Omt Dagen 17 Oktober 2019 I Stockholm

ORTOPEDISK MANUELL TERAPI MANUALEN fysioterapeuter i forskning och praktik

NR 3 | 2019

OMT DAGEN 17 OKTOBER 2019 I STOCKHOLM

REFERAT FRÅN WCPT- KONGRESSEN I GENÈVE

SIMON WIDH VINNARE AV POSTERPRESENTATION VID OMT-KONGRESSEN 2019 EVENEMANG/KONGRESSER Datum Ort ÖVRIGA KURSER Shoulder rehabilitation med Ann Cools 17-18 januari 2020 Stockholm Klinisk resonemang - Praktisk inriktad kurs om smärta, funktion och motorisk kontroll Kinesiologi Hands-on A introduktion nedre och övre extremitet 10-10 juni 2019 Stockholm Hands-on C repetition och examen 12-13 juni 2019 Stockholm OMT-UTBILDNING Datum Ort Hands-on B fördjupningskurs nedre extremitet 26-27 september 2019 Stockholm (OMT 1-kurser för leg. fysioterapeuter och fysioterapistudenter termin 6) Hands-on B fördjupningskurs övre extremitet 12-13 november 2019 Stockholm OMT 1 Övre 28-30 aug, 19-20 sep 10-11 okt 2019 Västerås Hands-on A introduktion nedre och övre extremitet 5-6 december 2019 Stockholm OMT 1 Övre 18-20 sep, 17-18 okt, 14-15 nov 2019 Lund Hands-on MSK kurs scanning av barn 7 december 2019 Stockholm OMT 1 Övre 25-27 okt, 22-23 nov, 6-7 dec 2019 Stockholm Hands-on Sweden grundkurs inom MSK injektioner 25 september 2019 Stockholm OMT 1 Nedre 6-8 sept, 12-13 okt och 9-10 nov 2019 Umeå med genomlysning med ultraljud OMT 1 Nedre 7-9 okt, 4-5 nov, 2-3 dec 2019 Göteborg

OMT 1 Nedre och Övre sep - dec 2019 Haninge Muskuloskeletal Ultraljudsdiagnostik(www.ultraljudsdiagnostik.info) OMT 2 Start 29 aug 2019 Lund Ultraljudskurser OMT 3 Start jan 2020 Göteborg Repetition och examenskurs 5-6 september 2019 Linköping Info samt anmälan av ovan OMT-kurser till aktuell lärare, se www.OMTsweden.se! Klinisk Neurodynamik Klinisk Neurodynamik - Nedre 10-11 oktober 2019 Stockholm

Manipulationskurs Manipulationskurs (High Velocity Thrust Technics) 3-4 oktober & Stockholm 25-26 november Kinetic Control Kurs i rörelskontroll & koordination rund ländrygg & höft 30-31 augusti 2019 Stockholm Kurs i rörelsekontroll & koordination runt nacke & skuldra 11-12 oktober 2019 Stockholm Flexibility for movement efficiency and movement health 16-19 maj 2019 Stockholm

På god FOT mot framtiden- biomekaniska och kliniska perspektiv

Under Fysioterapi 2019 anordnas en utbildningsdag fredagen den 25 oktober med tema: På god FOT mot framtiden- biomekaniska och kliniska perspektiv. Utbild- ningsdagen vänder sig till alla som är intresserade av fotens funktion och dysfunktion och kommer att erbjuda ett kliniskt perspektiv på undersökning och behandling samt funktionell rörelseanalys. Arrangörer är sektionerna för OMT, Fysisk aktivitet och Idrottsmedicin, MDT och OK. Anmälan och mer information om utbildningsdagen finns på förbundets hemsida Fysioterapi 2019.

James Moore är en av Storbritanniens ledande Fysioterapeuter och en mycket upp- skattad föreläsare. Han är ansvarig fysioterapeut för Olympisk friidrott i Storbritannien, terapeutiskt ledare för Londons Nationella prestationscenter samt konsulterande fysioterapeut för Rugby Football Union. James har arbetat med professionella och olympiska idrottare i Storbritannien, USA och Australien med allt ifrån friidrottare, rugby, fotboll, amerikansk fotboll, baseboll och bodybuilding. omt sektionen

Sammanfattning av det senaste decenniet

Tack Erik för inviten att skriva ledar- att utveckla förbundets specialist- en i detta nummer. Det är nu drygt kompetens 2007–2008, resten är 10 år sedan våren 2009 då jag sist historia. Hade det inte varit för Peter skrev en ledare i Manualen så jag är i spetsen med härliga kollegor (Inger, lite ”ringrostig”. Då hade jag varit Ulrik, Tommy, Lars m.fl.) på LTU... ordförande elva år, under två perio- #trägenvinner. der, 1995–2001 och 2004–2009. I mina ledare brukade jag samman- Efter 201 års ”namntjafs” inom pro- fatta ”dagsläget” och berätta vad som fessionen som eskalerade på nytt var på G. Vad har då hänt av vikt någon gång på 1980-talet samt ett under det senaste decenniet? enligt mitt synsätt ”oriktigt” under- byggt underlag från förbundet beslu- Det största som utan jämförelse hänt tade regeringen om namnbyte från LEDAREN | Ragnar Faleij är att det på Luleå Tekniska Univer- sjukgymnast till fysioterapeut den sitet sedan 2012 går ett program första januari 2014. På förbundets effekter som i många fall är överlägs- kallat ”Master fysioterapi, inriktning hemsida kan man läsa att fem år sena många former av behandling och Ortopedisk Manuell Terapi”. Pro- nare i januari 2019 fanns det 7 030 kirurgi när det utvärderas inom med- grammet går på halvfart över fyra år personer som har legitimation med icinsk vetenskap. Har du inte läst och uppfyller alla utbildningskrav yrkestiteln fysioterapeut. Av dessa Anders Ottosons avhandling från (OMT steg 3) från sektionen samt har 3 959 bytt titel och tidigare haft 2005 ”Sjukgymnasten, var tog han den internationella organisation IF- legitimation som sjukgymnast. Enligt vägen?” som beskriver vår professi- OMPT där Sverige har varit medlem Socialstyrelsen finns det totalt 15 ons uppgång och fall under perioden sedan 1982. Att OMT-utbildningen i 592 legitimerade fysioterapeuter/ 1813–1934 så gör det direkt, du får Sverige uppfyller kraven från IFOM- sjukgymnaster. Det hävdades av för- en helt annan känsla och stolthet för PT är en stor fördel, inte bara ur kva- bundet och andra som var för namn- vår profession... litetssynpunkt, men för de fysiotera- bytet att majoriteten av landets sjuk- #sjukgymnasterharhafträtthelatiden. peuter med OMT-examen som vill gymnaster var FÖR ett namnbyte Jag måste nämna något om det fak- bege sig ut i världen och jobba i ett men trots det har bara 25% bytt yr- tum att ”manuell terapi” under sena- annat ”medlemsland” inom IFOMPT. kestitel idag, tycker den siffran talar re år nästan har blivit ett ”skällsord” Där kan de efter viss prövning få för sig själv. I Sverige finns det när- på sociala medier där det uppstått samma status som i Sverige. Sektio- mare 50 olika titlar som innehåller någon form av konstlat motsatsför- nen hade jobbat med frågan om en ordet terapeut, men bara en sjuk- hållande med manuell terapi i all- universitetsutbildning under hela min gymnast, nu är vi ”en i mängden mänhet på ena sidan och ”träning, tid som ordförande och vi hade sam- terapeuter” i stället för unika sjuk- idrottsmedicin, evidensbaserad kun- arbete med flera olika universitet, gymnaster. Vad kunde vara finare än skap, Pain Neuroscience Education som mest ledde det till ett magister- att ”bota sjukdomar med gymnastik (PNE), you name it på andra sidan. program på KI som lades ned efter (träning/fysik aktivitet)” vilket nam- Jag har väldigt svårt att känna igen några år. Jag träffade Peter Michael- net sjukgymnast står för. Speciellt nu mig i den bild som målas upp då allt son, som idag är biträdande professor när FYSS och all annan forskning om ingår i min bild av OMT. Mitt råd till på LTU, när vi satt i en utredning för fysik aktivitet och träning visar på

Manualen är en medlemstidning som ges ut fyra nummer per år. OMT sektionen ger ut Manualen i samarbete med sektionerna för Mekanisk Diagnostik och Terapi, Ortopedisk Kirurgisk rehabilitering och Fysisk aktivitet och idrottsmedicin vissa nummer. Sektionerna arbetar och forskar kring undersökning, behandling och förebyggande av besvär i leder, muskler och nerver i nacke, rygg och extremiteter.

