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Identification of the Correct Cervical Level by Palpation of Spinous Processes
Abstract
The ability to identify the correct vertebral level through examination is an important skill for clinicians who are performing nerve blocks without fluoroscopy. The conventional palpation method, which identifies the most prominent cervical spinous process as the seventh cervical (C7) spinous process is unreliable in many cases. We compared the accuracy of 2 different palpation methods used for identifying C7.
Ninety-six patients scheduled for cervical spine procedures under fluoroscopy guidance were randomized into either the control group or the flexion-extension group. The control group was examined with the conventional method, and the flexion-extension group was examined through assisted flexion and extension of the patient's cervical spine and identifying the lowest freely moving spinous process as C6 and the following stationary cervical spinous process as C7. A single anesthesiologist attempted to identify the C7 spinous process by using either the conventional method or the flexion-extension method and marked the presumed C7 spinous process with a radiopaque indicator. The actual vertebral level was then confirmed by fluoroscopy. The accuracy of the 2 different palpation techniques was compared, and the influence of patients' age, gender, and body mass index (BMI) was also examined.
The C7 spinous process was correctly identified in 77.1% of patients in the flexion-extension group, compared with 37.5% in the control group (P<0.001). The C6 spinous process was identified as the most prominent cervical spinous process instead of C7 in 47.9% of patients in the control group, showing that errors are more common in the cephalad direction with the conventional method. The accuracy of the flexion-extension method was significantly higher than the conventional method regardless of the patient's age, gender, and BMI. Particularly, this difference in accuracy was seen not only in patients with a BMI <25 kg/m(2), but also in those with a BMI ≥25 kg/m(2) (BMI <25 kg/m(2), P=0.006 vs BMI ≥25 kg/m(2), P=0.008).
The flexion-extension method is more accurate than the conventional method when identifying cervical vertebral level.
... [4][5][6] As a standard part of the physical examination in musculoskeletal assessment, palpation methods targeting the location of inner body structure are required to be both valid and reliable for a valid clinical assessment. [7][8][9][10][11][12][13][14] The first cervical vertebra (C1) is an anatomic landmark for head and neck surgeries and interventions for otolaryngologic conditions. For instance, the accurate identification of C1 is necessary for avoiding vertebral artery damage during surgical procedures. ...
... [15][16][17][18] Additionally, the clinical evaluation of people presenting with headaches, facial pain, or suspected temporomandibular disorders includes the palpation of masseter muscles. [19][20][21] The accuracy of palpation methods has been addressed by validity studies that compared their results with an imaging reference standard, such as radiograph, 7,9,[22][23][24][25][26] computed tomography (CT), 27 ultrasound imaging, 23 fluoroscopy, 8 and magnetic resonance 28 imaging. In this context, accuracy represents the probability that an anatomic landmark is correctly located by a palpation test; it can be calculated by the sum of the true positives plus true negatives palpation results divided by the total number of individuals tested. ...
... To the best of our knowledge, this is the only study that aimed to examine the accuracy of palpation methods of other landmarks in the cervical spine using images as gold standards. 7,8,[11][12][13][14]22,25 One similar finding to Cooperstein et al 31 was that the majority of errors in identifying the C1TP occurred in the caudal direction. 31 In contrast to Cooperstein et al, 31 our study has several differences that might explain the difference in the observed accuracy. ...
Objective
The purpose of this study was to examine the accuracy of palpation methods for locating the transverse processes of the first cervical vertebra and masseter muscle using radiographic images as the gold-standard method and the association between personal characteristics with the observed accuracy.
Methods
This was a single-blinded, diagnostic accuracy study. Ninety-five participants (49 women, 58 ± 16 years of age) were enrolled in this study. A single examiner palpated the neck and face region of all participants to identify the transverse processes of the first cervical vertebra and masseter muscles bilaterally. In sequence, participants underwent a multislice computed tomography scan for assessment of the superimposed inner body structure. Two radiologists assessed the computed tomography images using the same criteria and were blinded regarding each other's assessment and the anatomic landmarks under investigation. The palpation accuracy was calculated as the proportion of the correctly identified landmarks in the studied sample. The correlation of the palpation outcome (correct = 1; incorrect = 0) with age, sex (male = 1; female = 0), and body mass index was investigated using the point-biserial correlation coefficient.
Results
The right and left transverse processes were correctly located in 76 (80%) and 81 (85%) participants, respectively, and bilaterally in 157 events (83%), as evaluated by the consensus of the 2 radiologists. The masseter muscles were correctly localized bilaterally in 95 of 95 (100%) participants. Body mass showed statistical evidence of a weak, positive correlation with the correct location of the transverse processes of the first cervical vertebra at the right body side (r = .219; 95% confidence interval, 0.018-0.403; P = .033).
Conclusion
Palpation methods used in this study accurately identified the location of the first cervical vertebra spinous processes and the masseter muscles.
... Res. Public Health 2022, 19, 6278 2 of 10 to using radiographic measurements for evaluating head and neck alignment. Therefore, in a clinical setting, photographs are often used to evaluate the alignment of body parts based on the relative positions of the bony indices on the body surface [8,9]. ...
... Blue adhesive dots, 8 mm in diameter, were posted on the C7 spinous processes, the tragus of the ear, and the lateral canthus of the eye. The inferior end of the C7 spinous process was identified using the flexionextension palpation method [19], and a marker was placed on the skin surface at that level. Using the flexion-extension palpation method, the two most prominent cervical spinous processes were palpated by the investigator's index and middle fingers while the seated patient's cervical spine was in flexion. ...
... Blue adhesive dots, 8 mm in diameter, were posted on the C7 spinous processes, the tragus of the ear, and the lateral canthus of the eye. The inferior end of the C7 spinous process was identified using the flexion-extension palpation method [19], and a marker was placed on the skin surface at that level. Using the flexion-extension palpation method, the two most prominent cervical spinous processes were palpated by the investigator's index and middle fingers while the seated patient's cervical spine was in flexion. ...
The cranial vertical angle (CVA) and cranial rotation angle (CRA) are used in clinical settings because they can be measured on lateral photographs of the head and neck. We aimed to clarify the relationship between CVA and CRA photographic measurements and radiographic cervical spine alignment. Twenty-six healthy volunteers were recruited for this study. Lateral photographs and cervical spine radiographs were obtained in the sitting position. The CVA and CRA were measured using lateral photographs of the head and neck. The C2-7 sagittal vertical axis (SVA), cervical lordosis (C2-7), and occipito-C2 lordosis (O-C2) were measured using radiographic imaging as a standard method of evaluating cervical spine alignment. Correlations between the CVA and CRA on photographs and cervical spine alignment on radiographs were analyzed. The CVA and SVA were significantly negatively correlated (ρ = −0.51; p < 0.05). Significant positive correlations were found between CVA and C2-7 (ρ = 0.59; p < 0.01) and between CRA and O-C2 (ρ = 0.65; p < 0.01). Evaluating the CVA and CRA on photographs may be useful for ascertaining head and neck alignment in the mid-lower and upper parts of the sagittal plane.
... Methods to correctly identify vertebral levels by palpation have been described for the lumbar, thoracic, and cervical regions; however, none are satisfactorily reliable. 4 In a systematic review, Cooperstein et al 5 pointed out that anatomically incorrect landmark benchmarks would hinder the accurate identification of spinal sites of clinical interest, beyond what is to be expected as a result of examiner error and variation among patients, which lends some value to a systematic review of the literature addressing other commonly used spinal landmark rules. 5 Compared with reliability studies, the accuracy of palpation has not received the same emphasis in the literature. ...
... Studies that have tried to analyze the relationship between BMI and sex have reported inconclusive results, only highlighting these factors as potential study limitations. 4,10 In their last systematic review, Póvoa et al 11 identified few studies that evaluated the validity of manual palpatory procedures for examining bony landmarks of the cervical spine. They reported fair to good methodologic quality with poor external validity as a result of the sampling heterogeneity. ...
... The rationale for this assumption is that the free C6 spinous process of the cervical spine is the last (lower cervical spinous process) vertebra to move during the test; therefore, the underlying vertebra, which is the first stationary vertebra, should be C7. 4 3. Then the evaluator shifted his middle and index fingers in the cranial direction and repeated the flexion-extension test. This second stage was used to confirm the localization of the first stationary vertebra of the cervicothoracic group. ...
