical Rehabilitation facility (Perth, Western Australia)

Patients: Consecutive sample of sixteen patients with stable or worsening equino-varus deformity, resistant to conservative physical therapy rehabilitation.

Intervention: Below knee plaster of Paris casts were applied with the plantarflexor and/or invertor muscles under tension to increase range of ankle motion and muscle extensibility. Casts were changed on a weekly basis.

Outcome measures: Maximal passive range of ankle motion was measured on five occasions (prior to application of the first plaster, after removal of the initial cast, mid-way through the casting regime, following removal of the final plaster and one week later). Range of motion was assessed with the knee fully extended and flexed to 45 degrees. Changes from the pre-test to each subsequent test were examined. Achievement of 10°dorsiflexion with the knee extended was the clinical criterion for success. The amount and type of assistance required to perform a standardised wheelchair to bed transfer was quantified using an ordinal scale developed by the facility.

Results: A significant improvement in maximal passive ankle joint range, for knee flexed and extended conditions, was achieved (p<0.0001). Differences in the achieved ranges were also significant when the initial test was compared with the middle, end and follow-up test occasions (p<0.05). Ten of the nineteen casted limbs achieved the clinical criterion of 10° of dorsiflexion with the knee extended while fourteen subjects achieved this range with the knee flexed. Following casting thirteen subjects showed a significant reduction in the degree of assistance required to perform a standardised transfer (p<0.0015).

Conclusion: Serial casting is effective in reducing equino-varus deformity in some subjects following acquired brain injury. Severity of brain injury was the main factor associated with failure to respond to this intervention.

Singer B, Singer KP, Allison GT (2002) Evaluation of extensibility, passive torque and stretch reflex responses in triceps surae muscles following serial casting to correct spastic equinovarus deformity: preliminary data. Brain Injury. Accepted for publication

Abstract

Spastic equinovarus deformity of the ankle in adults with acquired brain injury can severely limit the achievement of rehabilitation goals. This study examined changes in triceps surae muscle extensibility, passive resistive torque and soleus stretch reflex responses in ten adult brain injured subjects undergoing serial casting to correct ankle equinovarus deformity.

Method: Goniometric measurement of maximal passive dorsiflexion was used to evaluate extensibility of the triceps surae muscles. Computer controlled ankle dynamometry and surface electromyography were used to identify passive resistive torque and soleus stretch reflex onset angle in response to stretches at two velocities.

Results: The mean casting period was five weeks. One subject was withdrawn due to failure to achieve measurable gain in ankle range over three consecutive cast changes. Median improvements in maximal ankle dorsiflexion, with the knee flexed and extended, of 30° and 15° respectively, were achieved in the remaining nine subjects over the time course of the casting intervention [p< 0.0001]. The median passive ankle range in response to a displacing torque of 10N.m increased 4.3° over the same period [p< 0.0001]. Consistent soleus reflex activity in response to passive stretches at 25°.s-1 was elicited in only four subjects. A trend for the stretch reflex onset to move further into the available range was demonstrated in these subjects.

Conclusion: In the present study, serial casting contributed to significant change in triceps surae extensibility and passive resistive torque, corresponding with improved maximal passive ankle dorsiflexion range and an increase in the angle achieved with a displacing torque of 10N.m. Increased stretch reflex threshold was observed in some subjects. The use of pre-determined outcome criteria and careful measurement of responses to this intervention were important to prevent premature discontinuation of casting when gains are slower than expected.

Singer BJ, Dunne J,. Singer KP, Jegasothy GM, .Allison GT (2002) Incidence of ankle contracture following moderate to severe acquired brain injury. Submitted

Abstract

Objectives

Loss of ankle joint range has been considered to be a common secondary complication of acquired brain injury; however few data are available to support this. The aim of this study was to examine the incidence of ankle contracture in adults admitted for rehabilitation following moderate-severe acquired brain injury, and to examine factors which may contribute to the development of this deformity.

Methods

Data were collected prospectively on all patients with a new diagnosis of moderate-severe brain injury admitted for rehabilitation over a twelve month period. Goniometric evaluation of ankle range of motion was performed at fortnightly intervals until contracture was diagnosed or the subject was discharged from the study. Contracture was defined as an inability to passively achieve a plantigrade ('right angle') position of the ankle with the knee extended. Muscle tone was also evaluated and subjects were allocated into one of three categories (normal, spastic or dystonic) according to the predominant pattern of muscle tone over the study period.

Results

One hundred and five patients were categorised as having moderate-severe acquired brain injury. Muscle tone was designated 'normal' in 67 subjects (64%), 'spastic' in 15 subjects (14%) and 'dystonic' in 23 (22%) subjects. The incidence of ankle contracture in this cohort was 16 % (17 of 105 cases). The occurrence of ankle deformity was highly correlated with the 'dystonic' category of muscle tone. Seventeen of twenty-three cases with dystonia developed contracture at some point between one and sixteen weeks post brain injury, whilst no subject with normal tone or spasticity developed the deformity. There was a weakly significant association between initial Glasgow Coma Score and the development of ankle contracture.