MANUALEN 3 | 2019 3 Ansvarig utgivare

Lina Wallensten Bästa poster på OMT-kongressen 2019...... 6 Redaktör Skuldra och armbåge: framsteg vid Kristian Larsson ([email protected]) undersökning och hur vi ska behandla...... 7 Annonsansvariga Five good reasons to be disappointed with Helen Bäckstedt ([email protected]) randomized trials...... 9 Diagnostic accuracy and validity of three OMT-sektionens styrelse manual examination tests to identify alar ligament lesions: results of a blinded case- Ordförande: Erik Nexborn ([email protected]) control study...... 13 Kassör: Christina Matson ([email protected]) Sekreterare: Cindy Ejneborn ([email protected]) AU IFOMPT/ lärarrådet: Ingela Lundholm ([email protected]) AU Manualen: Kristian Larsson ([email protected]) Hemsida/webredaktör: Helen Bäckstedt ([email protected]) AU Externa kurser: Benjamin Zairi ([email protected]) Ledamot/ kongressansvarig: Christoffer Akbas ([email protected]) Ledamot/ vice ordförande: Kari Huseth ([email protected]) Valberedning: Henrik Olsson ([email protected])

Vill du lämna bidrag till tidningen, kontakta redaktören. Redaktionen förbehåller sig rätten att korta i manus. För insänt bild- och textmaterial ansvaras ej.

Nr Manusstopp Ut i vecka Bild framsida: 4/2019 14/11 v.49 Diane Lee omt sektionen

”Frågan är då varifrån alla problem med långvarig ryggvärk kommer?”

alla som blir ”stressade av allt snack”, ten har ”välfungerande” copingstrate- internationella lärarföreningen Kal- ta det med en nypa salt men fortsätt gier. En bedömning av patientens tenborn-Evjenth OMT som för öv- lyssna och diskutera samt ifrågasätt, tilltro till den egna förmågan att han- rigt hade en fantastisk konferens i inte minst dig själv! Sist jag skrev tera de aktuella ryggbesvären bör USA i juni detta år. Jag har som ledaren i Manualen Nr 1/2009 tala- därför ALLTID finnas med TIDIGT medförfattare publicerat några veten- de jag om att ”Akut lumbago kan ha i bedömningen. DÄREFTER lägger skapliga artiklar och tillsammans många orsaker”. Jag talade om preva- man upp en behandlingsplan tillsam- med Maria Klässbo skrivit ett kapitel lens och kostnader för ”ont i ryggen”. mans med patienten. OMT är det om höftleden i boken ” Motorisk Vidare hur akut ryggvärk anses själv- internationella fysioterapeutiska spe- kontroll och inlärning - Med inrikt- läka, vilket inte stämmer enligt evi- cialistområdet inom rörelsesystemet, ning på muskuloskeletal rehabilite- densen, och frågan är då varifrån alla inte ”bara manuell behandling” i or- ring” som kom ut 2019. Har du inte problem med långvarig ryggvärk dets sämsta bemärkelse. OMT-sek- boken så köp den, en ”kioskvältare” kommer? Jag nämnde att omhänder- tionen står för kontinuerlig kompe- med assisterande professor Ulrik Rö- tagandet måste förbättras och vikten tensutveckling inom ett både brett ijezon på LTU som editor. Decenniet av ett kliniskt resonemang med ute- och djupt specialistområde som för har varit OK, trots allt, skall bli kul slutande av röda flaggor och en mig är lika med grunderna i fysiote- att blicka tillbaka från 2029... #all- grundlig anamnes är A och O. Jag rapi. #individuelltutformadbehand- tidstudentiblandlärare. tog upp att vi från vetenskaplig evi- ling, #patientenicentrum, #effektiv- dens känner till att psykosociala risk- manuellbehandling, alltidaktivo- Fortsätt att reflektera över vad du gör faktorer spelar större roll än andra chiblandpassivbehandling. i det dagliga arbetet och jobba på din individuella riskfaktorer och därför kontinuerliga kompetensutveckling, måste vi lära oss att känna igen en Vad har jag då själv pysslat med de sektionen finns där som ditt stöd, det person som är i farozonen för att senaste 10 åren? Jag har jobbat kli- lönar sig både för dig själv och dina utveckla långvariga ryggbesvär. Nå- niskt med patienter och som lärare patienter... #väldensbästajobb! inom sektionen. Jag har undervisat gon form av screening av gula flagor Ragnar Faleij bör därför alltid finnas med då vi internationellt, på OMT-mastern i Luleå samt på min klinik Medfit. Jag Leg. sjukgymnast, specialist OMT annars inte har en chans att veta vad [email protected] den aktuella patienten tänker och har varit representant för sektionen tror om sin ryggvärk samt om patien- inom IFOMPT fram till 2016 och är sedan 2013 vice ordförande i den

MANUALEN 3 | 2019 5 omt sektionen Bästa poster på OMT-kongressen 2019

Simon Widhs poster har titeln ”Huvudvärk vid koniska whiplashrelaterade besvär” Abstractdetaljer Introduktion: Trots att huvudvärk är vanligt efter Whiplash- Associated Disorders (WAD), finns ingen konsensus avseende rehabilitering. Syfte: Syftet med denna studie var att undersöka effekten på huvudvärk av nackspecifik träning med (NSEB) eller utan (NSE) beteendeinriktad intervention jämfört med Fysisk Aktivitet på Recept (FaR) hos individer med kronisk WAD. Ett annat syfte var att undersöka faktorer som påverkar självskattad huvudvärk. Metod: Studiens är en subgruppsanalys av en prospektiv ran- domiserad multicenterstudie där individerna randomi- serades till tre olika interventioner; NSE, NSEB eller FaR. Deltagare (n=203) med kronisk WAD grad 2 och 3 samt huvudvärk inkluderades (137 (67,5%) kvinnor, medelålder 40 år (SD 11,6)). Frekvens och intensitet av huvudvärk registrerades med huvud- värksfrågan i Neck Disability Index (NDI-HV) som huvudutfallsmått. Mätningar utfördes före behandling samt efter 3, 6, 12 månader. Resultat: NSEB visade signifikant skillnad jämfört med NSE (p=0,01) samt FaR (p=0,003) enligt NDI-HV vid 12 Simon Widhs poster utsågs till Bästa poster på OMT- men ej vid 3 och 6 månader. Det fanns även signifi- kongressen 2019. Priset utsågs av en jury bestående av kant skillnad mellan NSEB (p=0,06) och NSE FoU inom OMT-sektionen och med extern bedömning (p=0,002) jämfört med FaR vid 12 månader, men ej av docent Annelie Gutke, Göteborgs Universitet. vid 3 eller 6 månader. För övriga variabler sågs ingen signifikant gruppskillnad. NDI-HV korrelerade med kön (r=0,22, p=0,001), nackstelhet (r=0,21, p=0,003), yrsel/ostadighet (r=0,32, p=<0,001) samt muskeluthållighet i flexion (r=-0,34, p=<0,001). Konklusion: Nackspecifik träning påvisades kunna vara en viktig del i behandlingen mot huvudvärk vid kronisk whiplash vid 12 månaders uppföljning, där det verkar finnas ett stort värde i att lägga till beteendeinriktad behandling. Kön, nackstelhet, yrsel/ostadighet samt nackmuskeluthållighet verkar vara faktorer som korre- lerar till självupplevd huvudvärk.

