Modern Manual Therapy Blog

The previous blog introduced why I feel breathing patterns are something we should be spending more time assessing or at least delving into more detail about. This blog looks at the different aspects of assessment - questioning and physical tests - that we can build into clinical practice. 
The first question to address is - where does it fit in? 
Do we start regionally or holistically? For example, a patient presents with chronic lower back pain and structural diagnostic label of a disc bulge. 
  • Day 1 - are you going to look at lumbar active range of movement, palpation, muscle strength and length tests. Then day 2 - look at the area above and below, clear a neurological exam, check a neurodynamic exam. Then day 3 -  spend more time looking at breathing, motor control and functional positioning. 
Or....
  • Day 1 - are you going to look more holistically at the resting posture, quiet breathing and gait. Then build out the assessment to a more focussed structural or body-region-specific assessment?
How we choose and order the priority of our clinical assessment is a clinical reasoning challenging that we are faced with daily. What I am finding more frequently is that my approach changes depending on the person and depending on the program. I have to ask myself - is it more important to reproduce their pain on the first session or is it more important to look at global contributing influences to their pain - like abnormal breathing?
I don't think there is a right or wrong, and as I continue to practice, my ability to choose seems to become more refined. I do think that is all comes down to the personality of the individual and the expectations for treatment and recovery. Fundamentally breathing is like all our other areas of assessment and treatment. There is so much complexity to breathing alone, that it is impossible to assess every aspect in detail. But, after reading this book, these are the few key areas and tactics for treatment that I'll try to use in 2018. 
"How we breathe and how we feel are intimately conjoined in a two-way loop." (Chaitow, Bradley & Gilbert., 2014, p. 24). 
Patients don’t just choose to breath abnormally - their bodies are forcing them to adapt to a problem and our role as therapists is to understand the underlying drivers. When reading this book I came across the section below, which suddenly helped me grasp the reason breathing abnormally can have such a profound impact on the human body.

“Both respiratory suspension and over-breathing in preparation for action are unbalanced, in the sense that the individual is not living entirely in the present. This projection into the future creates a discrepancy between actual and anticipated metabolic needs. The trouble arises when the threat is non-physical or not imminent. If such feelings become habitual, then the preparation will become chronic.” (Gilbert., 2014, p.82). 

ASSESSMENT OF BREATHING PATTERNS

The assessment by a physiotherapist is more than just physical, it includes understanding the past medical history, social history, medication history and general health for conditions or contributing factors to breathing disorders. Only once these have been questioned for and excluded, should one continue to look at physical and structural tests. 
Breathing assessment might comment on posture and patterning:
  • If the breathing is diaphragmatic, abdominal etc. Where is the movement coming from?
  • Place one hand on the chest and other on the stomach. Inhale and comment on the movement of the hands. If the upper hands moves first and more then this is called upper chest breathing(Chaitow., 2014, p. 101). 
  • How much of the abdomen moves and in which direction? Does it expand forward, sideways or suck inwards?
  • How much to the accessory muscles activation can be seen?
  • Do the shoulders elevation during breathing? What is the resting position of the clavicles and scapula?
  • What is the rate of breathing?
  • How would you rate the duration of inspiration compared to expiration i.e. does the person completely exhale or stay hyper-inflated?
  • Is there movement felt in-between the shoulder blades (posterior mediastinum) during inspiration or is all of the movement anterior in the chest? 
  • Is there a natural pause at the end of expiration?
  • Does the person exhibit any altered phonation (voice changes) while they breathe?
Assessment can be performed in supine, sitting, quadruped or standing - it depends on how demanding you wish to make the postural component of breathing. For example, if you assess a patient in supine there is not a lot of room to palpation lateral and posterior expansion of the ribs. If you assess them on hands and knees (quadruped), you get a sense for scapulohumeral positioning, neck strength and expansion of the full thoracic spine, but is is more difficult to visualise the clavicles and accessory muscles. 

ASSESSMENT IN SITTING

When assessing a person in sitting I like to focus on movement of the sternum. Often patients don't realise it, but they are hitching their shoulders up, activating neck muscles and lifting the sternum upwards (cranially). The ideal breathing pattern would not exhibit scapula elevation, accessory muscle activation and instead show anterior movement of the sternum and posterior expansion of the ribs. To assess this, the patient can place one hand on their chest and belly while you place one hand between the shoulder blades and one on the top of one shoulder. This also provides the patient with a lot of proprioceptive feedback when moving towards changing their pattern. 