Objective:
The aim of this study was to evaluate the accuracy of a motion palpation procedure, the flexion-extension test, in localizing the spinous process of the seventh cervical vertebra (C7).
Methods:
We analyzed 101 adult participants with metal markers that permitted the identification of the C7 spinous process. This analysis occurred during a flexion-extension test and was confirmed by radiography. Data sample characteristics were analyzed by descriptive statistics, and the relationship between independent variables (weight, height, sex, age, and body mass index [BMI]) and dependent variables (coincidence between the most prominent vertebra and the stationary vertebra, as determined by the flexion-extension test) was determined via logistic regression.
Results:
The sample population was 48.5% male with a mean age of 56.8 years (standard deviation, ±14.9) and a mean BMI of 25.54 kg/m2(standard deviation, ±5.5). In 54.5% of cases, the C7 spinous process was correctly identified by the flexion-extension test. The agreement between the flexion-extension test and radiography in accuracy of localization of the C7 spinous process was significant (P= .021), as was the correct localization of C7 (P= .05).
Conclusion:
The localization of the C7 spinous process was more accurate in individuals with a BMI <25 kg/m2and whose most prominent vertebra coincided with the stationary vertebra as determined by the flexion-extension test.
... Palpation, the most prominent of the C7 spinous process method, is the common technique to identify upper thoracic vertebral level. However, the accuracy of this method to identify C7 spinous process was lower than 50% (2,3) . ...
... Palpation method: Patients were placed in lateral position with slight neck flexion. C7 spinous process was identified by using flexion-extension assisted technique (3) . Two prominent cervical spinous processes were palpated by single investigator (Pakpirom J) using index finger and middle finger. ...
... The most prominent of C7 spinous process has been used as a landmark to describe the cervicothoracic junction and upper thoracic intervertebral space to perform central neuraxial anesthesia or thoracic paravertebral block (TPVB). However, previous studies (2,3,7) demonstrated that using this method to identify the C7 spinous process was not reliable and had a low accuracy rate. Shin et al (3) demonstrated that using flexion and extension assisted palpation method improved the accuracy of C7 spinous process identification. ...
Objective: To obtain the adequate surgical anesthesia from thoracic paravertebral block (TPVB), identifying the correct thoracic spine level is mandatory. Ultrasound has become a recent standard to perform regional anesthesia including TPVB. This study aimed to investigate two techniques of using ultrasound to identify C7 spinous process compared with the palpation method. Material and Method: Twenty volunteers were invited to participate in the investigation. Each volunteer was evaluated using palpation method with flexion and extension maneuver, ultrasound transverse scan (US-TS) and parasagittal scan (US-PS) to identify C7 spinous process. All volunteers were scanned on both sides randomly, and finally checked with fluoroscope. The examinations were independently performed by different investigators. The invisible marker pen was used to locate C7 spinous process from each technique. The accuracy and frequency of identified level, both correction and errors, were recorded and compared. Results: The accuracy of palpation method with flexion and extension maneuver for C7 spinous process identification was 72.5%. While identifications of C7 by using US-TS and US-PS were correct 52.5% and 30% respectively. Interestingly, most errors were one level higher than actual C7 spinous process. Conclusion: Identifying C7 spinous process using ultrasound assisted, both US-TS and US-PS techniques had a lower accuracy compared with palpation method with flexion and extension maneuver. Thus, the technique of ultrasound assisted C7 spinous process identification need to be modified. Keywords: C7 spinous process identification, Ultrasound assisted, Thoracic paravertebral block, Palpation method with flexion and extension maneuver To identify the correct level of upper thoracic spine in order to provide optimal surgical anesthesia for thoracic paravertebral or epidural block is an essential maneuver during chest wall surgery, upper abdominal surgery or thoracotomy surgery. The correct placement of paravertebral blockade will assure the optimization of surgical anesthesia and analgesia with minimized side effects. Multiple level thoracic paravertebral blocks for breast surgery reduce chronic pain incidence and also improve the quality of life for breast cancer patients (1). Palpation, the most prominent of the C7 spinous process method, is the common technique to identify upper thoracic vertebral level. However, the accuracy of this method to identify C7 spinous process was lower than 50% (2,3). Ultrasound has become a recent standard to perform regional anesthesia including TPVB. Moreover, using ultrasonography has been studied to identify the cervical nerve roots by differentiating the transverse process of C6 and C7. Identifying C6 transverse process based on presence of a large anterior tubercle (Chassaignac tubercle) and a posterior tubercle, while C7 transverse process is absent of anterior tubercle of transverse process (4,5). The studies showed 50% agreement between the landmark technique and
... This procedure is often included as part of an evaluation protocol in individuals with neck pain [6,7], temporomandibular disorders [8,9], oral facial pain [10], and headache [11][12][13] to determine the functional status and to assist in deciding which manual procedure to be used. Although several studies demonstrate the accuracy and reliability of locating cervical landmarks by palpation in both clinical and laboratory settings [14][15][16][17][18][19][20][21][22][23] there is still a call for providing evidence on the used palpation clinical tests by healthcare providers [24][25][26][27][28][29]. ...
... Previous research appraised the influence of anthropometric data on palpation methods for locating cervical landmarks, with a lack of consensus so far. Most studies did not identify a significant correlation between BMI and palpation accuracy in the cervical spine [15,16,18]. In the study of Povoa et al. [20] the location of the C7 spinous process (C7SP) with the flexion-extension method was more accurate in participants with a BMI <25 kg/m 2 . ...
... C-7 spinous process: The largest and most inferior spinous process in the neck. It can be identified with the palpation/flexion/extension method [23]. Sacral hiatus: The opening into the vertebral canal in the midline of the dorsal surface of the sacrum. ...
... This method is not 100% accurate, and discrepancies could occur, as reported by Christopher and colleagues [36]. Similarly, the C-7 spinous process can be identified correctly in only 77.1% of the population by the palpatory method [23]. Successful identification of sacral hiatus through the palpatory method is reported in up to 75% literature [37][38][39]. ...
Introduction:
Spinal anesthesia is commonly used for various surgical procedures. Prediction of spinal anesthesia block height is always a challenging task for anesthetists. Higher than desired levels of spinal anesthesia blocks are associated with serious side effects, while inadequate block height does not provide satisfactory surgical anesthesia. In this study, we observed the relationship between the ratio of trunk length (TL) and square of the abdominal circumference (AC2) and spinal anesthesia sensory block height in geriatric patients undergoing transurethral resection of the prostate (TURP).
Material & methods:
This is a cross-sectional study conducted at the Aga Khan University Hospital Karachi, Pakistan, on geriatric patients undergoing TURP under spinal anesthesia. Forty-three elderly patients (American Society of Anaesthesiology level I-III) between 60 and 80 years were recruited for the study. In hospital wards, trunk length (TL) and abdominal circumference were recorded before the procedure. In the operating rooms, spinal anesthesia was performed at L3-L4 intervertebral space with 0.5% hyperbaric bupivacaine 10mg (2mls). Block height was measured by the placement of ice pads at different dermatomes. Spearman rank correlation coefficient was used to analyze the physical parameters (TL/AC2) and spinal anesthesia block height. Results: The ratio of trunk length and square of the abdominal circumference (TL/AC2) correlates with spinal anesthesia block height in geriatric patients, where the spearman rank correlation coefficient was r =-0.284 with p = 0.015.
Conclusion:
The ratio of the long axis (TL) and transection area of the abdomen (AC2), which coincides with (TL/AC2), correlated with spinal anesthesia sensory block height. Hence, elderly patients with a low TL/AC2 ratio will have higher block height after spinal anesthesia.
... During cervical extension, the C7 spinous process should not move while the C6 spinous process moves anteriorly. 49 Shin et al 49 found this technique to be more accurate than simply relying on the C7 spinous process to be the most prominent. 49 Lumley 48 has stated the most precise spinal landmark in the lower thoracic and lumbar spine is found by identifying L4 using a line drawn between the iliac 680 Physical Therapy Volume 100 Number 4 2020 crests. ...