6 MANUALEN 3 | 2019 omt sektionen Symposium Skuldra och armbåge: framsteg vid under- sökning och hur vi ska behandla

Jeremy Lewis frågeformulär, bilddiagnostik, diagnos- speciellt utåtrotation. Man antar att inledde sympo- tiska injektioner, EMG, nervkonduk- det är en kronisk inflammation och siet med att be- tion, blodtester, ortopediska tester, kontrakturer i kapsuloligamentära ap- rätta att skul- funktionell undersökning. Även VR paraten som är orsak till smärta och dersmärta är (virtual reality) har börjat användas nedsatt rörlighet. vanligt med pre- vid undersökning. ”Muskelspasm” är vanligt vid smärt- valens på 70% En studie visar att det finns en korrela- samma muskuloskelettala dysfunktio- under en livstid. Jeremy Lewis tion mellan nedsatt cervikal motorkon- ner. Glenohumerala ledkapseln är för- Mellan 21-50% troll och skuldersmärta hos handbolls- stärkt av rotatorkuffens senor till en blir helt återställda efter 6 månader spelare (Asker, Ravnager et al, 2014, tight kapsel. Med tanke på den funk- medan så många som 40-54% har JOSPT). tionella anatomin så är muskeldys- besvär efter 1-3 år. funktion en avgörande faktor till all Vi vet inte orsaken till besvären eller Vilka blir bra och varför? skulderdysfunktion. bästa sättet att behandla. Det verkar Det finns en förväntan hos patienter som ett brett tillvägagångssätt kan vara Karen ville studera hur muskelförsva- med besvär inom det muskuloskeletta- rätt väg att gå. ret påverkar ROM vid frozen shoulder. la området att man ska bli smärtfri till Hon undersökte passiv abduktion och skillnad från astma, högt blodtryck Fyra föreläsare bidrog med var sin del i passiv utåtrotation hos patienter i sam- och diabetes där det är accepterat att forskningen om det här området. band med att dessa skulle göra en kap- tillstånden är mer kroniska. Professor Karen sulär release operation. Hon såg en Det har visat sig att psykosociala fak- Ginns, Austra- betydligt ökad rörlighet i abduktion torer är större prediktorer än fysiska lien, presenta- och utåtrotation. faktorer som rörlighet och styrka när tion, handlade Det kan tolkas som att smärta och det gäller patientens återhämtning om påverkan av nedsatt rörlighet kan bero av muskel- (Chester, Jerosch-Herold, Lewis, muskelförsvar försvar hos patienter med diagnosen Shepstone, 2016, BJSM). Self-efficacy som orsak till frozen shoulder. påverkar. De som tror att de ska bli smärta vid Karen Ginn bättre blir det och vice versa. Andra frozen shoulder. Ann Cools, Bel- faktorer är utbildningsnivå, komorbidi- Patogenesen är okänd och diagnosiskt gien, förklarade tet och symtomduration. test saknas. Diagnosen baseras klinisk varför lagom undersökning och även ibland på belastning är Det finns en mängd olika sätt att un- radiologisk undersökning. Det är ingen viktigare än dersöka skuldran med: olika sätt att degenerativ ledsjukdom men visar exakt vilken mäta den nedsatta funktionen (ROM, aktiv och passiv rörelseinskränkning, rörelse vi gör styrka, smärta, hållning), funktionella med tanke på Ann Cools belastningen på senan och vad senan tål. Det finns ingen konsensus över vilket tillvägagångssätt som är bäst: koncent- riska, excentriska, isometriska övning- ar, antal set, repetitioner, hur ofta etc. Ann gav exempel på övningar: För att avlasta rotatorcuffen kan man rulla boll på brits eller vägg på olika sätt. För att belasta rotatorcuffen kan man använda hantlar och ta ut svängarna lite mer. Hur mäta? En generell regel när det gäller träning Where are the symptoms coming from?

MANUALEN 3 | 2019 7 omt sektionen Foto: Jesper Aggergaard, Unsplash

”Rehabiliteringen bör vara så aktiv som möjligt och innehålla utbildning”

vid senrelaterad muskuloskelettal vara medveten om att förändringar Bill Vincenzino smärta är att anpassad belastning är sker centralt och kan ge ökad smärtnivå, pratade om en viktigare än vilken typ av belastning (central sensitisering), och förändrad pragmatisk evi- som används. Det finns olika sätt att ledkontroll och muskelkoordination, densbaserad försöka mäta belastningen vid träning: (förändringar i motorkortex). informativ app- EMG-aktiviteten i muskeln, biomeka- roach vid lateral Då vi möter dessa patienter är det bra niska belastningen på leden, ledrörel- armbågstendino- med ett brett tillvägagångssätt i under- sen, kompressionskrafter på leden. pati. sökning och rehabilitering. Förutom Bill Vincenzino Edwards et al (JOSPT 2017) har gjort den vanliga undersökningen med som Armbågssmärta en systematisk sammanfattning av tester, hållning, mobilitet, neurodyna- hos läkare behandlas med att avvakta emg-aktiviteten vid olika övningar hos mik, styrka och motorkontroll också åtgärd, kortisoninjektion, fysioterapi normala axlar. Där kan man se vilka ha en global approach. Det betyder att eller kombinera det två sistnämnda. övningar som kan tänkas vara bra titta på rörelsekvalitén, hur den utförs Kortisoninjektion ger bäst effekt på beroende på hur mycket eller lite som och förändrar smärtan vid korrektion, kort sikt (en månad) medan fysiotera- man vill att en specifik muskel ska beakta oro, smärtundvikande, kata- pi ger något bättre effekt än att inte belastas. stroftankar, central sensitisering, kolla göra någonting efter ett år. Sämre ef- Jean-Sébastien arbetsplats och idrottsaktiviteter, akti- fekt avseende injektion efter ett år. Ska Roy, Canada, vitetsnivå, sömn, sinnesstämning, vi göra något eller bara avvakta? pratade om stresshantering. En studie visar förändrad muskelakti- reorganisation Rehabiliteringen bör vara så aktiv som vitet också på motsatt arm vid unilate- i hjärnan vid möjligt och innehålla utbildning: att ral lateral armbågssmärta (Heals et al kronisk smärta vara aktiv, förklaringsmodell till ska- 2015). Detta kan tyda på en central i skuldra och dan och dess läkning, copingstrategier, påverkan också vid dessa tillstånd. armbåge. smärtfysiologi, och övningar: senso- Jean-Sébastien Roy / Refererat av Det är viktigt motorisk träning, successivt stegrad Christina Matson att tänka på att inte bara fokusera på träning, mobilisering/stretch endast nocicoceptiva signaler som kommer vid behov, minimera passiva tekniker. de från perifera receptorer utan också

8 MANUALEN 3 | 2019 omt sektionen

Five good reasons to be disappointed with randomized trials

Background Reason Two: The Marginal Patient: Perhaps the most well-known limitation of an RCT is external validity. Randomized controlled trials (RCTs) are recognized External validity is the degree to which the conclusions to exhibit very high levels of evidence, representing in your study would hold for other persons in other a coveted position near the top of the evidence- places and at other times. In RCTs, there are unavoidable based pyramid [1]. Both authors of this editorial disparities between the study conditions and populations have been part of small to large-scale RCTs and in comparison to the conditions and populations in support the need for this form of research design. which the finding will be inferred [8]. A common assump- Yet, few things annoy us more than the deification tion is that the findings would be transferable to all that clinicians and selected researchers have given patient populations, treatment environments, and cul- to randomize controlled trials. Yes, RCTs are useful tures. This ‘It-works-somewhere’[9] concept is defined in testing the efficacy and effectiveness of interven- as: projected realism. tions between groups; essentially, identifying which In an effort to ‘control’ for confounding variables treatment intervention is superior between two or and increase study power, a homogenous sample of more unique groups [2]. Moreover, RCTs are neces- diagnostically uniform patients are included that may sary to reduce bias and confounding and are per- not represent the actual demographics and complex- ceived to yield causal inferences [3]. However (and ity in the clinic. These less simple patients are termed we can’t emphasize this enough), it is our impres- ‘the marginal patients’ because the average patient sion that few understand the noteworthy limitations may or may not respond to a given treatment [10–12]. of RCTs, and even fewer are able to extrapolate how Unfortunately, many of the requirements needed in these limitations influence clinical practice. Our an RCT to improve internal validity (and control for experiences with these misunderstandings have confounding bias) result in an artificial-like setting prompted us to outline some (trust us, there are that does not closely match a real-world environment more) of the limitations of RCTs, specifically those [13]. Despite the notable juxtaposition between exter- that might influence clinical practice in an orthope- nal and internal validity, many RCTs and observational dic setting. designs involving similar interventions and participants find similar results [14]. Because RCTs are Limitations often exceptionally expensive, authors have recommended different designs, alternative data sources, Reason One: Right Question-Wrong Design: A common and unique methodological approaches to identify response we hear is the belittling of a given study similar findings (at a reduced cost) [15]. finding because it didn’t involve an RCT. It is impera- Reason Three: Mixed Treatment Effect- Just because tive to understand that RCTs are a form of research one group reports better outcomes than another design and this design is not appropriate for all forms group in an RCT, it does not mean that the interven- of research needs. For example, diagnostic accuracy tion in the group with better outcomes works for all studies are best analyzed using a case-based, case- individuals in that group or future groups [13]. Yes, if control design. Rare diseases are best studied using one finds differences between two groups, the inter- case-control designs. If one is looking at predictive vention that is associated with an improved outcome analytics then a prospective cohort design is the may indeed have higher efficacy (for the group design of choice [2]. Looking for patterns and effects tested). Nevertheless, as most studies demonstrate, across different data sources?; a systematic review or some individuals in both groups improve whereas a meta-analysis is the design of choice. And although some individuals in both groups do not. An RCT an influential paper from 2004 called for better report- only functions to show whether more people ing of harms in RCTs [4,5], an RCT is not the most improved in one group versus the other, or ‘who’ appropriate study design to truly understand the pre- (which group) benefits. Why someone improved is valence of these adverse events [6]. An observational not a property of a RCT. case-cohort design will better reflect the population, To determine ‘why’ someone improves requires fl prevalence and downstream in uence of harms asso- a causal mediation design. Causal mediation analysis ciated with dedicated care processes [7]. identifies potential pathways that could explain why