Conclusions

The incidence of ankle contracture from these data is much lower than the only identified previous study. This may be due to differences in inclusion criteria, the definition of contracture or rehabilitative management of the individuals studied. Patients with dystonic muscle overactivity appear to be at increased risk of developing ankle contracture. It remains to be seen whether prophylactic measures can prevent the development of the deformity in this group of patients.

Allison GT, Edmondston SJ Kiviniemi K, Lanigan H, Simonsen A, Walcher S (2000) Influence of standardised mobilisation on the posteroanterior stiffness of the lumbar spine in asymptomatic subjects. Physiotherapy Research International. 6: 145-156

Abstract

Background and Purpose

Spinal mobilisation is commonly used to relieve pain and assist recovery of mobility in individuals with low back pain. Fundamental to this concept is the belief that spinal mobilisation will influence the mechanical properties of the symptomatic motion segment. The objective of this study was to examine the segmental effects of a standardised mobilisation procedure on the posteroanterior (PA) stiffness of the lumbar spine.

Methods

Audio and visual feedback was used to train one physiotherapist to perform PA mobilisation at a consistent load and frequency. Following training, twenty-four subjects without low back pain were recruited for the intervention phase of the study. The spinal posteroanterior mobilisation (SPAM) apparatus was used to measure the PA stiffness of the lumbar spine at three measurement sites (L1, L3, and L5). The trained physiotherapist then applied the standardised PA mobilisation technique via the L3 spinous process for two minutes. Following the mobilisation, the PA stiffness was measured three times at the three locations.

Results

The therapist was able to apply a standardised mobilisation with a mean force of 146N (SD=8N) at a frequency of 1.5Hz. The first trial on each assessment demonstrated a pre-condition effect. Two minutes of PA mobilisation resulted in no significant change in the PA stiffness of the lumbar spine at the level to which the mobilisation was applied, or at the L1 and L5 segments. The 95% confidence intervals of the difference in PA stiffness before and after testing included zero at each measurement site.

Conclusions

Clinicians should pre-condition the spine when assessing PA stiffness both before and after interventions. A standardised mobilisation of 150N at 1.5Hz for 2 minutes had no segmental effect on spinal PA stiffness. Subsequent studies need to consider other mechanisms that may contribute to the changes that occur after PA spinal mobilisation.

B Singer, J Dunne, KP Singer & G Allison (2001) Evaluation of changes in passive resistive torque in triceps surae muscles following acquired brain injury. Submitted

Abstract

Objective: To examine the extent to which rheologic changes contribute to hypertonia in acutely brain injured patients.

Background: Increased resistance to passive lengthening (hypertonia) in the triceps surae muscles results from rheologic changes (increased muscle stiffness, loss of extensibility) and muscle overactivity and contributes to disability following acquired brain injury.

Design: Triceps surae muscle stiffness and soleus extensibility were measured prospectively in recently brain injured subjects and age matched normal controls. Comparison between limbs was made for subjects with unilateral neurological impairment.

Methods: Slow passive dorsiflexion stretches were performed using a computer controlled dynamometer. Muscle stiffness in the initial (S1) and final (S2) portion of the range, the angle achieved at 5N.m and 10N.m and the angle of onset of resistance, were determined from torque-angle curves. Goniometric evaluation of maximal ankle dorsiflexion was considered to reflect soleus extensibility.

Results: Significant differences in all parameters, except passive stiffness at the end of available range (S2) were demonstrated for comparisons between brain injured subjects and controls and between limbs in subjects with unilateral neurological impairment. The limb ipsilateral to unilateral brain injury had significantly less passive range of dorsiflexion.than control ankles. However, initial passive stiffness (S1) in the ipsilateral limb was significantly less than controls.

Conclusion: In subjects who are relatively immobile following brain injury, demonstrable changes in soleus extensibility occur bilaterally. Changes in passive resistive torque, which were only demonstrated in limbs with neurological impairment, may reflect the additional impact of muscle overactivity on disuse induced adaptations. The limb ipsilateral to unilateral neurological impairment cannot be considered to be a 'normal' control for comparative purposes.

Relevance

Decreased muscle length and increased passive stiffness alter ankle biomechanics and provide additional resistance to active ankle dorsiflexion. Loss of extensibility may be exacerbated by chronic muscle overactivity. Prophylactic management of inappropriate muscle activity and maintenance of muscle length is necessary to reduce subsequent disability and facilitate rehabilitation.