... 49 Shin et al 49 found this technique to be more accurate than simply relying on the C7 spinous process to be the most prominent. 49 Lumley 48 has stated the most precise spinal landmark in the lower thoracic and lumbar spine is found by identifying L4 using a line drawn between the iliac 680 Physical Therapy Volume 100 Number 4 2020 crests. 48 Hence, T12 was identified in the current study by first locating L4 using the technique described by Lumley 48 and then counting up the spinous processes to T12 using palpation. ...
Background:
Shoulder impingement syndrome (SIS) is the most common form of shoulder pain and a persistent musculoskeletal problem. Conservative and invasive treatments, aimed at the shoulder joint, have had limited success. Research suggests shoulder function is related to thoracic posture, but it is unknown whether thoracic posture is associated with SIS.
Objective:
The objective of this study was to investigate whether there is a relationship between SIS and thoracic posture.
Design:
This was a case control study.
Methods:
Thoracic posture of 39 participants with SIS and 39 age, gender, and dominant arm matched controls was measured using the modified Cobb angle from a standing lateral radiograph. Thoracic range of motion (ROM) was also measured using an inclinometer. Between-group differences were compared using t tests. The relationship between thoracic posture and thoracic ROM was determined with linear regression.
Results:
Twenty females and 19 males with SIS (mean age 57.1 years, SD 11.1) and 39 age, gender, and dominant arm matched controls (mean age 55.7 years, SD 10.6) participated. Individuals with SIS had greater thoracic kyphosis (mean difference 6.2o, 95% CI 2.0, 10.4) and less active thoracic extension (7.8o, 95% CI 2.2, 13.4). Greater thoracic kyphosis was associated with less extension ROM (i.e more flexion when attempting full extension: β = 0.71, 95% CI 0.45, 0.97).
Limitations:
These cross-sectional data can only demonstrate association and not causation. Both radiographic measurements and inclinometer measurements were not blinded.
Conclusions:
Individuals with SIS had a greater thoracic kyphosis and less extension ROM than age and gender matched healthy controls. These results suggest that clinicians could consider addressing the thoracic spine in patients with SIS.
... The C7 spinous process should not move while the C6 spinous process moves anteriorly. 23 Shin et al. 23 found this technique to be more accurate than relying on the C7 spinous process to be the most prominent. ...
... The C7 spinous process should not move while the C6 spinous process moves anteriorly. 23 Shin et al. 23 found this technique to be more accurate than relying on the C7 spinous process to be the most prominent. ...
... The C7 spinous process should not move while the C6 spinous process moves anteriorly. 23 Shin et al. 23 found this technique to be more accurate than relying on the C7 spinous process to be the most prominent. ...
... The C7 spinous process should not move while the C6 spinous process moves anteriorly. 23 Shin et al. 23 found this technique to be more accurate than relying on the C7 spinous process to be the most prominent. ...
Background:
Radiographs are used to monitor thoracic kyphosis in individuals with certain pathologies (e.g. osteoporosis), exposing patients to potentially harmful radiation. Thus, other measures for monitoring the progression of thoracic kyphosis are desirable. The gravity-dependent inclinometer has been shown to be reliable but its validity as a measure of thoracic kyphosis has not been investigated.
Objectives:
To determine the validity of the gravity-dependent (analogue) inclinometer for measuring thoracic kyphosis.
Design:
Cross-sectional study.
Method:
Participants (n=78) were recruited as part of a larger study of shoulder impingement syndrome. Healthy participants (n=39) were age and gender matched to the shoulder impingement syndrome group (n=39). Measurements of thoracic kyphosis using a gravity-dependent inclinometer were compared with modified Cobb angle results obtained from a sagittal view of lateral radiographs. A Bland-Altman plot assessed agreement. The Pearson correlation coefficient and linear regression was used to determine the association between modified Cobb angles and inclinometer measurements.
Results:
The Bland-Altman plot demonstrated good agreement. The Pearson correlation coefficient, r=0.62 (p<0.001), and linear regression model established a strong association between the thoracic kyphosis angle from the inclinometer readings and the modified Cobb angle measured from the radiographs (β=0.47, 95% CI 0.29, 0.65, p<0.001, R2=0.52, n=78). Age as a confounder was included in the model (β=0.35, 95% CI 0.19, 0.51, p<0.001).
Conclusions:
The gravity-dependent (analogue) inclinometer produces angles that are comparable to the modified Cobb angle obtained from radiographs, establishing its criterion validity as a safe clinical tool for measuring thoracic kyphosis.
... Spine palpation is commonly used in the assessment of patients with spine related pain. Consequently, accurately identifying anatomical structures in order to make a diagnosis and/or deliver a manual treatment constitutes an important ability for a number of health care providers (Shin et al., 2011; Hurwitz, 2012; Triano et al., 2013). From a clinical perspective, the required specificity for a spinal manipulation therapy to be clinically efficient is still unknown but recent studies highlighted a potential relationship between clinical improvement associated to spinal manipulation therapy and a decrease in segmental lumbar spinal stiffness (Fritz et al., 2011; Wong et al., 2015 ). ...
... Until there is clear evidence, researchers and clinicians should attempt to be as specific and accurate as possible. Various spine landmarks have been proposed to guide spinous process (SP) palpation, such as the use of the line connecting the superior aspect of the iliac crests posteriorly to identify the midline at L4 or L4-5 spinal level (Chakraverty et al., 2007), the lower angle of the scapula for T8 SP (Cooperstein et al., 2015), and head movement for C6 and C7 SPs (Shin et al., 2011). Despite these guidelines, clinicians frequently misidentify SPs (Harlick et al., 2007; Phillips et al., 2009; Snider et al., 2011). ...
Palpation methods (PMs) have been proposed to guide clinicians in locating the thoracic transverse processes (TTPs). However, no studies have assessed the validity of TTPs palpation or the added value of musculoskeletal ultrasound (MSU). The objectives of the present study were (1) to explore the validity of TTPs location using palpation as commonly performed by clinicians, (2) to develop an accurate and valid PM, and (3) to assess the added value of MSU. A standardized procedure was used on six cadavers. It consisted in the insertion of markers through the T3, T5, T6 and T8 TTPs and spinous processes, which were identified using palpation and MSU. First, a fresh cadaver was used to explore the validity of the common palpation method. Since poor validity was observed, one intermediate and a final PMs were tested on a total of five Thiel-embalmed specimens. A descriptive analysis was performed and agreement between MSU and the final PM was determined. The final PM led to the proper determination of all TTPs on three specimens with a mean error of 4 ± 1.8 mm in relation to the TTPs center. The coefficient of variations and root mean square errors were ≤ 0.15 and 0.21 mm, respectively. Bland-Altman plot showed no differences between palpation and MSU. In conclusion, this study reports the validity of a new PM using multiple landmarks to guide TTPs determination and for which MSU does not seem to add value in accuracy. These results may have important clinical implications for clinicians using palpation.
... The tool contains a perpendicular plate, handle, and slide bar (Figure 2A) in order to easily fix it to the wall with a weight w 0.6 kg. Prior to the assessments, all raters were trained to use the tool (the total training time was w30 minutes) and using the prominence of C7 as a landmark of measurement because it is more stationary and adjacent to the thoracic spine than the occiput [19,20] . Therefore, using C7 as a landmark for measurement would provide a more accurate compensatory distance due to thoracic kyphosis and reduce errors in the outcomes once the participant moved her head. ...
... Prior to the assessments, the raters identified and marked the bony landmarks (C7 and T12). The C7 is the lowest and most prominent cervical vertebra that remains stationary during flexion and extension of the cervical spine [19,20]. The T12 was identified by palpating the fourth spinous process superiorly to the fifth lumbar vertebra (L5 or the spinous process above the sacrum) [19]. ...
Background: In primary healthcare (PHC) service, community residents, village health volunteers (VHVs), and healthcare professionals need to work in partnership to facilitate universal and equitable healthcare services. However, these partnerships may need an appropriate tool helping them to execute an effective health-related activity.
Objectives: To investigate the reliability and validity of a simple kyphosis measure using a perpendicular distance from the seventh cervical vertebra (C7) to the wall (C7WD).
Methods: Elderly people with different degrees of kyphosis (n = 179) were cross-sectionally investigated for the intra- and interrater reliability of the measurement by a physical therapist (PT), VHV, and caregiver. The validity was assessed in terms of concurrent validity as compared with the Flexicurve, and discriminative validity for functional deterioration in participants with mild, moderate, and severe kyphosis.