MANUALEN 3 | 2019 9 omt sektionen

the outcomes were more effective with that interven- research participant) is tainted between clinician and tion [16]. Causal mediation analysis allows an under- research subject [26]. Lastly, contamination bias occurs standing of the roles of intermediate variables that lie when the members of one group in a trial receive the in the causal path between the treatment and outcome treatment or are exposed to the intervention that is variables, and allows the clinician to focus on both the provided to the other group. mediating and primary (intervention) variables with tar- To reinforce the influence of the Hawthorne effect and geted applications. Additionally, not all patients may be personal equipoise, we provide the following examples. appropriate to a given mix of interventions with similar First, provider, health services patterns, and comparison conditions. Thus, determining an effective treatment of profession are study foci that are particularly pre- mix may provide more clinically useful information as disposed to the Hawthorn effect. Although the studies opposed to a single treatment approach that demon- involve randomizing to control biases, clinician behaviors strates an effective average treatment effect [17–19]. are likely to change since they know they are being Sadly, although causal mediation designs are often sec- evaluated in a formal study. For example, if you are the ondary analyses within an RCT, an RCT in isolation does prescribing physician in a trial that is examining the nega- not provide that information. tive effects of opioids, you are likely going to prescribe Reason Four: Treatment Fidelity: Intervention fidelity fewer opioids. Personal equipoise toward a particular refers to the reliability and validity of the clinical intervention will unconsciously cause an improve out- interventions that are used in the randomized trial come for the treatment of preference. For example, in [20]. In other words, fidelity reflects the applicability randomized trials where clinicians preferred a particular of the interventions for the condition of interest, treatment approach (despite being randomized between whether the interventions are appropriately per- two groups), the preference influenced outcomes in formed (application, dosage, and intensity) and a way that supported their preference [27,28]. whether the interventions adequately represent how the intervention is performed in clinical practice. Interestingly, past studies have found that interven- Summary tion fidelity is consistently either poorly performed, Randomized controlled trials are useful in testing the poorly reported or both [21]. Unfortunately, because efficacy and effectiveness of interventions between of the costs associated with RCTs, fidelity is commonly groups [2]. Understanding their limitations is essential sacrificed. Even pragmatic randomized trials (trials before extrapolation to clinical practice. Other designed to test the effectiveness of the intervention research designs are needed to understand the diag- in a broad routine clinical practice) are guilty of lim- nosis, validity of outcomes, and other important ited fidelity in the application of behavioral or exer- research issues. Participants enrolled in RCTs may or cise-based interventions [20]. may not adequately represent the full population in Reason Five: Unmeasured Bias: The post-randomization which the study is designed to represent. Randomized experience is the period that immediately follows indivi- controlled trials evaluate the effects of treatment at duals’ consent and randomization to one of the treat- population levels and do not explain why the out- ment groups [22]. Randomization is used to reduce comes were more effective with that intervention errors, differences in groups, and confounding properties [9]. The care provided may or may not reflect what that are unforeseen. The post-randomization experience is appropriately provided in clinical practice. And (‘what happens after the randomization’) can also be lastly, a biased post-randomization experience is not a period in which bias may play a notable role. Outside protected by the initial randomization. Careful con- of fidelity and some of the aforementioned items, there trols are necessary at this phase of the trial as well. are five major considerations involving the post- randomization experience. The Hawthorn effect is a change in behavior of the research subjects, adminis- Disclosure statement trators, and clinicians in experimental or observational No potential conflict of interest was reported by the studies [23]. Patients hold certain beliefs and expecta- authors. tions regarding a treatment that have been shown to influence the outcomes [24]. If the allocated treatment group does not match the patients’ beliefs and expecta- References tions then the treatment effect is likely subdued. Personal [1] Murad MH, Asi N, Alsawas M, et al. New evidence equipoise exists when a clinician has no good basis for pyramid. BMJ Evidence Based Med. 2016;21(4). a choice between two or more care options or when one [2] Fritz JM, Cleland J. Effectiveness versus efficacy: more is truly uncertain about the overall benefit or harm than a debate over language. J Orthop Sports Phys ff Ther. 2003;33:163–165. o ered by the treatment to his/her patient [25]. Mode of [3] Deaton A, Cartwright N. Understanding and misun- administration bias exists when the method of outcomes derstanding randomized controlled trials. Soc Sci collection (how outcomes were collected from the Med. 2018;210:2–21.

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[4] CONSORT Group, Ioannidis JP, Evans SJ, Gøtzsche PC, [19] Birkmeyer JD, Reames BN, McCulloch P, et al. et al. Better reporting of harms in randomized trials: Understanding of regional variation in the use of an extension of the CONSORT statement. Ann Intern surgery. Lancet. 2013;382(9898):1121–1129. Med. 2004;141(10):781–788. [20] Cook CE, George SZ, Keefe F. Different interventions, [5] Chan AW, Tetzlaff JM, Altman DG, et al. SPIRIT 2013 same outcomes? Here are four good reasons. Br statement: defining standard protocol items for clin- J Sports Med. 2018;52(15):951–952. ical trials. Ann Inter Med. 2013;158(3):200–207. [21] Toomey E, Currie-Murphy L, Matthews J, et al. [6] Zorzela L, Golder S, Liu Y, et al. Quality of reporting in Implementation fidelity of physiotherapist-delivered systematic reviews of adverse events: systematic group education and exercise interventions to pro- review. BMJ. 2014;348:f7668. mote self-management in people with osteoarthritis [7] Checkoway H, Pearce N, Kriebel D. Selecting appro- and chronic low back pain: a rapid review part II. Man priate study designs to address specific research Ther. 2015;20:287–294. questions in occupational epidemiology. Occup [22] Choudhry NK. Randomized, Controlled Trials in Health Environ Med. 2007;64(9):633–638. Insurance Systems. N Engl J Med. 2017;377(10):957–964. [8] Pearl J. Challenging the hegemony of randomized [23] Sedgwick P, Greenwood N. Understanding the controlled trials: a commentary on Deaton and Hawthorne effect. BMJ. 2015;351:h4672. Cartwright. Soc Sci Med. 2018;210:60–62. [24] Harris J, Pedroza A, Jones GL. Predictors of pain and [9] Mulder R, Singh AB, Hamilton A, et al. The limitations function in patients with symptomatic, atraumatic of using randomised controlled trials as a basis for full-thickness rotator cuff tears: a time-zero analysis of developing treatment guidelines. Evid Based Ment a prospective patient cohort enrolled in a structured phy- Health. 2018;21(1):4–6. sical therapy program. Am J Sports Med. 2012;40 [10] McClellan M, McNeil BJ, Newhouse JP. Does more (2):359–366. intensive treatment of acute myocardial-infarction in [25] Cook C, Sheets C. Clinical equipoise and personal equi- the elderly reduce mortality - analysis using instru- poise: two necessary ingredients for reducing bias in mental variables. JAMA. 1994;272(11):859–866. manual therapy trials. J Man Manip Ther. 2011;19 [11] Brooks J, McClellan MM, Wong HS. The marginal benefits (1):55–57. of invasive treatments for acute myocardial infarction: [26] Cook C. Mode of administration bias. J Man Manip does insurance coverage matter? Inquiry. 2000;37 Ther. 2010;18(2):61–63. (1):75–90. [27] Cook C, Learman K, Showalter C, et al. Early use of thrust [12] Harris KM, Remler DK. Who is the marginal manipulation versus non-thrust manipulation: patient? Understanding instrumental variables esti- a randomized clinical trial. Man Ther. 2013;18(3):191–198. mates of treatment effects. Health Services Res. [28] Bishop MD, Bialosky JE, Penza CW, et al. The influence of 1998;33(5):1337–1360. clinical equipoise and patient preferences on outcomes [13] Gelman A, Loken E. The statistical crisis in science. Am of conservative manual interventions for spinal pain: an Scientist. 2004;102:460–465. experimental study. J Pain Res. 2017;10:965–972. [14] Ioannidis JPA. Randomized controlled trials: often flawed, mostly useless, clearly indispensable: Chad E. Cook a commentary on Deaton and Cartwright. Soc Sci [email protected] ,Department of Med. 2018;210:53–56. Orthopaedics, Duke University, Durham, NC, USA [15] Frieden TR. Evidence for Health Decision Making – Beyond Randomized, Controlled Trials. N Engl Duke MSK Group, Duke Clinical Research Institute, J Med. 2017;377(5):465–475. Durham, NC, USA [16] Rudolph KE, Goin DE, Paksarian D, et al. Causal med- [email protected] iation analysis with observational data: considerations and illustration examining mechanisms linking neigh- borhood poverty to adolescent substance use. Am Charles A. Thigpen J Epidemiol 2018. [Epub ahead of print]. ATI Physical Therapy, Department of Clinical [17] Bernstein J. Not the last word: choosing wisely. Clin Excellence, Greenville, SC, USA Orthop Relat Res. 2015;473(10):3091–3097. Arnold School of Public Health, Center for [18] McCulloch PM, Nagendran WB, Campbell A, et al. ff Strategies to reduce variation in the use of surgery. E ectiveness in Orthopedic, University of South Lancet. 2013;382(9898):1130–1139. Carolina, Greenville, SC, USA