Allison GT, Henry SM (2001) The influence of fatigue on trunk muscle responses to sudden self paced arm movement. Manual Therapy. 6: 221-228

Abstract

Sudden voluntary movements of the upper limb are preceded by increased activity of muscles of the lower limb and trunk. These centrally mediated anticipatory postural adjustments (APAs) provide a preparatory stabilisation of the lower limbs and trunk in preparation for the impeding perturbation due to arm movement. It has been purported that individuals with low back pain have an altered preparatory response to sudden movements of the body. The alteration in motor control strategy infers a centrally mediated difference between individuals with and without low back pain. The reduction of the motor unit drive frequency to the final common pathway of the muscle during fatiguing tasks is also a centrally mediated response. Such fatigue responses may be quantified by assessing the change in the median frequency of the muscle activity power spectrum. The purpose of this study was to examine the association between centrally mediated changes in APAs to self-paced perturbations induced by peripheral muscle fatigue. Four healthy, asymptomatic subjects performed 10 rapid arm raises before and after an isometric trunk extension fatiguing task. Surface and fine wire electromyography were used to determine abdominal muscle onsets.

The results indicated that 1. the anticipatory responses of the trunk muscles tended to occur earlier post-fatigue when compared to the pre-fatigue muscle onsets particularly evident in the Longissimus and Rectus Abdominis. 2. preparatory activity of the trunk muscles was not detectable in every trial in either condition. These findings suggest that there may be a link between centrally mediated response to isometric muscle fatigue and anticipatory motor control strategies.

Singer B, Dunne J, Allison GT. Clinical evaluation of hypertonia in the triceps surae muscles. Physical Therapy Reviews. 6: 71-80

Abstract

Hypertonia of the triceps surae muscles is a common consequence of acquired brain injury. The increased resistance to passive lengthening results from rheologic changes within the musculo-tendinous unit, in addition to unmodulated descending facilitatory influences on the alpha motorneurone. Hypertonia can contribute to abnormal ankle joint biomechanics during the performance of functional tasks. Therapeutic interventions need to be based on accurate measurement and analysis of the various components of hypertonia. Some options for the clinical evaluation of hypertonia at the ankle joint are discussed in this paper. Reflex hyper-excitability and rheologic changes within the musculo-tendinous unit are inextricably linked. Serial evaluation of passive range of motion and muscle stiffness in patients with hypertonia provides useful information for treatment planning. In addition to measurement of available passive range of motion when maximal force is applied, there is a need to consider methods of monitoring changes in muscle stiffness following acquired brain injury.

Singer B, Dunne J, Allison GT. Reflex and non-reflex elements of hypertonia in triceps surae muscles following acquired brain injury. Implications for rehabilitation. Disability Rehabilitation. 23: 749-757

Abstract

Following adult onset acquired brain injury, the triceps surae muscles tend to become shortened and exhibit increased resistance to passive lengthening; a phenomenon that has been termed ÔhypertoniaÕ. Spasticity (velocity dependent tonic reflex hyper-excitability) has traditionally been considered a major component of hypertonia. In addition, unmodulated descending excitatory influences on the alpha motorneurone pool may result in inappropriate or excessive muscle activity (dystonia). Non-reflex changes, secondary to the brain injury, and as a consequence of subsequent immobility, also take place in the passive and active elements of the muscle. These non-reflex changes affect the stiffness and extensibility of the musculo-tendinous unit. Atrophy of muscle fibres combines with collagen proliferation to produce increased muscle stiffness. This may be compounded by increased actin-myosin cross-bridge linkages, which are thought to be associated with reduced rates of cross-bridge detachment. Prolonged immobilisation in a shortened position results in a loss of sarcomeres in series. Arthrogenic changes associated with disuse include remodelling of dense connective tissue and intra-articular adhesions. Decreased muscle extensibility may be exacerbated by muscle overactivity. Consideration of all of the potential factors contributing to hypertonia of the triceps surae muscle will assist clinicians to identify appropriate intervention strategies, which may facilitate better treatment outcomes.

KP Singer, G Svansson, RE Day, WH Breidahl, A Horrex (2001) The utility of diagnosising lumbar rotational instability from twist CT scans. Journal of Musculoskeletal Research. 5: 45-51

Abstract

The twist CT has been advocated as a useful diagnostic tool for determining lumbar segment instability. According to this test, facet joints showing wide separation on trunk rotation are believed to be pathological. However, no reports have reported the reliability of measuring facet joint separation from clinical twist CT films, nor tested for an association between separation and joint orientation.

Forty five patients, referred for mechanical low back pain, were scanned first in neutral, then right and left trunk twisted positions. Images were video-dgitised onto computer for quantitative measurement of facet joint morphology. Induced joint separation was contrasted with the neutral scan joint approximation and any difference expressed in millimeters.

The coefficient of variability (c.v.) of defining right and left transverse plane facet joint orientation, and of joint separation, from repeated assessment in 10 images was acceptable [c.v.=2% & 3.5%, respectively]. The joint angle increased from L2-3 to L5-S1 and the mean joint separation of 2.6mm was greatest at the L4-5 level. Forty-three percent of all segments showed little additional separation (<0.2mm) when in a rotated posture. In the remainder, a slight relationship existed between facet geometry and separation; joints with wider angles were associated with greater separation than those with a more sagittal configuration (r=0.36, p<0.01).