Results: The method showed excellent reliability among PT, VHV, and caregivers (ICC > 0.90, p
... Q7 Participants were marked for the level of C7 using the flexion extension of the cervical spine, whereby the lowest freely moving spinous process was the sixth cervical vertebra (C6) and the following stationary cervical spinous process was identified as C7 (Shin et al., 2011). Then, they stood upright as tall as possible with their heels, sacrum, and back against the wall, and their head in a neutral position as determined using the lower orbital margin and upper margin of the acoustic meatus in a horizontal plane (Figure 1b; Amatachaya et al., 2016;Antonelli-Incalzi et al., 2007;Balzini et al., 2003;Suwannarat et al., 2018). ...
Thoracic hyperkyphosis could affect mobility and independence of older adults. However, there was no clear evidence on the use of the seventh cervical vertebra wall distance (C7WD), a practical measure for thoracic hyperkyphosis, to indicate mobility deficits relating to independence of these individuals. This study explored the ability of C7WD to determine mobility impairments in 104 older adults. Participants (average age of 74.1 ± 7.4 years) with various degree of thoracic kyphosis were cross-sectionally measured for their C7WD, mobility, and Cobb angle. The findings indicate that participants with thoracic hyperkyphosis (Cobb angle = 46.1 ± 5.2°) had significantly poorer mobility than those without thoracic hyperkyphosis (Cobb angle = 32.8 ± 5.9°, p < .05). A C7WD of ≥7.8 cm could indicate mobility deficits of the participants (sensitivity = 71%–92%, specificity = 75%–94%, and area under the curve >0.80). The findings confirm the ability of C7WD that could be clinically measured using rulers to indicate mobility deficits of older adults.
... Then, the half point between the superior and inferior edges of the spinous process was marked with a skin-friendly pen. If both palpated spinous processes remained stationary, the upper cervical spinous process would be C7, and the palpation process was repeated by moving 1 level (27). ...
Non-specific neck pain is a common musculoskeletal disorder with a high prevalence and involves impaired joint movement pattern. Therefore, this study aimed to compare the trajectory of the instantaneous axis of rotation(IAR) in flexion-extension movements of the neck between people with and without nonspecific neck pain, using functional data analysis techniques. Furthermore, possible relationships between neck kinematics and perceived pain and disability were explored. Seventy-three volunteers participated in this cross-sectional study. They were allocated in a non-specific pain group (PG, n = 28) and a control group (CG, n = 45). A cyclic flexion-extension movement was assessed by a video photogrammetry system and numerical and functional variables were computed to analyze IAR trajectory during movement. Moreover, to explore possible relationships of these variables with pain and neck disability, a visual analogue scale (VAS) and the neck disability index (NDI) were used. The instantaneous axis of rotation trajectory during the flexion-extension cyclic movement described a path like Greek letter rho both in the CG and the PG, but this trajectory was shorter and displaced upward in the PG, compared to the CG. A reduction of the displacement range and a rise in the vertical position of the IAR were related to VAS and NDI scores. Non-specific neck pain is associated with a higher location of the instantaneous axis of rotation and a decrease in length of the path traveled during the flexion-extension movement. This study contributes to a better description of neck movement in people with non-specific neck pain, which would help to plan an individualized treatment.
... First, spinous processes from C7 to S3 were palped and marked with an ink pen on the skin by an examiner (SGU) who has twenty years of postgraduate relevant experience. The C7 spinous process was identified using the flexion-extension method (Shin et al., 2011). Then, Idiag M360 was rolled along the spine from the spinous process of C7 to the spinous process of S3 in the neutral standing position, maximum flexion position, and maximum extension position, respectively. ...
Recent studies suggest that patients with lower extremity osteoarthritis may have altered spinal posture. We aimed to investigate age and body mass index-adjusted sagittal spinal alignment and mobility and their relation to physical function in women over 40 years of age with and without mild-to-moderate knee osteoarthritis (KOA). Thirty-two women with unilateral mild-to-moderate KOA and thirty-two asymptomatic women were included. A skin-surface device was used to assess sagittal alignment and mobility of the thoracic, lumbar, and sacral regions and trunk inclination angle. Physical function was assessed using the Timed Up and Go test. Analysis of covariance was used to compare groups and correlation coefficients were calculated separately for two groups. Women with KOA had higher thoracic kyphosis and lumbar lordosis compared to asymptomatic women (p<0.05). The mean differences were 6.60 (%95 Confidence Interval 1.38;11.82) and -5.63 (-10.06;-1.20) for thoracic kyphosis and lumbar lordosis, respectively. Physical function score was moderately correlated with trunk inclination angle and lumbar, sacral, and trunk inclination mobility in asymptomatic women (r=0.400, -0.504, -0.602, and -0.681, p<0.05), but a significant correlation was not found in women with KOA (p>0.05). In conclusion, women with KOA had altered spinal alignment. Spinal alignment and mobility were related to physical function in asymptomatic women over 40 years of age. Addressing sagittal spinal alignment in the clinical management of KOA may provide valuable data, especially for preventing possible spinal disorders.
... Q7 Participants were marked for the level of C7 using the flexion extension of the cervical spine, whereby the lowest freely moving spinous process was the sixth cervical vertebra (C6) and the following stationary cervical spinous process was identified as C7 (Shin et al., 2011). Then, they stood upright as tall as possible with their heels, sacrum, and back against the wall, and their head in a neutral position as determined using the lower orbital margin and upper margin of the acoustic meatus in a horizontal plane (Figure 1b; Amatachaya et al., 2016;Antonelli-Incalzi et al., 2007;Balzini et al., 2003;Suwannarat et al., 2018). ...
Background:
Thoracic hyperkyphosis is common in the elderly, especially in women, and results in impaired balance control, impaired functional mobility and an increased risk of multiple falls. The 7th cervical vertebra wall distance (C7WD) is a practical method for evaluating thoracic hyperkyphosis.
Objective:
This study calculated C7WD cut-off scores that may identify impaired balance control, impaired functional mobility and an increased risk of multiple falls in elderly community-dwelling women with thoracic hyperkyphosis. This study also explored the correlation between C7WD, balance control and functional mobility.
Methods:
Sixty participants were assessed for thoracic hyperkyphosis using the C7WD, balance control using the functional reach test (FRT), functional mobility using the timed up-and-go test (TUG) and a history of falls using their personal information.
Results:
The data indicated that a C7WD of at least 7.95 cm, 8.1 cm and 8.8 cm had a good to excellent capability of identifying impaired balance control, impaired functional mobility and an increased risk of multiple falls, respectively. The C7WD results were significant and correlated with balance control (rs=-0.68) and functional mobility (rs= 0.41).
Conclusions:
The C7WD may be utilised as a screening tool for these three impairments in this population.
... Since the back plate is aligned at 1" below Suprasternale, about 3.6" (female) -4.1" (male) from the top edge of back plate to C7 is exposed. Theoretically, C7 does not move during the neck flexion and extension (Shin et al., 2011;Póvoa et al., 2018), thus covering the exposed area by increasing the back plate length up to C7 should not restrict neck mobility. For each front Table 3. Specification of the family of armor plates. ...