ASSESSMENT IN SUPINE

What I look for in supine is different from sitting and focusses on abdominal movement and rib flare. When in lying, if you can palpate the border of the inferior ribs the patient is demonstrating rib flare, which often indicates a loss of synchronisation of the abdominal muscles with the diaphragm and over-activity of the spinal extensor muscles. As the patient breathes in there should be an equal distribution of movement throughout the chest, not just the stomach lifting forward. As the patient breathes out, the ribs shoulder downwardly rotate and connect into the abdominal wall. This is why noting inhalation:exhalation ratios are important because if the patient doesn't fully exhale, their ribs will never drop down into the abdomen. 

ASSESSMENT IN QUADRUPED

The key finding I look for in quadruped is how well a person can position their scapula on the thorax. More importantly, as they exhale, if the ribs drop down towards the table the scapula will wing off the thorax (seen in image 2). If this occurs the patient is not able to stabilise their upper body while in a static position and this exercise will be a great starting point for rehabilitation.

OTHER POSITIONS FOR ASSESSMENT

The author of the book mentioned above describes in detail what an assessment entails with a patient sitting but also suggests that side lying hip abduction SLR and prone active SLR are great tests for palpating where movement begins and providing information about hip abduction or extension being initiated in the lumbar spine. These lumbar muscles are also breathing muscles, therefore if altered timing is found during the assessment, it may suggest poor synchronisation between muscle regions. 
You should also spend time watching how the patients spine is moving and the distribution of flexion (which I refer to often as segmental control). This often tells you how well ribs are moving and air is being distributed throughout the chest. You can observe their spinal movements in flexion or just as they lie prone. This is not diagnostic but a helpful way to approach your observation technique.
I actually have been integrating more observatory techniques into my practice to compliment my structural tests. 
So the observation of breathing can be built into many other tests we commonly use - it just has to be a specific intension and focus of what you are looking for. 

SOME OTHER TESTS WE CAN INCLUDE:

  • Measuring respiratory rate
  • Measuring controlled expiratory pause. 
    • “While no standardized test yet exist, breath-hold times are recorded by many clinicians as part of HVS/BPD assessment. Failure to hold beyond 30 seconds is considered by some a positive diagnostic sign of chronic hyperventilation (Gardner 1996).” (bradley., 2014, p. 122).
  • Pulse-oximetry
  • Peak-expiratory Flow Rate
  • Range of movement and palpation assessment of the thoracic spine, shoulder girdle and ribs
  • Looking a voice control during breathing. Things to observe include (Au Zveglic., 2014, p.208):
    • The audibility if inspiration
    • The speed of speech
    • The ability to finish phrases and sentences
    • The quality of the voice

QUESTIONNAIRES:

“Breathing is a dynamic system which is under the influence of many factors. These are of physical and pathological nature, as well as from psychic and emotional origin and also may be part of social and behavioural patterns.” (Courtney & van Dixhoorn., 2014, p.137).  Therefore, not all aspects of breathing can be assessed objectively. I love using questionnaires to improve my understanding of asking questions. I am not the most consistent in applying them to my patients - and perhaps this is an area I can improve on - but I integrate the questions into the subjective assessment. 

NIJMEGEN QUESTIONNAIRE:

  • The Nijmegen Questionnaire (NQ) assesses stress and arousal, presumed consequences and symptoms of hypocapnia and difficulty breathing.
  • The normative values differ depending on the country/population evaluated but it is generally accepted that a score >19 (out of max 64) demonstrates the presence of respiratory distress and dysfunction.
  • This questionnaire is used in populations other than breathing disorders (heart and lung disease, anxiety, depression) but is the most commonly mentioned one I’ve read about in the assessment of breathing pattern disorders. 
“As yet there is no ‘gold standard’ laboratory test to clinch the diagnosis of chronic HVS. However, the Nijmegen Questionnaire is the next best thing, and provides a non-invasive test of high sensitivity (up to 91%) and specificity up to 95% (Van Dixhoorn & Duivenvoorden 1985)" (Bradley., 2014, p.121). 