No conclusive trend was recorded in this patient series for increasing separation with wider joint angulation. This technique must be performed by an experienced CT radiographer to optimise the reproduction of the same anatomical scan slice between the rotated and neutral scan positions. Scan slice inconsistencies potentially reduce the usefulness of this technique for identifying lumbar segments with suspected rotary instability, with the additional twist scans markedly increasing the total effective radiation dose to the patient.

Singer B, Singer KP, Allison GT (2001) Serial plaster casting to correct equino-varus deformity of the ankle following acquired brain injury in adults. Review and clinical implications. Disability Rehabilitation. 23: 829-836

Abstract

Equino-varus deformity of the ankle is a common secondary complication of acquired brain injury. It results from a combination of sequelae of the brain injury and subsequent immobility, including hypertonia, reduced muscle length and increased stiffness. Some evidence exists for the efficacy of serial plaster casts in the treatment of equino-varus deformity, although most reported studies are uncontrolled and involve small numbers of subjects.

Proposed mechanisms via which serial casting might effect increased joint range, muscle extensibility and reduced reflex excitability are outlined in this review. Support for these mechanisms stems largely from animal experimental studies. The applicability of these data to human muscle is unknown. Serial casting has been shown to result in decreased resistance to passive lengthening and a reduction in dynamic reflex excitability within the lengthened muscles in children with cerebral palsy. Currently documented effects of serial casting in brain injured adults are limited to changes in range of maximal passive dorsiflexion.

Serial casting should be considered as an adjunct to therapy aimed at improving functional mobility. A variety of therapeutic interventions have been used to augment the effect of the casting regime. Factors that have been demonstrated to be associated with a favourable outcome from serial casting, and recommendations for future research are also discussed in this review.

Slattery H, Allison GT (2000) Exercise, medication and the depressed patient - Part 1 Defining depression. Submitted

Abstract

The aim of this paper is to educate primary healthcare providers who have little formal mental health training about depression. It provides definitions of the essential terms and clarifies the difference between depression, the symptom and depression as a disorder. The clinical features of depression, the course of the illness and the current understanding of its cause are described. An overview of the bio-psychosocial model of treatment is given with a summary of antidepressant medications and common side effects. Finally, the interaction between physical illness and depression is explored. This paper provides a working knowledge of depression for the physiotherapist. The importance of understanding the basic concepts of depression is underpinned by the high likelihood of many individuals presenting to physiotherapy clinics having a co-morbid depressive condition.

Slattery H, Allison GT (2000) Exercise, medication and the depressed patient - Part 2 Depression and Rehabilitation. Submitted

Abstract

There is a complex relationship between exercise and depression. This manuscript summarises the features of depression which make exercise difficult for persons with this disorder. It also looks at the evidence for the claim that exercise has a direct antidepressant effect. The limited information on the effect of antidepressants on exercise is also outlined. The paper outlines these issues for the physiotherapist so that they may be better informed and therefore more effective in the prescription of exercise programmes.

Edmondston SJ, Bricknell R, Fersum K, Humphries P, Davies P, Wickenden D, Song S, Singer KP (2000) Response of the lumbar intervertebral disc to flexion and extension positions: A Magnetic Resonance study. Manual Therapy 5:158 - 165

Abstract

Flexion and extension movements or positions have been advocated in the treatment of various forms of low back dysfunction due to the potential pain relieving effects attributed to displacements of the intervertebral disc (IVD). Objective in vivo determination of the segmental behaviour of the disc to contrasting positions has until recently been difficult. Magnetic resonance imaging (MRI) was used in this study to evaluate the influence of sagittal plane positions on lumbar IVD height and nucleus displacement in a small asymptomatic population.

Method: T2-weighted sagittal plane images from L1 to S1 were obtained from ten subjects (mean age: 30±5 years) positioned supine in lumbar flexion, followed by extension. Changes in disc height and localisation of nucleus position (determined by peak MRI signal intensity) between the two positions were calculated. Discs were classified for degenerative changes using a semi-quantitative grading scale.

Result: The mean range of lumbar sagittal movement achieved in the MRI was 44 degrees (range: 22 to 77degrees). Between flexion and extension, a significant increase in measured anterior disc height of 1.1mm (p<0.0001) and anterior displacement of the nucleus of 6.7% (p<0.0001) was observed. Despite the anterior displacement of the nucleus in extension observed in the pooled analysis, 30% of discs did not follow this trend. Nucleus degeneration was observed in at least one disc in nine subjects and in 26% of all discs examined.

Discussion: Lumbar spine position was found to be associated with small measured changes in anterior disc height and nucleus position, however, this response was variable within and between individuals. The theoretical concept of a stereotypical effect of spinal position on the lumbar IVD is challenged by these data. Since the health of the disc is often unknown in clinical practice, manual therapy treatment for lumbar spine pain should be based on the symptomatic response to movement and position rather than biomechanical theory.

Goh S, Price RI, Leedman P, Singer KP (2000) A comparison of three methods for measuring thoracic kyphosis: Implications for clinical studies. Rheumatology. 39: 310-315

Abstract

Objectives: To compare the Cobb technique for measuring kyphosis with an alternative method and a computer assisted curve assessment technique, and to examine the influence of vertebral body and disc shape on kyphosis.