The development of optimized fitting body armor is critical to the fightability and protection of our warfighters and first responders. Body armor systems generally worn by warfighters consists of three protective portions: rigid plates, a soft armor insert, and a carrier/vest. Rigid plates are inserted into the front, back, and sides of the body armor to provide a higher level of protection for the wearer, while the soft armor is positioned behind the plates and in areas of the body where a lower level of protection is acceptable or required for mobility and comfort. Previously, a comprehensive fit mapping study on the family of armor plates to investigate the relationship between the coverage, anthropometry and mobility relative to size specifications of torso and side plates was conducted (Choi et. al., 2017). There is a delicate tradeoff between covering more (i.e., a greater area of protection) while not degrading the wearer’s mission performance (primarily their mobility). However, some level of mobility degradation is unavoidable. Choi et. al. (2017)'s results quantitatively defined the impact of coverage on mobility, visualized the mobility degradation as coverage increase, and set the allowable mobility degradation to be 10%. The coverage corresponding to the allowable mobility degradation was then converted into anthropometric dimensions. Accommodation envelopes for the current U.S. Army torso plates, relative to the male and female US Army population, were reported. Final size tariffs were calculated using the front plate. A sizing system for the back plate and/or side plates were not developed.This current study explores a theoretical framework for ballistic rigid plate size optimization for the front, back and side plates. When the protection coverage is maximized with minimal mobility degradation, the system would be considered optimized. For this study, minimal mobility degradation was set to 10%. For the front plate, Choi et. al. was revisited to retrieve the maximum width and length while limiting the mobility degradation to 10%. Chest Breadth, was measured using the ANSUR II (Gordon et. al., 2014) procedure, and Suprasternale -Tenth Rib Length was used to derive the width and length of plates, respectively. Then, a specification of the front ballistic plate, given anthropometric characteristics of the current U.S. Army population was developed from a reverse engineering approach. Theoretical accommodation envelopes for each front plate size were then developed and plotted against the current ANSUR II data. Once the front plate sizing system was developed, anthropometric characteristics of cases within each accommodation envelope per size were investigated to develop the required size specifications for the back plate. The width of the back plate shares the width of the matching front plate, but the length takes into account the back length, from the Cervicale -Tenth Rib Length. Size specifications for the side plates were also developed. Given that the front and back plates are worn together; the maximum width of the side plate is defined by the surface availability at the location of the tenth rib level. The side plate length is defined using the distance between Tenth Rib and the Axilla. A theoretical size system for a family of rigid armor plates is presented in a series of tables as well as bivariate plots. A detailed process for plate size prediction and the interaction between the front, back and side plates is presented.
... During the pre-session, participants lay comfortably in the prone position on an examination plinth suitably undressed for the QST procedures. The test sites were located by palpation following a strict protocol as below [19][20][21][22]. ...
Background
Changes in pain sensitivity are a commonly suggested mechanism for the clinical effect of spinal manipulative therapy (SMT). Most research has examined pressure pain thresholds (PPT) and has primarily been conducted in controlled experimental setups and on asymptomatic populations. Many important factors are likely to differ between research and clinical settings, which may affect PPT changes following SMT. Therefore, we planned to investigate PPT before and after clinical chiropractic care and investigate relationships with various potentially clinically-relevant factors.
Methods
We recruited participants from four Danish chiropractic clinics between May and August 2021. A total of 129 participants (72% of the invited) were included. We measured PPT at eight pre-determined test sites (six spinal and two extra-spinal) immediately before ( pre-session ) and immediately after ( post-session ) the chiropractic consultation.
We used regression analyses to investigate PPT changes, including the following factors: (i) vertebral distance to the nearest SMT site, (ii) rapid clinical response, (iii) baseline PPT, (iv) number of SMTs performed, (v) at the region of clinical pain compared to other regions, and (vi) if other non-SMT treatment was provided. We also performed topographic mapping of pre-session PPTs.
Results
After the consultation, there was a non-significant mean increase in PPT of 0.14 kg (95% CIs = − 0.01 to 0.29 kg). No significant associations were found with the distance between the PPT test site and nearest SMT site, the clinical response of participants to treatment, the pre-session PPT, the total number of SMTs performed, or the region/s of clinical pain. A small increase was observed if myofascial treatment was also provided. Topographic mapping found greater pre-session PPTs in a caudal direction, not affected by the region/s of clinical pain.
Conclusions
This study of real-world chiropractic patients failed to demonstrate a substantial local or generalized increase in PPT following a clinical encounter that included SMT. This runs counter to prior laboratory research and questions the generalizability of highly experimental setups investigating the effect of SMT on PPT to clinical practice.
... Location of C7 vertebra Initially, the C7 vertebra was located by palpation, using the assisted flexion-extension method. [8] It was then confirmed using portable ultrasound imaging (7.5 Hz frequency probe). The transducer was placed in sagittal axis, to identify the transverse process of C7 as a hyperechoic shadow without continuing to the rib laterally. ...
Introduction: In recent literature, there is some suggestion of vertebral column length (VCL) and abdominal girth (AG) in determining cephalad spread of spinal anesthetic. Bodily habitus including abdominal fat distribution, AG, and VCL may vary among individuals from different races/ethnicity. We thus aimed to evaluate the role of AG, and VCL measured with the patient in sitting as well as lateral position, in determining the cephalad spread of intrathecal hyperbaric bupivacaine.
Methods: Prospective blinded study conducted in 60 consenting adult male patients of ASA status I or II, undergoing lower limb surgery using standardized combined spinal epidural performed. The cephalad spread of subarachnoid block was assessed using loss of discrimination to pin-prick and cold temperature. The VCL was measured from C7 vertebra to the sacral hiatus in sitting as well lateral decubitus position. The AG was measured at level of umbilicus during end of expiration.
Results: The mean AG and VCL in sitting/lateral positions were: 78.4 ± 11.0, 60.9 ± 3.2, and 59.2 ± 3.2 cm, respectively. VCL in sitting position was significantly longer than in lateral position (P = 0.000). There was no significant correlation between the Smax (pin-prick) and AG (P = 0.138), or VCL in sitting position (P = 0.549), or VCL in lateral position (P = 0.323). Similar lack of correlation was noted with the Smax (cold) as well (P > 0.05).
Conclusions: Contribution of AG or VCL on the extent of intrathecal drug spread is not a consistent finding.
... First, the spinous processes of the seventh cervical (C 7 ) and twelfth thoracic (T 12 ) vertebrae were detected by palpation. The C 7 has the most prominent spinous process and the minimum range of motion during flexion and extension movements (Shin, Yoon, and Yoon, 2011). To locate the T 12 , the participants were asked to inhale deeply to properly locate the ribs. ...
Background
A variety of noninvasive instruments have been introduced in the literature to assess thoracic curvature, although the psychometric properties of many of these instruments have not been satisfactory. Photogrammetry is a safe, accessible, and reliable technique. However, its validity in adolescents with hyperkyphosis has not yet been investigated.
Objectives
To investigate the validity and test–retest reliability of photogrammetry in the measurement of thoracic kyphosis among adolescents with hyperkyphosis.
Methods
Fifty adolescents with hyperkyphosis participated in this study. The kyphosis angle was measured using radiography and photogrammetry. A two-way random model of the intraclass correlation coefficient (ICC2,3) was used to estimate relative reliability. Absolute reliability was assessed by calculating the standard error of the measurements (SEM) and the minimal detectable change (MDC). Pearson’s correlation coefficient was calculated to evaluate the validity of the photogrammetry technique. Bland–Altman plots were plotted to determine the agreement between the angles measured by radiography and photogrammetry.
Results
There was a strong correlation between the values obtained from the photogrammetry technique and those from the radiography method (r = 0.94). The 95% limits of agreement indicated that the photogrammetric measurements of thoracic kyphosis angle might range from 2.4 degrees greater to 10.2 degrees lower than the Cobb radiographic angle. Photogrammetric measurements of thoracic kyphosis showed excellent test–retest reliability (ICC = 0.97; SEM = 1.67; MDC = 4.62).
Conclusion
High reliability of photogrammetry technique and its strong correlation with radiographic Cobb angle support the application of this technique for the measurement of thoracic kyphosis in clinical practice.
... Second, the electrode positions near the spinal cord were mainly determined by finding the C7 spinous process using the conventional method of palpating the most prominent cervical spinous process. However, it is possible to falsely identify the C6 as the C7 spinous process using this palpation method as shown in a previous study [43]. Third, the stimulation intensity can also substantially influence the axons/neurons that are activated. ...
Objective:
Transcutaneous cervical spinal cord stimulation (tsCSC) has been demonstrated to activate the dorsal root and activate targeted muscles. However, it is unclear whether tsCSC can elicit functionally relevant movements of the upper limb for assistive/rehabilitative purposes.
Approach:
The current study sought to elicit arm and hand movements by tsCSC by placing an electrode array near the cervical segments of the spinal cord. Anode stimulation current pulses were delivered to the dorsal side at 120 Hz and 30 Hz in separate trials. The elicited joint kinematics were captured using a motion tracking system.
Main results:
The results revealed that distal and proximal joint movements can be elicited either independently or synergistically. Specifically, different motions, including flexion and extension of the elbow, wrist, and five digits, can be selectively elicited by adjusting the stimulation parameters, such as stimulation location and stimulation intensity.