THE SELF-EFFICACY BREATHING QUESTIONNAIRE:

  • “The SEBQ is useful as a means of evaluating the quality and quantity of uncomfortable respiratory sensations, and the person’s perception of their own breathing, and may help to give insight into the origins of the discomfort.” (Courtney & van Dixhoorn., 2014, p.140)
  • It has questions relating to air hunger and ones relating to effort of breathing
Image source: https://ars.els-cdn.com/content/image/1-s2.0-S1360859210000951-gr2.jpg
Image source: https://ars.els-cdn.com/content/image/1-s2.0-S1360859210000951-gr2.jpg
Breathing difficulties come in many symptoms and forms and there is no single measure or diagnostic tool. Clinicians need to be aware of the variety of symptoms associated with breathing pattern disorders to best identity, document and address them. 
We're over half way through the book now and I hope your thinking around breathing is starting to expand (as well as the frequency of nasal breaths while you read). The next blog looks at tips for treatment drawn from physiotherapy, osteopathic and more alternative approaches. 

REFERENCES:

Chaitow, L., Gilbert, C., & Morrison, D. (2014). Recognizing and Treating Breathing Disorders E-Book. Elsevier Health Sciences.


Sian Smale is an Australian-trained Musculoskeletal Physiotherapist. Sian completed her Bachelor of Physiotherapy through La Trobe University in 2009 and in 2013 was awarded a Masters in Musculoskeletal Physiotherapy through Melbourne University. Since graduating from her Masters program, Sian has been working in a Private Practice setting and writing a Physiotherapy Blog "Rayner & Smale". Prior to moving to San Francisco, Sian worked at Physical Spinal and Physiotherapy Clinic and has a strong background in manual therapy and management of spinal spine, headaches and sports injuries. Since moving to the Bay area, Sian has become a Physiotherapist for the Olympic Winter Institute of Australia, traveling with their Para Alpine teams. Sian currently works full time at TherapydiaSF as a physical therapist and clinical pilates instructor. 

twitter @siansmale
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We have a new ministerial post in Britain: the minister of loneliness. Tracey Crouch was recently appointed to continue the work of Jo Cox and following the recommendations of a cross-party report. This is a positive move to address a problem that is embedded within a society that has championed individualism at others’ cost, a rat-race, and a ‘me-first’ model of economics (The Guardian editorial, 20th Jan, 2018). Happiness does not emerge from such a context, instead isolation for many, with very real effects upon health.
Of course this approach is not just evident in the marketplace and the workplace. It has been encouraged in schools where grades are the measure of success, and being better than everybody else is a driver. The reality is that no-one is better than anyone else, and on continually feeling that they must look a certain way, be on a certain social media channel, have certain material things and strive to be better than the others, the pressure builds. This is one of the main reasons for the ever-growing issue of childhood and teen ill-health. Loneliness is almost certainly in the mix. How lonely must it be to always be thinking about oneself?
“You are no better than anyone else and no one is better than you
~ John Wooden
Yet this is a society of our making. We must all wake up to this and build structures that promote collectivism and connection in line with our design to co-operate. It will not be enough to try and minimise suffering downstream by picking up the pieces. We need top down change in attitudes and beliefs, because what we are doing at the moment is not working. The next generation needs this desperately. They need to be prepared for the modern world: creativity, critical thinking, communication and collaboration — the 4Cs.
Suffering is part of life. How we address our suffering and support others who suffer determine what it is actually like. Suffering affords opportunities to learn and transform experiences. To try and wrap people up in cotton wool will not work. Giving them practical tools to roll with life’s ups and downs together with know-how, creating opportunities to pursue a purpose, to master chosen skills and feel a sense of autonomy are all part of a healthy, evolving society.
Those who are familiar with the scientific literature on loneliness know about the biological effects. There are several key points to consider. Firstly, it is the perception of loneliness that is the governing factor. Secondly, in the case of perceived loneliness, we switch at a gene level to being inflammatory. This makes sense because being isolated means that if we are bitten by the sabre-tooth tiger, our healing responses are ready to go. That’s basic biology at play. If we perceive ourselves to be part of a community and connected, we are pro-viral because we are more likely to pass viruses to on another. Great system, but being pro-inflammatory for a prolonged period has health consequences: e.g./ chronic pain, depression–the two largest global health burdens.
Tracey Crouch has a job of huge importance. This is not just about people who live alone. This is about how society functions to enable people to connect with purpose, to support and trust each other and to share a planet. Now that’s a job worth doing well!