Methods: Kyphosis measurements were derived from 93 lateral spinal radiographs or sagittal CT images of cadaveric spines, using [i] a computer-assisted method for estimating radius of curvature, [ii] the traditional Cobb method, and [iii] an alternative Cobb method. Regression models were applied for agreement analyses, and to examine the relative contribution of vertebral body and disc shape on the extent of curvature.

Results and Conclusions: Strong associations existed between curvature and angle data derived from the three methods, confirming the clinical utility of these techniques for quantification of thoracic kyphosis. However, the traditional Cobb method tended to over-estimate kyphosis in the presence of vertebra; body end-plate deformation. The degree of kyphosis was strongly reflective of the extent of deformity of the vertebral bodies, and to a lesser extent the shape of the thoracic discs.

Goh S, Price RI, Song S, Davis S, Singer KP (2000) Magnetic resonance-based vertebral morphometry of the thoracic spine: Age, gender and level-specific influences. Clinical Biomechanics 15: 417 - 425

Abstract

Objective. The aim of this study was to examine age, gender, and segmental trends in thoracic vertebral body shape, utilising thoracic spine magnetic resonance images involving an age range spanning the life span.
Design. A quantitative, cross-sectional, retrospective study design involving a sample of convenience.
Background. Thoracic vertebral shape data are commonly derived from radiographic resources. The non-ionising properties of MR imaging and availability of digital data for image analysis suggest potential for MR-based morphometric studies. For the thoracic spine, there is limited vertebral shape data on males, while few studies have examined the pattern of age-related changes across the life span.
Methods. Morphometry was performed on 220 mid sagittal T1-weighted MR images using image analysis software. Three indices of vertebral shape were utilised: the antero-posterior height ratio or anterior wedge index, mid-posterior height ratio or biconcavity index, and ratio of posterior vertebral height to mid antero-posterior diameter or compression index. Results. Different segmental patterns were noted for the vertebral shape indices. Significantly lower mean values were noted in males for the compression index. Age trends were significant, with a linear age-related decline demonstrated for the anterior wedge and biconcavity indices, and a quadratic trend noted for the compression index.
Conclusions. Thoracic vertebral body shape may be uniquely described using specific shape indices, for examining various segmental, gender and age-associated changes.
Relevance. These results suggest the importance of defining specific reference criteria for thoracic vertebral body shape indices, particularly age-related data encompassing a wide age range. Magnetic resonance studies enable interpretation of vertebral shape data in relation to the wide spectrum of pathologies afflicting the thoracic spine, without the concerns of ionising radiation.

Goh S, Tan C, Price RI, Edmondston SJ, Song S, Davis S, Singer KP (2000) Age and gender influences on thoracic vertebral body shape and disc degeneration: An MR investigation of 169 cases. Journal of Anatomy. 197: 647-657

Abstract

There is limited data detailing the pattern of age and gender-related changes to the thoracic vertebral bodies and intervertebral discs.

A retrospective MR investigation, involving T1-weighted mid sagittal images from 169 cases, was undertaken to examine age influences on the anterior wedge (antero-posterior height ratio or Ha/Hp), biconcavity (mid-posterior height ratio or Hm/Hp), and compression indices (posterior height/antero-posterior diameter or Hp/D) of the thoracic vertebral bodies.

Disc degenerative changes in the anulus, nucleus, end-plate and disc margin were noted on T2-weighted sagittal images for the 169 cases, based on a three-level grading system. A linear age-related decline in the Ha/Hp and Hm/Hp indices was noted. The Hp/D index increased during the first few decades of life, then decreased gradually thereafter. The prevalence of abnormal findings in the anuli, nuclei and disc margins increased with increasing age, particularly in the mid and lower thoracic discs. Greater disc degenerative changes were observed in males.

These findings provide further insight into the nature of thoracic vertebral shape changes across the lifespan, and the typical patterns of degeneration of the thoracic intervertebral discs.

Singer KP (2000) Editorial: Manual Therapy and science: a marriage of convenience? Manual Therapy. 5: 61-2

"The toughest part to absorbing new evidence is the last few centimetres"

By now the memory of vintage champagne imbibed around the 2000th New Year will have faded along with most of the resolutions pledged during that period. But what of the New Year resolutions for the Journal of Manual Therapy? With it’s expanding international subscriber base and meteoric rise in recognition as a credible science publication, indexed widely, what are the responsibilities of this Journal and it’s mentors for the next few years? As tempting as it might be to coast on these recent achievements, it would be valuable to ‘raise the bar’ in promoting the developing science of manual therapy. There are three dimensions to this challenge, ranging from the philosophical to the practical and the political.