Significance:
The findings demonstrated the feasibility of the spinal cord stimulation technique in eliciting functional movements of the upper limb. The outcomes also revealed the potential of the tsCSC technique as a promising assistive or rehabilitative method for individuals with impaired function of the upper limb.
... The location of the C7 spinous process was confirmed using the flexionextension test, which identifies the freely moving spinous process as C6 and the stationary spinous process as C7 during active-assisted cervical flexion and extension. 23 The goniometer's stationary arm was placed parallel between the T1 and T2 spinous processes and the scapular spine opposite the rotational side. During trunk rotation, the stationary arm was held in the starting position, and the moveable arm of the goniometer followed the spine of the scapula of the opposite side from the rotational side. ...
Context
Deficient glenohumeral rotational range of motion (ROM) is a risk factor for shoulder pain. Adapted ROM of the trunk and hip in response to loss of glenohumeral ROM has been suggested, as the nature of baseball leads to ROM adaptations.
Objective
To compare the bilateral rotational ROM values of the trunk and glenohumeral and hip joints in adolescent baseball players with or without shoulder pain and to measure the correlation between shoulder-pain intensity and bilateral rotational ROM values for each body area.
Design
Cross-sectional study.
Setting
Research laboratory.
Patients or Other Participants
Ninety-five adolescent baseball players (60 with shoulder pain, 35 without shoulder pain).
Main Outcome Measure(s)
Bilateral trunk rotation and internal rotation, external rotation, and total rotation of the dominant and nondominant glenohumeral and hip joints.
Results
Glenohumeral and hip ROM did not differ between groups, and pain intensity and rotational ROM were not related in either joint. Trunk rotational ROM was greater in the pain group than in the control group (dominant side = 48.8° ± 14.2° versus 41.8° ± 11.9°, respectively; nondominant side = 45.1° ± 14.2° versus 38.9° ± 7.7°, respectively; P values < .05), although the difference was clinically small (mean differences = 7.0° ± 2.7° [95% confidence interval = 1.7, 12.4] on the dominant side, P = .01, and 6.1° ± 2.7° [95% confidence interval = 0.8, 11.5] on the nondominant side, P = .03). Positive but low correlations in all players (ρ = 0.27, P = .01) and in those with shoulder pain (ρ = 0.36, P = .001) were present between shoulder-pain intensity and trunk rotational ROM toward the dominant side.
Conclusions
We found no clinical relationship between shoulder pain and rotational ROM and no clinical differences in rotational ROM values between players with and those without shoulder pain.
... To insure the fixed position of the trigger point in the treatment sessions, nonmuscular sites, including 7 cervical vertebral spinous process and acromion were used. The C7 spinous process was found through flexion-extension method of the cervical spine and then the examiner drew a line between C7 and acromion process and marked the midpoint of this line [18]. All measurement and treatment methods were performed on this point that is the primary point of upper trapezius muscle trigger points. ...
Background: Dry needling is one of the main therapeutic approaches in patients with Myofascial pain syndrome. Few studies have been compared the superficial and deep dry needling methods in these patients.
Objective: To evaluate the effects of superficial and deep dry needling on pain and muscle thickness in subjects with upper trapezius myofascial pain syndrome.
Design: A randomized quasi-experimental double-blinded trial.
Methods: 50 subjects with upper trapezius myofascial pain syndrome (age=26/08 ± 4/62, weight=63/88 ± 8/71 kg, height=167/7 ± 4/82 cm, pain duration=9/75 ± 7/05 m) randomly assigned to the superficial (n=25) and deep (n=25) dry needling groups. The pain and maximum thickness of upper trapezius muscle in rest, fair and normal contractions were measured by visual analogue scale (VAS) and an ultrasound device respectively before and after the intervention as well as 7 and 15 days follow-up.
Results: The mixed-model ANOVAs revealed a significant group-by-time interaction (F=44.03, p<0.001) for pain and muscle thickness in rest (F=67.00, p<0.001), fair (F=108.73, p<0.001) and normal contraction (F=17.73, p<0.001). The main effects of group and time were statistically significant for pain, rest, fair and normal muscle thickness (p<0.001). There were not any significant differences in rest, fair and normal muscle thickness after intervention as well as 7 and 15 days follow-up.
Conclusion: Both superficial and deep dry needling techniques induced significant short-term changes in the VAS. Muscle thickness in rest, fair and normal contractions did not show any significant changes between the groups.
... The accuracy in identifying C7 using manual palpation by clinicians is limited due to the inter-individual variation in the morphology of C7-SP (15)(16)(17)(18)(19). While several studies have assessed the anatomic structures of C7-SP, most of them focus on the mechanisms of diseases affecting it (8,20,21). ...
Palpation of the seventh cervical vertebra (C7) is important for the diagnosis and treatment of neck and chest conditions. However, the spinous process of C7 (C7-SP) displays an anatomical deviation among individuals. The present study aimed to clarify anatomic characteristics of C7-SP by using a three-dimensional (3D) computed tomographic (CT) reconstruction technique. A total of 245 subjects meeting the selection criteria were examined. After CT scanning, the images were reconstructed in 3D. All subjects were grouped according to their deviation of C7-SP: Deviating to the right (DR group), deviating to the left (DL group) and no deviation (ND group). Three distances and three angles were recorded on C7-SP. The vertical distances between the borders of the left and right transverse processes and the tip of the SP, were termed DLTS and DRTS, respectively. The length of the SP was also determined. The angle of the SP deviation was referred to as ∠α, the angle between the SP axis and the line crossing the tips of the transverse processes was referred to as ∠β and the angle between the vertebral body axis and the SP axis was referred to as ∠γ. Among the three groups, differences in ∠α and ∠β were statistically significant (P<0.05). Furthermore, the DLTS was significantly different between the DL and ND groups (P<0.05). In addition, a significant difference in the DRTS was identified between the DR and ND groups (P<0.05). 3D CT reconstruction was reliable for studying anatomic characteristics of C7-SP. Based on this, patients may be preliminarily grouped according to the deviation of their C7-SP and the measurement of the C7-SP may guide clinical diagnoses and treatments.
... The spinous process of C7 was located through the palpation of the most prominent cervical spinous process and the flexion-extension method that is more accurate than the conventional method. 17 The mastoid process, an easily palpable structure, is just posterior to the ear. The marker on the mastoid process (Fig 2) is used in flexion-extension processing only. ...
Objective:
The purpose of this study was to assess the inter- and intra-assessor reliability of the cervical spine device (Formetric, DIERS International GmbH, Schlangenbad, Germany) in measuring cervical range of motion.
Methods:
The cervical spine device was used to measure the cervical range of motion of 65 asymptomatic participants. Flexion-extension, right and left rotation, and right and left lateral flexion were analyzed. Two different assessors performed the measurements on the same day to estimate inter-assessor reliability and 2 days later to examine intra-assessor reliability. Intra-assessor and inter-assessor reliability was assessed using the intraclass correlation coefficient (ICC). The standard error of measurement (SEM) and the smallest detectable difference (SDD) were also estimated.
Results:
Inter-assessor reliability ICCs for flexion + extension and total lateral flexion movements were >0.90. The ICCs for rotation movements and for left lateral flexion were >0.70. The ICCs for flexion (0.64), extension (0.58), and right lateral flexion (0.56) indicated moderate correlation. Mean SEMs ranged from 2.28° (SDD = 6.31°) for left rotation to 8.08° (SDD = 22.38°) for total rotation. As for intra-assessor test-retest reliability, all ICCs were >0.70. Mean SEMs ranged from 3.14° (SDD = 8.70°) for total lateral flexion to 7.50° (SDD = 20.77°) for extension.
Conclusion:
Both inter- and intra-observer reproducibility correlation values are moderate to high for measurements obtained using the cervical spine device.
... Spherical markers were placed onto the most posterolateral edge of the spine of scapula (defined as the posterior acromion), the root of the spine of scapula, and the inferior angle of the scapula. These palpatory techniques for identifying these anatomical landmarks are considered reliable and valid methods [38][39][40][41][42][43]. Calculation of distances and angles were done using digital analysis software (Siliconcoach Live, Dunedin, NZ) using the spherical markers described. ...
Background:
Scapular orientation may be influenced by static body posture (sitting and standing) and contribute to the development of shoulder pain. Therefore a consistent body posture should be considered when assessing scapular orientation as well as enhancing optimal scapular positioning.
