Some Physical therapists commonly use pre-manipulative screening tests involving cervical end-range rotation and extension. It is hypothesized that these tests help screen patients who are not appropriate to receive cervical manipulations, due to a potential risk of having vertebro-basilar insufficiency (VBI).

This study compared the commonly used VBI tests to Duplex ultrasound with colour Doppler flow imaging.

Study conclusion: "Pre-manipulative testing (i.e. end-range cervical rotation and extension) does not distinguish between patients with varying degrees of vertebral artery flow impedance and is generally unlikely to be able to detect the patient at increased risk of stroke following manipulation."

Thanks to: Michael Westway, B.Sc. P.T. FCAMT of Calgary, AB for bringing this study to my attention.

Personal opinion: Since the present pre-manipulative screening tests are the 'best' tests we have at the present time, they should still be used until a better option is found.

Better option: Physical therapists have at their hands many options for treating cervical pain and cervical headaches, such as mobilizations and research based muscular control and kinaesthesia retraining. Although cervical spine manipulation can be highly effective, I rarely need to practice it; as my personal philosophy is… 'use it as a last resort'!

For an excellent reference on the 'better option' read:
Jull GA 2000 Deep cervical neck flexor in whiplash. Journal of Musculoskeletal Pain 8(1/2);143-154



Diagnosing Meniscal Lesions…
not so hard if there is a "good" history!

1) History of a specific trauma involving tibia or femoral rotation on a weight bearing foot
2) Reports of "clicking" since the injury
3) Reports of knee "buckling or giving way"
4) Reports of knee spontaneously "locking"




Meniscal Tests…as accurate as MRI!!

Reference: Muellner T et al. 1997 The diagnosis of meniscal tears in athlete's; A comparison of clinical and MRI investigations. American Journal of Sports Medicine (25):1;7-12

Magnetic resonance imaging (MRI) is considered to be a "gold standard" test for diagnosing meniscal lesions, however it is not easily accessible, it is expensive and usually involves being on a long waiting list.

This study supported that taking a good history and using a group of tests to stress the meniscus may be as accurate, sensitive and specific as MRI.

	Clinical	Testing MRI
Accuracy:	94.5%	95.5%
Sensitivity:	96.5%	98%
Specificity:	87%	85.5%

The testing consisted of all the 6 tests outlined below: (monitoring for symptom reproduction of pain or 'clicking')

Test #1: Joint Line Tenderness
Simply palpate the anterior and posterior tibio-femoral joint.

Test #2: McMurray's Test
Medial and lateral rotation of the tibia performed in various stages of knee flexion.

Test #3: Apley's Test
With the patient in prone and the hip extended to neutral-flex the knee >90° and then rotate and compress the tibia.

Test #4: Bohler's Test
Same technique as when testing for the collaterals but we are concerned with the compressive aspect of this test.

Test #5: Steinman's Test
Sitting with knee hanging over the exam bed; medial and lateral rotation of the tibia in performed.

Test #6: Pary's Test
Flex the knee to 90° and apply a varus stress-this compresses the medial meniscus posterior horn.

Clinical conclusion: This study shows us the importance of correlating many tests in order to achieve a more accurate "Physical Therapy diagnosis". This is a practice we should use with most of our investigations.

Prepared by: Dana Clark, B.Sc.P.T., FCAMT of Toronto, ON



STOP using Neural "TENSION" Tests!!

The old term "Neural Tissue Tension Tests" almost implied 'stretching' of the nerves, which is an incorrect assumption. The mentality that we must 'move' neural tissue if it is restricted in also inaccurate.

Reference: Hall T, Elvey R. 1998 Adverse mechanical tension in the nervous system? Manual Therapy 3(3):140-146

The term "Neurodynamics Testing" (NDT) is more accurate and has much greater acceptance with the medical community.

(E.g. in charting write: NDT med.n. bias +ve)

A randomized, double-blind study was conducted comparing US treatments to sham US on 61 patients with symptomatic calcific tendinitis of the shoulder.

Patients in the treatment group received within six weeks, 24 15-minute sessions of pulsed ultrasound (frequency, 0.89 MHz; intensity, 2.5 W per square centimeter; pulsed mode, 1:4).

Results: After six weeks of US, calcium deposits had resolved or decreased by at least 50 percent in 47% of the patients, as compared with no significant change in the sham US-treatment group (P=0.003).

At the end of the six weeks, patients who had received ultrasound treatment had greater decreases in pain and greater improvements in the quality of life than those who had received sham US treatment.