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Diagnostic accuracy and validity of three manual examination tests to identify alar ligament lesions: results of a blinded case-control study Piekartz Harry Von a, Rakan Maloulb, Marisa Hoﬀmannc, Toby Hall d, Med Martin Ruche and Nicolaus Ballenbergerf

aDepartment of Physical Therapy and Rehabilitationscience, University of Applied Science Osnabrueck, Osnabrueck, Germany; bDepartment of Physical Therapy and Rehabilitation, University of Applied Science Osnabrück, Osnabrueck, Germany; cPrivatpraxis Schwerpunkte Manuelle Therapie Kiefer-/Kopf-/Gesichtsschmerz, Nieder-Olm, Germany; dSchool of Physiotherapy and Exercise Science, Curtin University, Perth, Australia; eDie Radiologen Weiterstadt Dr. Martin Ruch, Weiterstadt- D, Germany; fDepartment of Physical Therapy and Rehabilitationscience, University of Applied Science, Osnabrueck, Germany

ABSTRACT KEYWORDS Introduction: Tests to evaluate the integrity of the alar ligaments are important clinical tools Alar ligaments; clinical tests; for manual therapists, but there is limited research regarding their validity. validity – MRI Method: A single blinded examiner assessed alar ligament integrity using the lateral shear test (LST), rotation stress test (RST) and side-bending stress test (SBST) on a sample of convenience comprising 7 subjects with MRI confirmed alar ligament lesions and 11 healthy people. Alar ligament lesions were identified using both supine and high-field strength upright MRI. Results: The RST had a sensitivity of 80% and a specificity of 69.2%. The SBST and the LST both showed a sensitivity of 80% and a specificity of 76.9%. In cases where all three tests were positive, the specificity increased to 84.6%. Discussion: Tests of manual examination of alar ligament integrity have some diagnostic utility; however, these findings require further corroboration in a larger sample.

1. Introduction a cluster of tests, sensitivity ranged between 0.69 and 0.84 and specificity between 0.91 and 1.0. The positive predic- The alar ligaments are important stabilizers of the cervical tive value ranged between 0.93 and 1.0, while negative spine and may become damaged following trauma, predictive value was 0.8 [3]. hence require careful examination, particularly in patients The LST has good intrarater reliability (modified Kappa who present with neck-related problems with a history of 0.67). Preliminary support for the validity of this test has injury [1,2]. The gold standard for determining alar liga- been shown in a case report, correlating positive results ment damage is MRI [3,4] for which there is a growing on the LST and the SBST with X-ray imaging [12]. Further body of evidence supporting its use [5–7]. New technical evidence of validity was provided by Osmotherly et al. [1]. developments in MRI such as high-fidelity 3-T MRI [8] and In that study, the SBST had excellent inter-tester reliability improved protocols [9] provide better visualization of the while the RST inter-tester reliability was rated only as alar ligaments than previous MRI methods [8,10]. average. In the absence of MRI investigations, physiotherapists The process of validating diagnostic tests has been must perform specific tests to assess the integrity of alar subdivided into four phases [16]. Phases 1 and 2 investi- ligaments [1,3,11,12,4] if they suspect ligament injury. The gate the ability of a test to discriminate and correctly rational for these tests is on the one hand for diagnostic identify subjects with and without a verified diagnosis. purposes but more so in order to ensure safety during Phases 3 and 4 are evaluated in a clinical setting, where physical examination and treatment [2,13,14,15]. As with the diagnostic properties are evaluated in subjects who many manual examination procedures, the validity and are suspected of having the disease and whether imple- reliability of tests for alar ligament integrity have not been menting the test improves clinical outcomes. adequately investigated. Hence, it would appear that there is preliminary evi- A number of tests for evaluating alar ligament integrity dence for the validity of the alar ligament stress tests; have been described (Figure 1) including the side-bend- however, no study has investigated the reliability and ing stress test (SBST) [1,12], rotation stress test (RST) [10] validity of a battery of alar ligament stress tests in com- and the lateral shear test (LST) [11,12]. Reliability of the parison to MRI. Additionally, it is unclear whether different RST has been investigated with Kappa scores of 0.69–0.83, forms of MRI yield identical results. Therefore, the purpose with good validity when comparing manual examination of this study was (a) to assess the accuracy of detecting with MRI findings [3]. When this test was used as a part of lesions of the alar ligaments using three different

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Figure 1. Tests are performed for the left alar ligament. (a) Figure 1. (Continued.) Side-bending test in sitting. Evaluation of C2 rotation during upper cervical lateral flexion toward the right. The spinous process of C2 is palpated with one hand, while the upper cervical spine is laterally flexed to the right. The spinous process should move to the left. Lack of rotation would indicate a positive test; (b) rotation test in supine. The spinous process of C2 is fixed with one hand while the head is rotated to the right with the other hand. Range of rotation between the occiput and C2 should be approximately 20° to each side. Range greater than 20° indicates a positive test; (c) lateral shear test. The C2 vertebra is fixed on the left poster- olateral aspect with one hand while the occiput and C1 are translated to the left with the other hand. Translation is perpendicular to the neck. Any movement would indicate a positive test.

individual alar ligament tests (Figure 1), (b) to evaluate a Figure 1. (Continued.) cluster of all three tests compared to two different kinds of MRI scans and (c) to evaluate agreement in detecting well as asymptomatic healthy controls. Manual exam- alar ligament lesions between two different forms of MRI ination tests were performed by a blinded, experi- scan. enced manual therapist on the same day as MRI. High-field 3-T MRI scans were performed in sitting prior to the study commencement and a standard 2. Methods supine MRI carried out as part of the study using a In this single-blind case-controlled study conducted specialized cervical protocol in a radiology clinic in according to STARD protocols (Appendix 1), specific the greater area of Darmstadt, Germany. There is manual alar ligament tests were carried out on sub- evidence for validity of MRI in determining upper jects with MRI determined alar ligament lesions as cervical ligament damage in that high-field strength

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3-T MRI identifies a higher proportion of alar ligament history of WAD, or any form of headache. All subjects lesions in people with chronic whiplash-associated were checked for the inclusion and exclusion criteria disorder (WAD) when compared to a non-injured by the first examiner. population. Furthermore, an association was found between high-grade changes in the alar ligaments determined by MRI and disability [17]. In addition, 2.2. Study protocol MRI studies evaluating alar ligament integrity show After recruitment, by the first assessor, subjects were fair-to-moderate agreement in detecting high-signal informed about the study protocol and informed con- intensities in healthy subjects [10] and moderate-to- sent obtained. The participants were informed that good agreement in detecting lesions in people with the blinded (second) assessor should not receive any chronic WAD [18]. All scans were reviewed by an information about their health status so that blinding experienced radiologist, specialized in examination could be guaranteed. The included manual tests were of the craniocervical region, who was blind to the those most often implemented and mentioned in the subject group allocation. literature the SBST, the RST, and the LST (Figure 1). All tests were performed on both the left and right alar 2.1. Subjects, inclusion and exclusion criteria ligaments. Determination of a positive test is described in Figure 1. The examiner documented the Subjects were recruited from November 2016 to April test results on a form, which was given after each 2017 in a manner of convenience through advertise- subject to the first assessor. On the day of testing, fi ments seeking people with high- eld strength 3-T MRI each subject underwent a supine MRI which was fi con rmed alar ligament lesions diagnosed by a radiol- reviewed by a radiologist specialized in imaging the ogist associated with symptoms of upper cervical head and neck region. The radiologist was not instability. Volunteers were recruited from various phy- informed about the results of the clinical test results siotherapy, orthopedic and radiology clinics. Subjects from the second assessor. The data from the radiolo- were required to be able to tolerate manual examina- gist’s interpretation of the MRI images were collected tion procedures used in this study and were excluded if by the first assessor (Figure 2). The study was con- they were unable to undergo MRI. Additional exclusion ducted in accordance with the Helsinki guidelines and criteria included rheumatoid arthritis, Down’s syn- approved by the local ethics committee of the drome, Ehlers–Danlos syndrome, Klippel–Feil syndrome University of Applied Sciences Osnabrück (WiSO MS- and Pierre-Robin syndrome. In total, 15 people volun- MP-WS 1617-08). teered but 6 were subsequently found not to have an alar ligament lesion on MRI, and 1 had extreme dizziness in lying and another fear of manual examination 2.3. Examiner and training of the examiner preventing inclusion. Hence, seven subjects (aged 18 and 67 years; five male) were included who demon- The examiner carrying out alar ligament testing was both strated an alar ligament lesion on high-field strength 3- an experienced manual therapist (IFOMPT standard) with T MRI with a history of cervical trauma. more than 10 years of experience and postgraduate Eleven subjects (10 male, 1 female) were included training up to specialist level in the examination of the in the control group. These subjects had no complaint cervical spine. This examiner received an additional two of neck pain in the last 3 years, nor had a previous training sessions to review the alar ligament tests.