The now worn phrase ‘Evidence based Medicine’ (EBM) imposes a stringent demand on all professionals to align their practice according to best available evidence. This is a serious challenge to all to reconcile market place demands with the delivery of treatment that confers clinical efficacy. The rhetoric of evidence is seductive whereas a real commitment to changing practice requires a change in philosophy. Recognition of the fact that change can be resisted by clinicians is amply demonstrated by Volinn (1966) who challenges the readership of professional journals to use new information and not abandon this to library shelves.

Educators too must discern between a traditional syllabus in favour of emphasising evidence. This process does not insist on the rejection of all traditions for, as Sackett indicates, knowledge will never replace individual clinical experience [Sackett 1998]. However, it still requires that we seek the best source of evidence to complement clinical empiricism. The continued rapid expansion of the Cochrane and PEDRO evidence databases serves to remind us of the dramatic rate of change in knowledge [Cochrane, PEDRO]. One risk here is to downgrade the real research priorities in manual therapy for yet another meta-analysis. In some areas of back pain research the latter are beginning to outnumber original studies.

Embracing the research process is the most fundamental way forward for manual therapy, but only if this tool is used skillfully and dispassionately. Good evidence will be rated as such, poor evidence discarded, thus the research sponsor must identify a sound pre-investment in terms of research design, execution plan and objectivity. With diminishing research funding, such efforts should be concentrated on investigations which bridge clinical science and verification of intervention efficacy.

Manual skills are the hallmark of the therapy clinician; combining the intellectual process of clinical reasoning and mechanical dexterity. However such practical ability must be developed alongside guidelines on the appropriateness of application and the requirements for safe practice. In parallel must be a recognition of the value of in-depth fundamental science and of the psychological domain of neuromuscular and musculoskeletal pain disorders (Main & Watson 1999). Indeed, new neuroanatomical information defining the intricacies of spinal innervation, and of complex pain referral patterns (Groen & Stolker 2000), may invite a re-think of traditional clinical belief systems.

The political dimension of manual therapy will require a preparedness to advocate our proven outcomes in relevant multidisciplinary forums. Why should this be necessary? At a recent conference, ‘contemporary physiotherapy’ was identified as contributing negatively to the management of chronic back pain subjects recruited into a longitudinal outcomes trial (Mannion et al 1999). The nature of this presentation to an international audience of senior spine researchers and clinicians has obvious implications. The challenge will be for manual therapists to broaden the scope of their presentations away from partisan groups, if their research is to impact meaningfully on our medical and science colleagues, and in turn on health policy advisors.

In a global world, there needs to be a serious resolve to mediate differences, join forces and funds to improve knowledge and practice. In order for manual therapy practice to advance, opportunities for decision makers, clinicians and educators to agree on the directions to take in the future, to secure the necessary resources to examine major research issues and to execute these in a transparent manner will be imperative. To these ends, we must also be prepared to collaborate outside of our professional disciplines to invite constructive scrutiny and challenge. Within such discussions a commitment to use a clear classification system for neuromuscular and musculoskeletal disorders, without sectarian jargon, will be crucial.

The up-coming IFOMT conference (IFOMT-2000) is one such opportunity for interactions on all levels, including clinical and scientific exchange. The convenors of this and similar meetings have the responsibility to ensure that delegates are confronted as well as comforted with new knowledge. Greater efforts must be made to enhance relationships between educators and clinicians, and colleagues from other disciplines, to ensure that our science is founded on the best available knowledge and intellectual rigor.

There must be more than a marriage of convenience between manual therapy and science if our profession is to gain enhanced credibility in the years ahead.

Raise the bar!

Acknowledgements:

I express my gratitude to colleagues: Max Zusman, Stephen Edmondston and Garry Allison for their critical and collegial argument. Illustration by Leonardo da Vinci (1452 – 1519).

Kevin P. Singer
www.cms.uwa.edu.au

References:

Groen GJ, Stolker R-J 2000 Thoracic neural anatomy. In: Giles L & Singer KP [eds] Clinical anatomy and management of thoracic spine pain. Butterworth-Heinemann, Oxford. pp 114-142
Main CJ, Watson PJ 1999 Psychological aspects of pain. Manual Therapy 4: 203-215
Mannion AF, Muntener M, Taimela S, Dvorak J 1999 A randomized clinical trial of three active therapies for chronic low back pain. Spine 24: 2435-48
Sackett D 1998 Evidence-based medicine. Spine 23: 1085-6
Volinn E 1996 Between the idea and the reality: Research on bed rest for uncomplicated acute low back pain and implications for clinical practice patterns. Clinical Journal of Pain 12: 166-170

Web links:

IFOMT 2000: http://www.ifomt.uwa.edu.au/
PEDRO database: http://ptwww.cchs.usyd.edu.au/pedro/
Cochrane database: http://www-epid.unimaas.nl/cochrane/field.htm

KP Singer, B-K Tan (2000) Navigating the internet maze. Manual Therapy 5: 165 - 172

Abstract

The ‘Internet driven information age’ is a by-line in common usage, implying that everyone can access all the information they need, when they need it.