Clinical Conclusion: Ultrasound treatment helps resolve tendon calcifications and is associated with clinical improvement of symptoms and function.

Excellent published evidence to support Physical Therapists using ultrasound for patients with symptomatic calcific tendinitis of the shoulder.

Personal comment: If you have never applied Ultrasound for 15 minutes continuously to one area…consider it for your next patient with calcific tendinitis!

Reference: Ebenbichler G et al. 1999 Ultrasound therapy for calcific tendinitis of the shoulder. The new England Journal of Medicine May 20;340(20):1533-8



SI Joint…Study supports it may be involved in patients with Persistent Low Back Pain

Reference: Schwartzer A, Aprill C, Bogduk N. 1995 The sacroiliac joint in chronic low back pain. Spine 20(1):31-7

43 patients with chronic low back pain were investigated with sacroiliac (SI) joint provocative injections and analgesic blocks under image intensifier using radiographic contrast.

Study conclusion:

1) The prevalence of SI joint pain in patients with LBP appears to be as high as 30% as 13 of the 43 patients had relief of symptoms after the local analgesic block.
2) Groin pain was highly associated with response to SI joint block



Are SI Tests of any Predictive Value? No?

Reference: Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bogduk N 1996 The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine (21):22;2594-2602

Twelve of the 'best' SI joint tests chosen by an expert panel were evaluated against the 'gold standard' test of pain relief with an intra-articular injection of local anaesthetic into the SI joint.

Study conclusion: "Sacroiliac joint pain cannot be diagnosed from history or physical examination.
If the diagnosis is to be made, controlled diagnostic blocks are, at present, the only means to make that diagnosis." (In other words, Physical Therapy assessment for the SI joint is a 'waste of time'!) Personal Challenge:

Please Feel Free to Contact APTEI… 1) If you are interested in contributing to this report 2) If you are interested in instructing a post-graduate Physical Therapy related course, I would be happy to assist you in the course organization 3) If your Clinic / Physiotherapy department is interested in hosting an APTEI course in the future

In that study they quote "It remains possible that a major part of the so-called sacroiliac pathology is a pathology of the soft tissues surrounding the joint. The ‘gold standard’ diagnostic block may be accurate for diagnosing pain within the joint (intra-articular), but NOT as accurate for diagnosing pain from the soft tissues surrounding the SI joint complex!

I hypothesize that many of the SI tests stress the soft-tissues surrounding the joint (i.e. the ligaments) and not the actual intra-articular structures.

Is it possible that the so-called 'gold standard' diagnostic blocks are not so 'gold' when it comes to diagnosing sacroiliac joint extra-articular pain? Although studies seem to indicate that various SI tests are in fact 'useless', I will personally continue to perform them clinically and rely on them for determining the treatment for my patients with LBP.



Reliable SI Joint Provocative Tests

Reference: Wurff P, Hagmeijier HM, Meyne W 2000 Clinical tests of the sacroiliac joint: a systematic methodological review. Manual Therapy 5(1);30-36

The authors of this article reviewed 11 studies and conclude:

1) The validity and reliability of most sacroiliac tests are poor. "Therefore, at this time, it is questionable whether any SI joint tests are of any value for clinical practice."

2) The Gaenslen test and the Thigh thrust test seem to be clinically reliable test

3) The Patrick's test and the Gapping test may be reliable but studies contradict each other.

Patrick's Test / FABER test
Gapping/
Distraction test

Reference: Vicenzino B, Wright A. Effects of a novel manipulative physiotherapy technique on tennis elbow: a single case study. Manual Therapy 1995; 1(1): 30-35 (This article was also reprinted in the March/April 1999 issue of the Orthopaedic Division Review, CPA)

I have had great and immediate positive results using the lateral glide technique as described by Brian Mulligan on my patients suffering from 'tennis elbow'. To apply the technique…

1. Ask the patient to grip in the position that produces their symptom e.g. in elbow extension and pronation

2. Ask the patient to relax, then a sustained lateral glide mobilization is applied to the proximal forearm either with a belt or with the hands.

3. While the lateral glide is maintained, the patient is asked to form a grip again and hold for approx. 3 seconds…frequently the patient will report that this time the grip is pain-free.

Note: To achieve this positive effect, the mobilization must be applied in the 'right' direction with the 'right' amount of force…, which varies among all individuals!

4. Step #3 may be repeated 10 times and 3 sets may be required to eliminate the normally painful grip.

Note: The technique must be pain-free; never continue if the patient reports of pain.