Volunteers with 3-T MRI confirmed alar ligament lesions (n= 7) and control group (n=11) recruited

Blinded 2nd assessor evaluates 3 clinical alar ligament tests

Images from supine MRI scan evaluated by blinded specialized radiologist

Data collection 1st assessor

Figure 2. A ﬂowchart of the study.

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2.4. MRI scanning the sum of single positive test results was presented through a receiver-operating characteristic curve. The The standard MRI scan was performed in supine with a optimal cutoff was assessed by maximizing the Youden cervical coil (GE Discovery 750 3 T with a 16ch HNS coil by Index. General Electric) as described in the literature [2,8]. Images were taken of all 11 healthy subjects as well as the 7 subjects with alar ligament damage. All scans were 4. Results carried out by a radiology assistant with 9-years clinical 4.1. Group characteristics experience. The scans were evaluated by the radiologist who was blind to the subjects group allocation. The scan No significant differences were found between groups protocol for MRI was specifically matched for the evalua- regarding gender (alar ligament group: male = 5, tion of the alar ligaments. Proton-weighted, coronal female = 2; control group: male: 10, female 1, p = 0.52), plane images, proton-weighted images in the transverse neck circumference (alar ligament group: mean 27.4 cm plane with fat saturation (fatsat), T1-weighted fast spin [5.4], control group mean: 39.1 cm [4.3], p = 0.51) and age echo (FSE) images in the transverse plane and T2- (alar ligament group: mean 50 [8.5], control group: mean weighted FSE images in the transverse plane were taken. 52.2 [8.4], p = 0.6). The agreement between standard supine and high- field strength upright MRI is shown in Table 1. Five out of 3. Statistical analysis seven subjects with lesions of the alar ligaments detected All collected data were analyzed by R (R core team, 2014). by standard supine MRI were found to be positive in the The sample size was based on a comparable study, where high-field strength upright MRI. This corresponds to a significant results were achieved with a group of 16 Cohen’s Kappa of 0.75, indicating high, yet not perfect participants [1]. T-tests and Fisher’s exact tests were agreement. In the control group, no alar ligament lesions used to determine statistical differences between the were found. group with alar ligament damage and the control Sensitivity, specificity, positive and negative likelihood group. A p-value less than 0.05 was considered as an ratios and the Youden Index of all three tests compared indication of a statistically significant result. Agreement to the high-field strength upright MRI are depicted in between the standard supine and high-field strength Table 2. The accuracy of the LST and the SBST was upright MRI was evaluated by Cohen’s Kappa. identical showing a sensitivity of 80% and a specificity Sensitivity, specificity, positive/negative likelihood ratios of 76.9%. The positive likelihood ratio was 3.46, the nega- and the Youden Index of all three tests were compared to tive likelihood ratio was 0.26, while the Youden Index both the high-field strength upright and standard supine amounted to 0.57. The RST achieved a sensitivity of MRI results through cross-classified tables. It was 80% and a specificity of 69.2%. Positive and negative assumed that all subjects in the control group, who did likelihood ratios were 2.6 and 0.29, respectively, and the not have a lesion in the standard supine MRI scans, would Youden Index amounted to 0.49. also have no lesion in the high-field strength MRI scan. The results of the sensitivity and specificity, positive/ Furthermore, we examined whether a combination of negative likelihood ratios and the Youden Index of all alar ligament manual examination tests would lead to three tests compared to the standard supine MRI are an improvement in sensitivity and specificity. Therefore, depicted in Table 2. Also here, the results of LST and the

Table 1. Manual testing versus standard MRI with specialized protocol. No alar ligament Alar ligament Positive likeli- Negative likeli- Youden lesion lesion Speciﬁcity Sensitivity hood ratio hood ratio Index Lateral shear test Intact 10 1 76.9% 80% 3.46 0.26 0.57 Not intact 3 4 Side-bending stress test Intact 10 1 76.9% 80% 3.46 0.26 0.57 Not intact 3 4 Rotational stress test Intact 9 1 69.2% 80% 2.6 0.29 0.49 Not intact 4 4

Table 2. Manual testing versus upright MRI. No alar liga- Alar ligament Negative likeli- Positive likeli- Youden ment lesion lesion Speciﬁcity Sensitivity hood ratio hood ratio Index Lateral shear test Intact 10 1 90.9% 85.7% 0.16 9.43 0.77 Not intact 1 6 Side-bending stress test Intact 10 1 90.9% 85.7% 0.16 9.43 0.77 Not intact 1 6 Rotational stress test Intact 9 1 81.8% 85.7% 0.17 4.71 0.68 Not intact 2 6 Sum of symptomatic tests >2 11 1 100% 85.7% 0.15 Inf 0.86 ≤2 06

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Figure 3. Receiver-operating curve of the cluster of all three alar ligament test results in comparison to the standard supine magnetic resonance imaging (with diagonal line for orientation).

SBST were identical showing a sensitivity of 85.7% and a 0.86. In comparison to high-field strength supine specificity of 90.9%. The positive likelihood ratio was MRI, the AUC amounted to 81%. The optimal cutoff 9.43 and the negative 0.16, respectively, and the for detecting an alar ligament lesion was greater Youden Index amounted to 0.76. The RST achieved a than two positive test results. The corresponding sensitivity of 85.7% and a specificity of 81.8%. Positive specificity and sensitivity were 80% and 84.5%, and negative likelihood ratios were 4.71 and 0.17, respectively. Positive and negative likelihood ratios respectively, and the Youden Index amounted to 0.68. were 5.19 and 0.24, respectively, and the Youden The results of the cluster of all three tests are Index amounted to 0.65. presented in Figures 3 and 4. In comparison to standard supine MRI, the area under the curve 5. Discussion (AUC) amounts to 93%. The optimal cutoff for detecting an alar ligament lesion was greater than In this early phase diagnostic case-control study, 18 two positive test results. The corresponding specifi- subjects (7 with alar ligament lesions) were tested city and sensitivity were 100% and 85.7%. Positive with 3 manual examination tests for alar ligament and negative likelihood ratios were infinity and 0.15, laxity and 2 different forms of MRI scan to determine respectively, and the Youden Index amounted to alar ligament integrity.

Figure 4. Receiver-operating curve of the cluster of all three alar ligament test results in comparison to high ﬁeld strength upright magnetic resonance imaging (with diagonal line for orientation).