Objective:
To determine if there are differences in scapular orientation between standing, neutral sitting and habitual sitting, while adjusting for spinal posture.
Design:
A single group randomised repeated measures study.
Setting:
University Laboratory PARTICIPANTS: Twenty-eight participants with shoulder pain were recruited from the community.
Methods:
Scapular orientation between standing and seated positions was compared, with the arm by the side and at 120° of glenohumeral scaption. Thoracic kyphosis and lumbar lordosis angles were used as covariates.
Main outcome measurements:
Scapular elevation, lateral translation, upward rotation, and posterior tilt.
Results:
Scapular orientation was marginally but significantly different between sitting postures for lateral translation (mean 0.5cm (95%CI 0.2 to 0.7 cm), p<.001), upward rotation (mean 3° (95%CI 1.1 to 5.0°) p<.001), and posterior tilt (mean 2.3° (95%CI 0.2 to 4.3°) p=.009) in the arm by side position. A small but significant difference between standing and neutral sitting was found for upward rotation (mean 1.8° (95%CI 0 to 3.7°) p=.02), and between standing and habitual sitting for lateral translation (mean 0.6cm (95%CI 0 to 1.1cm) p=.02) in the arm by side position.
Conclusions:
The results of this study suggest that scapular orientation can be slightly affected by body posture, although the clinical relevance is uncertain. To enhance scapular upward rotation or posterior tilt, it may be preferable to place the patient in neutral sitting.
... The patient seated on a treatment plinth, with the posterior aspect of the head aligned with the most posterior aspect of the thoracic kyphosis. Standardized procedure of surface anatomy was used to identify precisely each cervical segmental level where to perform the 3D CSSB [39] and the raters' fingers were positioned on the articular pillar of the inferior vertebra of the tested joint. The rater passively invoked a side-bending motion at each cervical segment, allowing synkinetic rotation and extension to occur (see Fig. 1) [23], and assessed mobility, end-feel and pain provocation of each joint, starting at C2-C3 and ending at C6-C7 [23]. ...
Background:
Passive Intervertebral Movements (PIVMs) are commonly used to assess and treat patients with nonspecific neck pain. Only very few studies have investigated 3D movements until now.
Objective:
This study assessed intra- and inter-rater reliability of three-dimensional (3D) cervical PIVMs performed by physical therapy students in patients with nonspecific neck pain.
Methods:
Thirty-one patients, mean age 47.2 ± 7.2 years, were independently evaluated by 2 physical therapy students. The raters (A and B) assessed mobility, end-feel and pain provocation performing bilaterally the 3D cervical segmental side-bending test (3D CSSB) from levels C2-C3 to C6-C7. Percentage agreement (raw, positive and negative), Cohen's kappa (95% CI), prevalence index and bias index were calculated to estimate intra- and inter-reliability.
Results:
Intra-rater reliability showed kappa values ranging between fair and substantial (k 0.29-0.80) for pain provocation, mobility and end-feel, with percentage agreements between 61%-90%. Inter-rater reliability presented kappa values ranging between fair and substantial (k 0.22-0.62) for pain provocation, mobility and end-feel, with percentage agreements between 61% and 80%.
Conclusions:
Intra-rater reliability of 3D PIVMs was superior to inter-rater reliability in patients with nonspecific neck pain. The most repeatable evaluation parameter was pain. However overall poor reliability suggests avoiding the use of these techniques alone to examine patients and measure their outcome. Further studies are needed to investigate PIVMs reliability in combination with other assessment procedure in symptomatic patients.
Background
Forward head posture (FHP) is a common malalignment affecting the cervicothoracic spine. This deviation is associated with neck disability and muscle imbalance.
Objective
This study aimed to investigate the efficacy of FHP correction using regional versus comprehensive spinal programs on the craniovertebral (CV) angle, neck disability, and spinal muscle activity.
Methods
Sixty participants with FHP were randomly assigned to receive either a cervicothoracic correction program (control group) or a cervicothoracic plus lumbopelvic program (experimental group). The CV angle, neck disability index (NDI), and normalized electromyography as a percentage of maximum voluntary isometric contraction (%MVIC) from spinal muscles were measured before and after the intervention.
Results
Post-intervention, both groups showed significant improvement across time in CV angle and NDI (p < 0.001, p = 0.002). However, the between-group comparison was not statistically significant. The NDI showed significant improvement only in the experimental group ( p = 0.005). The minimal clinical important difference (MCID) obtained was 6.44 for the NDI. A reduction in %MVIC over time was observed in both groups for cervical erector spinae (Right, p = 0.006, Left, p = 0.001). The between-group comparison of spinal muscle activation was not significantly different.
Conclusion
The study suggested that FHP management using a cervicothoracic or cervicothoracic plus lumbopelvic protocol could improve cervical posture and lower cervical muscle demand. Incorporating a lumbopelvic into the cervicothoracic protocol was more effective in reducing short-term neck pain and disability than a cervicothoracic protocol alone. A comprehensive spine program may be a clinically beneficial rehabilitation protocol for FHP to improve neck pain and disability.
The hardest connective tissue in the human body is formed by the bones. They provide support and stability and provide the origins and attachments for the skeletal muscles and thus the connection to the active musculoskeletal system. This chapter explains the procedure for palpating and delineating palpable bony reference points. Precise grip technique plays a crucial role in examining the regions of the pelvis, lower and upper extremities and the spine or head. Pictures and instructional videos help to locate the reference points more quickly and accurately. In addition to direct pressure on bony structures, the measure of mobilisation is often a good variant to delineate smaller bones from surrounding tissues.
Background: Increasing evidence suggests that people with chronic neck pain (CNP) may display altered biomechanics beyond the cervical spine. However, whether spinal alignment and mobility are associated with neck pain is not clarified.
Objectives: To investigate whether there is a significant association between neck pain intensity and sagittal spinal alignment and mobility in people with CNP, and to examine whether sagittal spinal alignment and mobility differ according to pain intensity.
Design: A cross-sectional study
Method: Forty-four women with CNP were included. The neck pain intensity at rest and during neck movements was assessed with the visual analogue scale (VAS). A skin-surface measurement device was used to assess sagittal alignment and mobility while sitting and standing. Linear regression analysis was used to assess associations. Participants were divided into two groups according to the pain intensity as group with mild pain (VAS≤4.4 cm) and group with moderate to severe pain (VAS>4.4 cm) and compared using the analysis of covariance.
Results: Greater resting pain was associated with a more forward trunk during sitting (Beta=0.433, p<0.05). Greater pain during neck movements was associated with increased lumbar lordosis during sitting (Beta=-0.376, p<0.05). Classified by pain intensity at rest, trunk mobility while sitting was lower and forward trunk inclination and sacral kyphosis while sitting were higher in those with moderate/severe pain (η2p=0.093-0.119, p<0.05). By pain intensity during neck movements, women with moderate/severe pain exhibited lower sacral mobility (η2p=0.129, p<0.05).
Conclusions: Addressing the entire spine in the assessment and management of CNP may help reduce pain.
The use of kilohertz-frequency (KHF) waveforms has rapidly gained momentum in transcutaneous spinal cord stimulation (tSCS) to restore motor function after paralysis. However, the mechanisms by which these fast-alternating currents depolarize efferent and afferent fibers remain unknown. Our study fills this research gap by providing a hypothesis- and evidence-based investigation using peripheral nerve stimulation, lumbar tSCS, and cervical tSCS in 25 unimpaired participants together with computational modeling. Peripheral nerve stimulation experiments and computational modeling showed that KHF waveforms negatively impact the processes required to elicit action potentials, thereby increasing response thresholds and biasing the recruitment towards efferent fibers. While these results translate to tSCS, we also demonstrate that lumbar tSCS results in the preferential recruitment of afferent fibers, while cervical tSCS favors recruitment of efferent fibers. Given the assumed importance of proprioceptive afferents in motor recovery, our work suggests that the use of KHF waveforms should be reconsidered to maximize neurorehabilitation outcomes, particularly for cervical tSCS. We posit that careful analysis of the mechanisms that mediate responses elicited by novel approaches in tSCS is crucial to understanding their potential to restore motor function after paralysis.