A brief note on loneliness and pain

Chronic pain is often described to me as being a cause of loneliness for several reasons. Firstly because of the limits that the pain can seem to impose until the person learns skills and has tools to change his or her experience, and secondly because no-one else can actually feel that pain.
Pain is a shared experience however. Each person will suffer their own pain of course, and for different reasons, yet it is a conscious phenomena that most will feel. Being that it is unavoidable, it becomes essential that people understand pain so that they can address their needs with effect.
One of many actions that can be chosen and committed to, is that of making connections and ensuring meaningful interactions as often as possible. These practices and others can easily be interwoven into life as a means to address the effects of loneliness.



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Fixes are nothing without assessments to tell you the need to do them in the first place. A quick scratch test will tell you whether or not your shoulder needs more mobility. If the more common pattern of IR more than ER limitation is seen, repeated shoulder extension (passive) works great as a reset. 

In the Eval, Reset, and Stabilize System, "stability" doesn't mean strength. I use stability to mean the area can accept load in a threat free and efficient manner. After Sidegliding in standing is equal or FN bilaterally, but if the LCAP test is positive, homework should include exercises designed to help single limb stance and the lumbar spine's ability to accept load on the involved side. Below is a sample of a progression I may prescribe in this case. The example is for loading the right LQ with the exception of Eccentric-Isometric Goblet Squats, which is for mobility and proprioception for equal loading.

Think of adding stability exercises especially when SGIS exercises help reset LQ complaints, but despite patient compliance and high dosage, their single limb stance stability makes them unload more during ADLs than the loading resets can compensate for. 

5 Step Progression for Unilateral Lumbar Loading and Single Limb Stance



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Listen in to Dr E. sharing one of his early treatment stories (17 years ago!) of when a patient he treated did not respond to manual therapy...but got better with some unexpected fancy treatments.
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Untold Physio Stories is sponsored by the EDGE Mobility System, featuring the EDGE Mobility Tool for IASTM, EDGE Mobility Bands, webinars, ebooks, Pain Science Education products and more! Check it out at edgemobilitysystem.com .  Be sure to also connect with Dr. Erson Religioso at Modern Manual Therapy and Jason Shane at Shane Physiotherapy.


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While growing up, every New Years Day my whole family, including my parents, three siblings, and myself, would go out for breakfast at the Golden Skillet. The Golden Skillet was your stereotypical diner, from the mediocre coffee to the old men (the “regulars”) always sitting at the counter reading the newspaper. Interestingly enough, one thing I always remember about this experience is our waitresses. It always seemed to be a middle-aged woman with some grittiness to her that showed she might have worked at the diner just a little too long.

“Alright, what would you like?” she would ask us, and then with no pen or order pad, and her arms behind her back, she would proceed to take each of our orders. She would then take our menus and walk away to input the orders.The next ten minutes of the table conversation would consist of “how the heck does she memorize all our orders?” Yet, sure enough, we seemed to always get the food we wanted just as we ordered it.

We always seem to have a fascination with memory. “I can always memorize people’s birthdays” or “I can memorize this many digits of the number pi.” I’m sure the examples are endless, but I don’t want to talk about memorizing things. I want to talk about the easiest way to not have to memorize things: the use of a checklist.

Again, I have received inspiration for this blog post from a nonfiction book, The Checklist Manifesto by Atul Gawande. Besides being an author, Gawande is an American surgeon and public health researcher. His book describes the trials and successes of the adoption of checklists in operating rooms across the world. He also describes the successful use of checklists in numerous industries, most notably aviation and commercial building and construction. At one point, Gawande notes that he cannot imagine a single industry in which checklists cannot provide a benefit. So, let’s look a little further at the benefits of using checklists, what makes a good checklist, and how physical therapists can use checklists for our benefit.

Simply put, the reason for checklists is that humans are fallible and have inadequacies. We miss things and make mistakes. There are limits to our attention span (some more than others) and our memory. Of course, this is okay. The world is complex and the field of physical therapy is no different. Just think about the complexity of the human body, or think of the multiple diagnoses, co-morbidities, tests and measures, and treatment techniques that you’re exposed to or perform throughout the course of day. A checklist offers a simple way to avoid errors and oversight. It helps you avoid problems and make sure the stupid stuff isn’t missed.

What makes a good checklist? Gawande describes the key characteristics of a good checklist include that it is precise, efficient, and practical. It should be to the point and only include the “killer items.” Additionally, a good checklist should only be used as an aid. It should aid the decision-making and skills of the professional. However, most importantly, a checklist needs to be practical, which means that you should practice using it and continuously make refinements to improve its effectiveness and ease of use.