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Depending on type of MRI (standard vs. upright), the specialized craniocervical protocol) to evaluate liga- sensitivity and specificity of the clinical test ranged ment injury in the upper cervical spine. Hence, it is between 80–85.7% and 69.2–90.9%, respectively. This not possible to say if one form is better than another. resulted in positive and negative likelihood ratios ran- High-field strength upright MRI is a relatively new ging from 2.6 to 9.41 and 0.15 to 0.26, respectively, imaging procedure which allows images to be taken indicating small-to-moderate clinical diagnostic value in different positions: supine, sitting or standing. according to recommended thresholds [19,20]. The Several studies demonstrate that MRI scans in supine values of the Youden Index ranged between 0.49 show different results than MRIs in a standing position and 0.77. [23,24]. When sitting, cervical spine structures experi- However, when using the three clinical tests as a ence three times greater load than lying. Accordingly, cluster with a threshold of more than two positive test this results in more strain to the cervical ligaments results, the sensitivity and specificity amounted to which might illuminate ligament injury [24,25]. This 85.7% and 100%, respectively (Youden Index of might explain why more subjects were found to have 0.86), with 17 out of 18 diagnoses classified correctly. alar ligament lesions with upright MRI than with stan- Only one patient with alar ligament rupture was fal- dard MRI. sely diagnosed as healthy. Likelihood ratios improved One participant (subject 5) who was rated negative to infinity (positive likelihood ratio) and 0.15 (negative in each manual examination test did not report a likelihood ratio) indicating moderate-to-excellent clin- history of WAD; however, his symptoms of upper ical diagnostic value. In general, a high positive like- cervical instability occurred after neck surgery which lihood ratio increases the probability of having the might have damaged the alar ligaments. This subject disease given a positive test and is important for had a radiologist confirmed alar ligament lesion deter- ‘ruling in’. It addresses to what extent a clinician can mined by high-field strength MRI scans. The manual be confident about the accuracy of a positive test therapist identified six of the seven symptomatic sub- result. In contrast, a low negative likelihood ratio jects through the specific alar ligament tests. In these decreases the probability of having the disease six cases, all three tests were positive. given a negative test result and is important for ‘rul- A combination of three manual examination tests ing out’. It addresses to what extent a clinician can be resulted in greater diagnostic accuracy and therefore confident about the accuracy of a negative test result. criterion validity. However, two positive tests provided In the special case of an infinity positive likelihood no additional diagnostic accuracy when compared to ratio, as found in our study, the probability of truly one positive test. Specificity, but not sensitivity having an alar ligament lesion increases to 100% after increased, when all three tests were positive. being tested positive by the cluster of clinical tests. Improvement in diagnostic accuracy through a com- For a given negative likelihood ratio of 0.15, the prob- bination of test results was also found for manual ability of truly having an alar ligament lesion after examination procedures for identifying a symptomatic being tested negatively decreases to approximately sacroiliac joint disorder [18]. 8% in our study. The specific manual examination tests used in this In all healthy subjects, no alar ligament lesions study seem to be capable of identifying alar ligament were found. In the seven subjects with a history of lesions. Hence in the clinical setting, three positive trauma who had alar ligament lesions demonstrated tests would be justification to refer to for further on high-field strength 3-T MRI undertaken prior to imaging using more specialized MRI. In addition, the study, only five were found to have the lesion three positive tests indicate caution in the use of on standard MRI in supine even with a specialized certain manual therapy procedures as well as vigorous craniocervical protocol. Of these seven subjects with activity. It might also indicate the need for manage- alar ligament lesions, six had all three manual exam- ment aimed at reducing the symptoms associated ination tests positive. All subjects in this group with upper cervical instability. complained of subjective features associated with It was assumed in this study that an alar ligament cervical instability on initial interview during the lesion seen on MRI would correlate with excessive recruitment (Table 3). None of the participants in mobility/instability on alar ligament stress testing. It the traumatic group had a diagnosis of alar liga- is possible that an MRI determined alar ligament ment damage prior to high-field strength MRI. This lesion is not always positive on alar ligament testing, would suggest that the diagnosis of an alar liga- but there is no evidence to confirm or refute this ment lesion remains challenging [5,8,21,22], unless possibility. At what point an MRI lesion becomes highly specialized MRI machines and protocols are clinically relevant in terms of instability requires followed. further investigation. However, we assume that a To the best of the authors’ knowledge, no study normal clinical test indicates sufficient ligament has compared different forms of MRI (high-field integrity to not warrant concern about upper cervical strength 3-T MRI and standard supine MRI with a instability.

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5.1. Limitations There are a number of limitations to this study. Even though we demonstrated in this case control study the ability of the tests (when used as a cluster) to clearly discriminate patients with and without alar ligament lesions, we cannot draw any conclusions about diagnostic properties of these tests for their clinical applicability due to the fact that we recruited subjects with extreme status of disease, namely conﬁrmed diseased in upper extremities, dysarthria, impaired cervical ROM, vertigo, impaired concentration ability impaired cervical ROM, vertigomovement and dysfunction eye activity, impaired concentration ability ROM, vertigo upper limb pain, vertigo, impairedROM, cervical visual disturbance, hearing disturbance impaired cervical ROM ROM, dizziness comparison to truly not diseased. Overestimation of the accuracy is likely. In future studies, the use of these tests in the clinical setting must be addressed by investigating their diagnostic ability 3 Y, 0 M Dorsal headache, paresthesia lower and 2 Y, 6 M Dorsal and ventral headache, eye pain, 6 Y, 6 M Right dorsal headache, impaired cervical 2 Y, 3 M Left side headache, left ear and eye pain, left Duration 30 Y, 0 M Whole body pain, body sweating during 10 Y, 0 M Bilateral dorsal headache, tinnitus right ear, 4 Y, 11 M Right dorsal headache, impaired cervical symptoms Localization and type of the symptoms in consecutive recruited subjects who are suspected of having alar ligament injury. This implies that all subjects would receive MRI and manual examination. This would have given a better understanding of the incidence of alar ligament lesions and also the diagnostic accuracy of manual examination and standard MRI. However, this

brosis would likely involve a very large number of parti- ﬁ cipants (although the incidence of alar ligament Supine MRT lesions has not been thoroughly investigated). Hence, the costs and time involved would likely not be feasible. Second, although the examiner

dense fracture was blind to subject allocation, all three manual Left alar ligament abnormality. Consolidated Bilateral alar ligament No alar ligament abnormality* Right alar ligament partial rupture No alar ligament abnormality* Left alar ligament partial rupture Right alar ligament attenuated examination tests were performed consecutively. This might have led to conﬁrmation bias if the ﬁrst test was positive, but there does not appear to be a way around this with such a small sample size. Third, there has been some question as to the veracity of MRI to identify ligament injury in the upper cervical spine [26]. Nonetheless, the liga- brosis

fi fi brosis, consolidated dens ment injury was con rmed in this study by high- fi Upright MRI field strength upright MRI with a specialized protocol, which is supported by the increased incidence of alar ligament lesions on high-field strength MRI compared to standard MRI. Fourth, fracture elongation Left alar ligament Alar ligament scarring bilaterally Right alar ligament Left alar ligament scarring. Right alar ligament Alar ligament scarring bilaterally statistical analysis was based on the assumption that upright MRI scanning in the healthy control group would find normal alar ligaments, which would also be the case for standard MRI. Finally, all subjects in this study with MRI confirmed alar ligament lesions were long-term sufferers of neck pain and other symptoms (Table 3). All subjects had a history of trauma or surgery, with the major- ity suffering symptoms from a WAD which surgery occurred more than 1 year previously. Hence, the evaluated diagnostic property of these tests cannot be transferred to patients with acute or subacute conditions. Despite these limitations, the study provides some preliminary support for the use of Age (years) Gender History and type of neck trauma Overview of the demographic details for subjects in the traumatic group. clinical examination tests in the diagnosis of alar ligament lesions in clinical practice. 7 55 Male Motorbike accident 6 38 Female WAD car accident 5 47 Male Prolonged cervical extension during 4 64 Male WAD car accident 3 41 Female Sports trauma cervical rotation Left alar ligament partial rupture 2 57 Male Sports trauma cervical rotation Left alar ligament rupture 1 44 Male WAD car accident Subject *No alar ligament lesionWAD: found. Whiplash-associated disorder; ROM: Range of motion; Y: years; M: months. Table 3.