The purpose of this brief paper is to outline some contemporary web sources to highlight the possibilities and potential for accessing web-based knowledge. From this the clinician will be encouraged to follow leads along the labyrinth of links to a greater appreciation of how this resource can be used to shape their practice.

Examples of some web links are provided for: search engines; library based sources; including medical databases and electronic journals; evidence based practice databases; mail-groups; electronic conferences; research centres, and general health sources. Importantly, this review does not aspire to be all-inclusive, for the web changes, chameleon-like, to the seasons.

The web is here to stay. It will provide the framework for much education and will guide clients to a greater appreciation of their disease or disability than ever before. It may ultimately be the tool through which health fund agents will promote best practice, including self-help to clients, and therefore direct discriminating individuals to select health practitioners who have been endorsed by professional and fund agencies as providing a contemporary service which conforms to evidence based practice.

Barrett CJ, Singer KP, Day R (1999) Assessment of combined movements of the lumbar spine in asymptomatic and low back pain subjects using a three-dimensional electromagnetic tracking system. Manual Therapy 4: 94-99

Abstract

Combined movement examination (CME) is used by physiotherapists to assess and treat patients with low back pain (LBP). However, this method has not been subjected to quantitative assessment. The purpose of this study was to discover if CME of the lumbar spine could be measured with acceptable intra-examiner reliability and to make a preliminary investigation of the effect of LBP on the results of CME.

Combined movement examination of the human thoracolumbar spine was measured using a three-dimensional electromagnetic goniometer (3SPACE®FastrakTMPolhemus, Colchester, Vermont, USA). 1. Intra-examiner reliability of CME was evaluated using a test-retest design; examination was repeated in 23 subjects without LBP and 16 with LBP. 2. A sample of 31 subjects without LBP and 23 subjects with LBP underwent CME, which involved measuring right and left sideflexion in the flexed, neutral and extended position. Pearson's r and the intraclass correlation coefficient for all variables ranged from 0.79 to 0.93 (P<0.05).A MANOVA test (P<0.05), comparing the combined effects of the two variables for each position, was used to test for a difference between the positions attained by the subjects with LBP and those without.

Generally LBP subjects showed smaller ranges of movement than those without LBP. Each position was recorded as a degree of rotation around the x-axis (flexion/extension) and around the y-axis (left and right sideflexion).

CME can be carried out with acceptable intra-examiner reliability; preliminary evidence is presented concerning the effectiveness of CME in identifying reduced spinal movement in LBP subjects.

Goh S, Price RI, Leedman P, Singer KP (1999) Age - independent correlation of optically determined thoracic kyphosis with lumbar spine bone mineral density. Journal of Musculoskeletal Research. 4: 267 - 274

Abstract

The thoracic spine is susceptible to age-related increases in the sagittal curve, a process which is accentuated in osteoporosis. Previous studies have demonstrated an association between low vertebral bone mineral density (BMD) and accentuation of kyphosis. However, concerns of ionising radiation associated with radiographic evaluation of osteoporotic fracture risks creates a demand for alternative non-invasive detection methods. Back shape, and in particular the thoracic kyphosis, may act as a surrogate for bone density and complement methods of screening individuals for osteoporosis or monitoring progression. The aim of this prospective study was to establish the statistical association of mean lumbar spine BMD and the age-independent BMD Z-score with kyphosis, measured from non-invasive, rasterstereographic analysis of back shape.

Back shape imaging of 42 females was performed following routine lumbar bone densitometry using dual energy X-ray absorptiometry. Kyphosis parameters derived from an optical back shape imaging system were correlated, using simple linear regression models, against mean lumbar BMD and BMD Z-scores.

Moderate associations were noted between lumbar BMD and thoracic kyphosis (r = 0.63 to 0.71, p < 0.0001). The trend was still evident when correlating kyphosis against BMD Z-scores (r = 0.57 to 0.68, p < 0.0001). These data confirm earlier studies comparing radiographic indices of thoracic curvature with vertebral BMD, and suggest potential application of non-invasive back shape imaging to assist in the screening of individuals at risk for spinal osteoporosis, particularly in younger populations.

Goh S, Price RI, Leedman P, Singer KP (1999) Rasterstereographic analysis of the thoracic sagittal curvature:A reliability study. Journal of Musculoskeletal Research. 4: 137 - 142

Abstract

Limitations associated with radiological evaluation of spinal curvature have resulted in the increased application of non-invasive optical imaging systems to define various shape parameters of the spine. There is little information describing the reliability of the thoracic spine upright posture measured using these imaging systems. The objective of this study was to examine the reliability of thoracic kyphosis measurement from non-invasive back surface analysis.

Repeated imaging of back shape was performed in 10 volunteers of widely different ages (range 19-64 years), and in a back phantom, utilising the Jenoptik Formetric video rasterstereography imaging system. Coefficients of variation (CV) for five repeated measurements of the subjects ranged from 2.4% to 3.0% for the kyphosis parameters measured. The reproducible nature of derived angles was further reflected by low standard deviation values (1.2° to 2.0°). Inter-trial CV values for repeated imaging of the back phantom ranged from 0.4% to 1.3%. High intraclass correlation coefficients were noted for all measurements (0.98 to 0.99). Consistent results were demonstrated across the varying age cohorts.