Physical therapists can utilize checklists in a variety of situations. We can have a checklist for initial evaluations. For example, a checklist might include history, posture, strength, ROM, functional mobility, etc. From here, we could have sub-checklists for different sections of the evaluation. What part of the patient history should I absolutely ask and not forget? We can use checklists that are specific to certain diagnoses or patient populations. We can use a checklist for red flags. What are the red flags that I absolutely must ask about for each patient? The same thing can be done for yellow flags and psychosocial factors. There also are the huge lists of contraindications and precautions for different treatments and modalities. Don’t tell me you’ve memorized all the contraindications to electrical stimulation, and for every patient you ask about each one.

It seems clear that physical therapists can benefit from using checklists. There are probably different examples that I didn’t even think of. So, what are the reasons we don’t use them? First we have to consider the mindset of the skilled expert clinician. “I am a knowledgeable and skilled therapist and I don’t need the aid of a checklist, and plus, my patient will consider me less skilled and knowledgeable if he or she sees me using a checklist”…This thinking is flawed. A checklist is not supposed to completely eliminate any decision-making, problem solving, or skilled care. The purpose of the checklist is to take care of the simple stuff, so that you can focus on the complex stuff. If used correctly, a checklist should not turn you into an automated robot or diminish the personal connection with the patient. In fact, a checklist can improve communication with the patient, improve thoroughness, and make sure important things aren’t missed.
“I’ve never used a checklist, and I’ve never had a problem.” 
Another argument against using checklists might be, “I’ve never used a checklist, and I’ve never had a problem.” It’s true that most parts on a checklist can seem unimportant or unnecessary (“Do you have Raynaud’s syndrome?” “Do I have what?”). However, as Gawande notes 49/50 times there is no problem…until there is. The things that are uncommon, but can occur, are the things we are most likely to miss. Following the checklist is the easy way to not miss those things.

We shouldn’t fear the rigidity of implementing checklists. As Gawande notes, checklists “get the dumb stuff out of the way, so you can focus on the hard stuff.” Consider that Steve Jobs wore the same clothing (black turtleneck and blue jeans) every single day. He did this because he didn’t want to expend mental energy making silly decisions such as what to wear for the day. He wanted to use his mental energy creating amazing products for Apple. We should use checklists the same exact way. Let’s expend our mental energy on the tough stuff and keep the simple stuff simple.

Note: This post should really be considered as a synthesis of Atul Gawande’s book, The Checklist Manifesto, with my personal thoughts in relation to the field of physical therapy.

via Luke Pedersen, DPT



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Image result for neck surgery
https://upload.wikimedia.org/wikipedia/commons/thumb/4/4e/ACDF_surgery_english.png/350px-ACDF_surgery_english.png

It is well established that conservative treatment should be the primary choice of intervention for non-specific neck pain as the benefit of surgery over conservative care is not clearly demonstrated.  For rehabilitation professionals, the use of exercise therapy and/or manual therapy is obviously the most appropriate decision and should always be utilized prior to most invasive, risky procedures.
This is echoed in the Cervicogenic Dizziness / Cervical Vertigo literature as well.  We have three systematic reviews demonstrating the benefit of non-surgical and non-pharmacological interventions, specifically manual therapy, for these patients.  The high level of evidence all originated in 2005, then again in 2011 and even though just showing effectiveness of acupuncture, endorsed recently in 2017.  Although only three SRs, I think this is very positive considering a condition not well studied and continues to carry the burden of controversy.
Even with substantial evidence showing the effectiveness of conservative care, specifically manual therapies, for Cervicogenic Dizziness / Cervical Vertigo, there are still several citations illustrating success following surgery.
Here is a glimpse of the literature with accompanying conclusion:
Yang Y et al 2007
“Percutaneous laser disc decompression can decrease intradiscal pressure, increase local temperature and remove the spasm of the vertebral artery while providing a remarkable therapeutic effect for the treatment of cervical vertigo.”
 Ren L et al 2014
“Excellent outcome in 18 out of 35 patients who underwent percutaneous laser disk        decompression”
Li J et al 2014
“Good results following more extensive cervical surgery”
Park J et al 2014
“Patient vertigo disappeared after surgical decompression of transverse foramen of C1”
Liu XM et al 2017
“ACDF provided a good resolution of cervical vertigo in a retrospective study of 116 patients”
Yin HD et al 2017
“Radiofrequency ablation nucleoplasty improves the blood flow in the narrow-side vertebral artery in 27 patients diagnosed with cervical vertigo and illustrates the therapeutic effect on cervical vertigo. Radiofrequency intradiscal nucleoplasty can be used as a minimally invasive procedure for treating cervical vertigo”
You can see a trend in the just the last few years indicating success of vertigo/dizziness after surgical procedures.  As an evidence-informed practitioner or even a vestibular specialist who isn’t trained in treating the neck, and recognizes lack of consistent relief in your patient, you may seek out this research and consider referring on to a surgeon.  Before you do so, let’s dive into the most recent article with surgical success to jack into a clinical reasoning discussion.