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6. Conclusion and clinical implementation membrane injuries in the upper cervical spine region—A comparison with MRI results. Man Ther. A battery of three alar ligaments test may be helpful in 2008;13(5):397–403. determining the diagnosis of a lesion of the alar liga- [4] Aspinall W. Clinical testing for the craniovertebral ments. These tests can be incorporated in the clinical hypermobility syndrome. J Orthop Sports Phys Ther. examination of patients with symptoms associated with 1990;12(2):47–54. [5] Bitterling H, StäBler A, BrüCkmann H. Mysterium upper cervical instability. Traditional supine MRI scans Ligamentum alare Ruptur: stellenwert der MRT- have the potential to underdiagnose alar ligament Diagnostik des Schleudertraumas - biomecha- lesions; hence, alar ligament manual examination test nische, anatomische und klinische Studien. should provide some additional information that may Fortschr Röntgenstr. 2007;179(11):1127–1136. be useful in diagnosis. Hence, it is suggested that three [6] Li Q, Shen H, Li M. Magnetic resonance imaging positive alar ligament manual examination tests could be signal changes of alar and transverse ligaments not correlated with whiplash-associated disorders. a potential reason for referral for upright MRI. Conversely, Eur Spine J. 2013;22(1):14–20. an alar ligament lesion seen on MRI may not necessarily [7] Knackstedt H, KråKenes J, Bansevicius D, et al. indicate upper cervical instability. However, the presence Magnetic resonance imaging of craniovertebral struc- of such a lesion with evidence of instability on clinical tures: clinical significance in cervicogenic headaches. testing warrants caution and may provide the basis for J Headache Pain. 2012;13(1):39–44. [8] Schmidt P, Mayer TE, Drescher R. Delineation of alar specific management of the individual patient. ligament morphology: comparison of magnetic resonance imaging at 1.5 and 3 tesla. Orthopedics. – Disclosure statement 2012;35(11):e1635 e1639. [9] Krakenes J, Kaale BR, Moen G, et al. MRI assess- No potential conflict of interest was reported by the ment of the alar ligaments in the late stage of authors. whiplash injury – a study of structural abnormal- ities and observer agreement. Neuroradiology. 2002;44(7):617–624. Ethics Approval [10] Lummel N, SchöPf V, Bitterling H, et al. Effect of magnetic resonance imaging field strength on The study was conducted in accordance with the Helsinki guide- delineation and signal intensity of alar ligaments lines and approved by the local ethics committee of the in healthy volunteers. Spine. 2012;37(17):E1062–7. University of Applied Sciences Osnabrück (WiSO MS-MP-WS [11] Cattrysse E, Swinkels RAHM, Oostendorp RAB, et al. 1617-08). Upper cervical instability: are clinical tests reliable? Man Ther. 1997;2(2):91–97. [12] Mathers KS, Schneider M, Timko M. Occult hypermo- Funding bility of the craniocervical junction: a case report and review. Orthop Sports Phys Ther. 2012;41(6):444–457. This research did not receive any specific grant from fund- [13] Jones M, Rivett D. Introduction in clinical reasoning. ing agencies in the public, commercial or not-for-profit In: Jones M, Rivett D, editors. Clinical reasoning for sectors. manual therapists. Elsevier Health Sciences, Edinburgh; 2003.p.3–23. [14] Mintken P, Metrick L, Flynn T. Upper cervical ligament Notes on contributor testing in a patient with os odontoideum presenting with headaches, Orthop. Sports Phys Ther. 2008;38 Piekartz Harry von is Professor for Physical Therapy, course (8):465–475. director of the MSc in musculoskeletal Therapy on the [15] Chen J, Wang W, Han G, et al. MR investigation in University of Applied Science in Osnabrück(Germany), clin- evaluation of chronic whiplash alar ligament injury in ician and researcher in head, face and neck pain. elderly patients. Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2015;40(1):67–71. [16] Sackett L, Haynes RB. Evidence base of clinical diag- ORCID nosis the architecture of diagnostic research. Bjm. 2002;324(7336):539. Piekartz Harry Von http://orcid.org/0000-0002-4509-929X [17] Krakenes J, Kaale BR. Magnetic resonance imaging Toby Hall http://orcid.org/0000-0003-4461-7259 assessment of craniovertebral ligaments and membranes after whiplash trauma. Spine. 2006;31 References (24):2820–2826. [18] Laslett M, Aprill CN, McDonald B, et al. Diagnosis of [1] Osmotherly PG, Rivett DA, Rowe LJ. Construct validity sacroiliac joint pain: validity of individual provocation of clinical tests for alar ligament integrity: an evalua- tests and composites of tests. Man Ther. 2005;10 tion using magnetic resonance imaging. Phys Ther. (3):207–218. 2012;92(5):718–725. [19] Jaeschke R, Guyatt GH, Sackett DL. Users’ guides to [2] Westerhuis P, Functional instability, clinical patterns the medical literature. III. How to use an article in manual therapy. Westerhuis and Wiesner. Thieme about a diagnostic test. B. What are the results Stuttgart; 2016. p. 284–352 and will they help me in caring for my patients? [3] Kaale BR, Krakenes J, Albrektsen G, et al. Clinical The evidence-based medicine working group. assessment techniques for detecting ligament and JAMA. 1994;271(9):703–707.

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[20] McGee S. Simplifying likelihood ratios. J Gen Intern [24] Kanno H, Ozawa H, Koizumi Y, et al. Changes in Med. 2002;17(8):647–650. lumbar spondylolisthesis on axial-loaded MRI: do [21] Johansson BH. Whiplash injuries can be visible by they reproduce the positional changes in the degree functional magnetic resonance imaging. Pain Res of olisthesis observed on X-ray images in the standing Manag. 2006;11(3):197–199. position? Spine J. 2015;15(6):1255–1262. [22] Radcliﬀ KE. al. Invitro biomechanics the craniocervical [25] Morishita Y, Hida S, Miyazaki M, et al. The eﬀects of junction—a sequential sectioning of its stabilizing the degenerative changes in the functional spinal structures.”. Spine J. 2015;15(7):1618–1628. unit on the kinematics of the cervical spine. Spine. [23] Kanno H, Endo T, Ozawa H, et al. Axial loading 2008;33(6):E178–82. during magnetic resonance imaging in patients [26] Dullerud R, Gjertsen Ø, Server A. Magnetic reso- with lumbar spinal canal stenosis: does it repro- nance imaging of ligaments and membranes in duce the positional change of the dural sac the craniocervical junction in whiplash-associated detected by upright myelography? Spine. 2012;37 injury and in healthy control subjects. Acta Radiol. (16):E985–92. 2010;51(2):207–212.

Extrajobba med digital artrosbehandling

Via appen Joint Academy sammanför vi fysioterapeuter med patienter i behov av artrosbehandling. På så vis kan vi tillsammans göra artrosvård tillgängligt för alla! Läs mer och anmäl dig på www.jointacademy.com

”Jag tycker att man kan följa upp patienten enklare” Emelie, fysioterapeut Joint Academy Abstract submissions are now open. Visit the website to find out more: www.ifomptconference.org

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Musculoskeletal Physiotherapy Australia The world’s leading musculoskeletal physiotherapists have chosen Melbourne as the place to exchange knowledge, share research and celebrate innovation within the neuromusculoskeletal physiotherapy sector. The 2020 Meeting of the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT 2020) will take place in beautiful Melbourne on 6 - 8 October 2020, at the multi-award winning Melbourne Convention and Exhibition Centre.

International keynote speakers

Associate Professor Professor Deborah Falla Annina Schmid University of Birmingham, Oxford University, UK UK

Invited speakers

Professor Kim Bennell Professor Michele Sterling Associate Professor The University of Melbourne, The University of Queensland, Mark Hancock Australia Australia Macquarie University, Australia

Physiotherapist and Senior Principal Research Researcher Fellow, Professor and Director Dr Tania Pizzari Paul Hodges La Trobe University, NHMRC Centre for Clinical Australia Research Excellence in Spinal Pain, Injury and Health, Australia Stötvågsbehandling ger snabbare resultat

Stötvågsbehandling är en väletablerad behand- Patienttrycket blev stort när Jesper Olsson och hans lingsmetod som vinner alltmer förtroende tack vare kollegor började erbjuda stötvågsbehandling och gehöret sina positiva effekter för patienter och genom att har varit positivt. underlätta arbetet för många läkare och terapeuter. – Stötvågsbehandlingen gör visserligen ont för patienten, men med den smärtlindring behandlingen ger, står de flesta ut med att det gör ont någon minut. – Stötvågsbehandlingen löser inte hela problemet, men startar en läkningsprocess. Smärtan minskar, vilket under Stötvågsutrustningen underlättar dessutom för terapeuten. lättar att få med sig patienten i övrig träning. Stötvågs – Det har sparat mina händer och fingrar mycket. Ti behandlingen ger snabbare resultat, vilket ger motivation digare behövde jag arbeta mycket mer med till övrig rehabilitering, säger Jesper Olsson, en av händerna. Dess utom går stötvågsbehand fyra sjukgymnaster på kliniken Stay Active i Troll lingen betydligt snabbare, vilket är skönt hättan. Medema även för patienten. Stötvågsbehandling används framgångsrikt erbjuder stötvågs - på svårbe handlade muskuloskeletala be apparater från Storz svär i senor, muskler och senfästen och är Medical för både radiell ett effektivt alternativ till kortison och kirur & fokuserad stötvågs- giska ingrepp. Jesper Olsson har goda er behandling. farenheter efter att ha arbetat med metoden i snart fem års tid.

– Stötvågsutrustningen är användarvänlig och den maskin vi använder mest. Den gör det möjligt att lägga upp en behandlingsserie för patienten, där jag till exempel kan se exakt antal slag från förra behandlingen. Tidigare kunde jag bara följa patienten via journalen.

» RADIELL STÖTVÅGSUTRUSTNING En luftkompressor accelererar en kula i handenheten och stötvågor uppstår av trycket. Tryck och frekvens styrs direkt från den ergo nomiska handenheten, som också visar antalet slag under behandlingen.

» FOKUSERAD STÖTVÅGSUTRUSTNING En patenterad teknologi där en elektromagnetisk cylinder avger hög energi. Den fokuserade behandlingen gör det enklare att med stor precision tillföra energi och genom att använda olika gelpads bestämma behandlingsdjupet. Energi och frekvens styrs från handenheten.