The reliability of rasterstereographic evaluation of thoracic kyphosis is largely influenced by the variability in subject posture, with minimal errors arising from internal system inaccuracies. These results confirm the utility of rasterstereographic back shape imaging in the detection of relatively small curve changes and hence the potential clinical role in monitoring kyphosis progression.

Goh S, Price RI, Leedman P, Singer KP (1999) The relative influence of vertebral body and intervertebral disc shape on thoracic kyphosis. Clinical Biomechanics 14: 439 - 448

Abstract

Objective

The aim of this study was to quantify the morphology or shape of thoracic vertebral bodies and intervertebral discs, and to examine the ex-vivo association of thoracic kyphosis with these shape parameters.

Design

A quantitative, retrospective study design was applied to define vertebral body and disc influences on thoracic kyphosis. Background. Age-related progression of thoracic kyphosis is a well defined process that is influenced by the morphology of vertebral bodies. However, little is known about the contribution of intervertebral disc shape to the thoracic curvature.

Methods

Vertebral and disc morphology, as represented by antero-posterior height ratios, were quantified in 93 lateral spine radiographs and mid-sagittal computed tomography films of ex-vivo spines. Kyphosis was indicated by the Cobb angle. Linear and stepwise regression were applied to examine relationships for cumulative (T1-T12) and regional (T4-T9) analyses.

Results

Vertebral morphology was highly predictive of thoracic curvature, while a poorer association was noted for disc morphology. The combined influence of both accounted for >85% of the variability in kyphosis. There was a trend for a more pronounced anterior wedge configuration of the mid-thoracic vertebral bodies and discs. Higher associations between variables were also noted in this region.

Conclusions

The normal kyphosis of the thoracic spine reflects the morphological adaptation of both the vertebral bodies and intervertebral discs.

This study contributes new data on the thoracic spine, particularly the characteristics of thoracic discs and their contribution to kyphosis genesis. Future directions for morphology studies should encompass more detailed examination of the thoracic discs and greater emphasis on the mid thoracic segments, considering the prevalence of osteoporosis related fractures and subsequent deformity at these levels.

Singer KP, Edmondston SJ, Zusman M, Allison GT (1999) Manual therapy in Australia. Journal of the Japanese Physical Therapy Association 16: 266 - 273

Abstract

The major emphasis of Manual Therapy courses in Australia is the evaluation and treatment of disorders of the musculoskeletal system, both peripheral and spinal. Given the urgency of structuring courses around available evidence, many programs have implemented best-practice models to their patient examination and diagnosis. This process includes clinical evaluation, manual examination, and interpretation of radiological and medical diagnostic procedures. Course units are structured to facilitate an integration of biomedical knowledge with clinical practice. A major emphasis is on the identification of the primary source of pain and dysfunction through detailed physical examination and formation of diagnostic hypotheses.

Several programs in Australia provide postgraduate training in Manual Therapy. The majority of courses are recognised as providing entry to the Manipulative Physiotherapy Association of Australia [MPAA], an organisation which provides policy, planning, and continuing education programs for its members. The MPAA is a founding member of the International Federation of manual Therapists [IFOMT] and will host the next major scientific conference of IFOMT in November 2000, Perth, Western Australia.

A variety of programs are offered, including clinical [professional] Masters, postgraduate diploma or certificate levels. These are typically, three, two semesters, respectively, or shorter in the case of Certificate programs. Courses typically review muscuoloskeletal anatomy, biomechanics, pathology, pain physiology, specialised training in manual therapy techniques, along with clinical assessment and reasoning skills within the context of supervised clinical practice. Theoretical and clinical examinations must be completed to satisfy requirements for the qualifications.

Advanced specialisation in Manipulative Physiotherapy is available through the College of Physiotherapy in Australia, which requires a high level of clinical performance, assessment by peers and a dissertation. This process recognises graduates with the title: Specialist Manipulative Physiotherapist.

Increasingly, Manual Therapists are undertaking supervised clinical and fundamental science research, often as part of their study. Research projects may be a requirement within some courses to assist graduates in understanding the principles and practice of sound clinical research. The strong commitment to this process of improving evidence based practice is highlighted by the fact that in 1998 over fifty percent of papers published in the new journal, Manual Therapy, were submitted from Australia.

Edmondston SJ, Valente B, Price RI, Singer KP (1999) Measurement of thoracolumbar vertebral body heights: ex - vivo comparisons between morphometric x - ray absorptiometry, morphometric radiography and direct measurements. Osteoporosis International 10: 7 - 13.

Abstract

Edmondston SJ, Allison GT, Althorpe BM, McConnell DR and Samuel KK (1999) Comparison of thoracic spine and ribcage stiffness: Investigation of the normal response. Manual Therapy 4: 157 - 162

Abstract