Patients/Methods: Of 145 patients with cervical spondylosis and dizziness, 116 underwent anterior cervical decompression and fusion and 29 underwent conservative treatment. All were followed up for one year. The primary outcomes were measures of the intensity and frequency of dizziness. Secondary outcomes were changes in the modified Japanese Orthopaedic Association (mJOA) score and a visual analogue scale score for neck pain
Results: There were significantly lower scores for the intensity and frequency of dizziness in the surgical group compared with the conservative group at different time points during the one-year follow-up period (p = 0.001). There was a significant improvement in mJOA scores in the surgical group.
Conclusion: This study indicates that anterior cervical surgery can relieve dizziness in patients with cervical spondylosis and that dizziness is an accompanying manifestation of cervical spondylosis.

Out of China, Dr. B Peng and his colleagues recently had this article published in the Bone & Joint Journal (not the best journal but higher impact factor than JOSPT). This is a level 2 multi center prospective cohort study—not bad when considering level of evidence as we have very few studies higher up on the chain and most involve the same name of Susan Reid & her colleagues from the land of Australia.
From initial glimpse of methodology, results and conclusion (you know we all typically look at the abstract…), my thoughts are that if my patient has arthritis and dizziness, then if they have surgery, they will have less intensity and frequency of dizziness compared to conservative route.
The first thing I did was to look at what type of conservative treatment was performed.  Here is the description:
Conservative treatment included physiotherapy, intermittent cervical immobilization with a collar, nonsteroidal anti-inflammatory drugs and rest.
This doesn’t tell us much what kind of physiotherapy was performed (stabilization exercises, heat/ice, e-stim, massage, squeezes for the shoulder blade squeezes with theraband, neck ROM—hell we don’t know!).  We don’t know what was meant by rest, or what was meant by intermittent immobilization of the spine (does anyone do this nowadays anyway?).  For all purposes, it could be the Physio Blend buffet style…but doubtful.
The second thing I did was look at the type of patients that were recruited.
Between March 2014 and March 2015, 157 patients with cervical spondylotic radiculopathy and/or myelopathy from three spinal centres (General Hospital of Armed Police Force, Beijing; 304th Hospital, Beijing; Changzheng Hospital, Shanghai) were enrolled in the study.
Additionally, the patients had failed conservative treatment (3 months of treatment!) prior to potentially having surgery—-34 of the 157 patients declined surgery—but continued with conservative treatment—and this was the group that surgery was compared to!  I’m sure the patients who continued with PT after 3 months were stoked to continue more of the same cervical immobilization, rest, NSAIDs and general physiotherapy….
The third thing I did—write this blog.

Big key points:

This is not a bash against the article—I thought it was well written and authors were open to the limitations in the conclusions.  They even stated the patients selected for study were for myelopathy/radiculopathy and not dizziness!  But, knowing the time and effort that goes into reading research in the profession—the title and abstract could be misleading to the consumer and I felt this blog would be beneficial to my rehabilitation colleagues.
Just like any condition we treat, this paper exemplifies a double entity.  Yes, the patients had improvement in dizziness following the procedure, but I would really say these patients had success of cervical pain due to cervical spondylotic radiculopathy and/or myelopathy, NOT cervicogenic dizziness.
This paper also exemplifies the notion that dizziness can arise from the neck, and can improve with intervention!  So yes, still can be controversial in the medical eyes, but this group sought out improvement in dizziness following the procedure indicating a cause/effect relationship.
Further, if you’re a vestibular therapist seeing patients you think that symptoms could be arising from the cervical spine, don’t just pass on to your orthopedic mate in the clinic.  Get some training, some real training.  We can help you with that.
You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.
If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    
Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts
Danielle N. Vaughan, PT, DPT, Vestibular Specialist  
Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts



Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...