The use of kilohertz-frequency (KHF) waveforms has rapidly gained momentum in transcutaneous spinal cord stimulation (tSCS) to restore motor function after paralysis. However, the mechanisms by which these fast-alternating currents depolarize efferent and afferent fibers remain unknown. Our study fills this research gap by providing a hypothesis- and evidence-based investigation using peripheral nerve stimulation, lumbar tSCS, and cervical tSCS in 25 unimpaired participants together with computational modeling. Peripheral nerve stimulation experiments and computational modeling showed that KHF waveforms negatively impact the processes required to elicit action potentials, thereby increasing response thresholds and biasing the recruitment towards efferent fibers. While these results translate to tSCS, we also demonstrate that lumbar tSCS results in the preferential recruitment of afferent fibers, while cervical tSCS favors recruitment of efferent fibers. Given the assumed importance of proprioceptive afferents in motor recovery, our work suggests that the use of KHF waveforms should be reconsidered to maximize neurorehabilitation outcomes, particularly for cervical tSCS. We posit that careful analysis of the mechanisms that mediate responses elicited by novel approaches in tSCS is crucial to understanding their potential to restore motor function after paralysis.
A B S T R A C T
Background: Neural structures of cardiac sympathetic and parasympathetic conduction emerge from the segments
of the cervicothoracic spine. The application of high-velocity low-amplitude (HVLA) techniques at this segment
can generate responses in heart rate (HR), blood pressure and sympathetic nervous activity of the skin. However,
it is not known whether these responses occur in subjects with C7-T1 dysfunction.
Objective: To evaluate the effects of HVLA technique in cervicothoracic junction in HR, blood pressure and skin
temperature (ST), in subjects with C7-T1 dysfunction.
Design: This is a randomized crossover trial.
Methods: Twelve male subjects were randomized into two groups: HVLA and Sham. HVLA group received a single
manipulation technique for C7-T1 dysfunction, while the sham group received a simulated HVLA. HR, blood
pressure and ST were measured pre, immediately after and 10 min after the application of the interventions.
Results: Immediately after the application of the interventions, an increase in HR, systolic blood pressure (SBP)
and ST was observed, in addition to a reduction in diastolic blood pressure (DBP). Also, 10 min after, a significant
reduction in SBP and DBP was observed in the HVLA group when compared to Sham group.
Conclusion: The application of a single HVLA technique in the cervicothoracic junction produced significative
effects on HR, BP and ST in subjects with C7-T1 dysfunction.
Achieving adequate analgesia in the chronic pain patient is often challenging. Regional anesthesia techniques are suggested as a method of bypassing tolerance in patients on chronic opioids. Regional techniques performed in proximity to the spinal cord and spinal roots are collectively described as “neuraxial.” Neuraxial anesthetic and analgesic techniques include spinal (subarachnoid), epidural, and combined spinal and epidural techniques. These techniques involve administering local anesthetics, opioids, or other medications around the neuraxis. This chapter will briefly introduce the relevant anatomy, physiology, indications, contraindications, techniques, side effects, and complications of neuraxial anesthesia.KeywordsSpinal anesthesiaNeuraxialEpiduralSubarachnoid blockVertebrae
Objective
The purpose of this study was to determine the accuracy and intrarater reliability of a palpatory protocol based on a combination of 3 palpatory methods to identify both the C7 spinous process (C7 SP) and the factors that affect the errors and inaccuracy of palpation.
Methods
Twenty-five women between the ages of 18 and 60 years were submitted to a palpation protocol of the C7 SP, and a radiopaque marker was fixed on the skin at the possible location of the vertebrae. A radiograph and a photograph of the cervical spine were obtained in the same posture by a first rater. A second rater performed the same palpation protocol and took a second photograph. The accuracy and measurement error of the palpation protocol of C7 SP were assessed through radiographic images. The inter-rater reliability was estimated by the interclass correlation coefficient and assessed using photographs of each rater. The Pearson's correlation coefficients (r), the Fisher exact test, and the χ² test were used to identify the factors associated with the error and inaccuracy of palpation.
Results
Accuracy of the C7 palpation was 76% with excellent reliability (interclass correlation coefficient = 0.99). There was a moderate correlation between weight and the measurement of palpation error (r = –0.6; P = .003). One hundred percent of inaccuracy palpation was related to the increased soft-tissue thickness (P = .005) in the cervical region.
Conclusion
The palpation protocol described in this study was accurate and presented excellent reliability in identifying the C7 SP. Increased weight and dorsocervical fat pad were associated to error and palpation inaccuracy, respectively.
Das härteste Bindegewebe im menschlichen Körper wird durch die Knochen ausgeprägt. Sie sorgen für Halt und Stabilität und stellen die Ursprünge und Ansätze für die Skelettmuskulatur und somit die Verbindung zum aktiven Bewegungssystem her. In diesem Kapitel wird die Vorgehensweise zur Betastung und Abgrenzung von palpablen knöchernen Referenzpunkten erklärt. Eine exakte Grifftechnik spielt dabei die entscheidende Rolle, um die Regionen am Becken, der unteren sowie oberen Extremität und der Wirbelsäule bzw. dem Kopf zu untersuchen. Bilder und Lehrvideos helfen dabei, die Referenzpunkte schneller und genauer aufzuspüren. Neben dem direkten Druck auf knöcherne Strukturen, bildet die Maßnahme der Mobilisation oft eine gute Variante, um kleinere Knochen von umliegenden Geweben abzugrenzen.
Objective
To investigate if muscle energy technique (MET) to the thoracic spine decreases the pain and disability associated with shoulder impingement syndrome (SIS).
Design
Single centre, three-arm, randomised controlled trial, single-blind, placebo control with concealed allocation and a 12-month follow-up.
Setting
Private osteopathic practice.
Interventions
Participants were randomly allocated to: MET to the thoracic spine (MET-only), MET plus soft tissue massage (MET&STM) or placebo.
Participants
3 groups of 25 (n=75) participants ≥ 40 years with SIS received allocated intervention once a week for 15 minutes, 4 consecutive weeks.
Outcome measures
Primary outcome measure: Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Secondary outcome measures: Shoulder Pain and Disability Index (SPADI) questionnaire, visual analogue scale (VAS-mm/100) –current, 7-day average, 4-week average, patient specific functional scale (PSFS) and global rating of change (GROC). Measures recorded at baseline, discharge, 4-weeks follow-up, 6-months and 12-months. Also baseline and discharge thoracic posture and range of motion (ROM) measured using an inclinometer.
Statistical Analysis
Mixed effects linear regression model for DASH, SPADI, VAS, PSFS, GROC and thoracic posture and ROM.
Results
MET-only group demonstrated significantly greater improvement in pain and disability (DASH, SPADI, VAS 7-day average) compared to placebo at discharge (mean difference DASH=-8.4; 95% CI -14.0,-2.8; SPADI=-14.7;-23.0,-6.3; VAS=-15.5;-24.5,-6.5), 6 -months (-11.1;-18.6,-3.7; -14.9;-26.3,-3.5; -14.1;-26.0,-2.2) and 12 -months (-13.4;-23.9,-2.9; -19.0;-32.4,-5.7; -17.3;-30.9,-3.8). MET&STM group also demonstrated greater improvement in disability, but not pain compared to placebo at discharge (DASH=-8.2;-14.0,-2.3; SPADI= -13.5;-22.3,-4.8) and 6 months (-9.0;-16.9,-1.2; -12.4;-24.3,-0.5). For the PSFS, MET-only improved compared to placebo at discharge (1.3;0.1,2.5) and 12 months (1.8;0.5,3.2); MET&STM at 12 months (1.7;0.3,3.0). GROC: MET-only improved compared to placebo at discharge (1.5;0.9,2.2) and 4 weeks (1.0;0.1,1.9); MET&STM at discharge (1.2;0.5,1.9) and 6 months (1.2;0.1,1.3). There were no differences between MET-only and MET&STM, and no between-group differences in thoracic posture or ROM.
Conclusion
MET of the thoracic spine with or without STM improved the pain and disability in individuals over 40 with SIS and may be recommended as a treatment approach for SIS.
Background
Orthotic immobilization is an early treatment for osteoporotic vertebral fracture at the hyperkyphotic thoracic spine.
Objective
This exploratory study compared the immediate impact of three types of trunk orthoses on the balance parameters of older people with osteoporosis hyperkyphosis.
Methods
Twenty older people (aged 60-65 years) with osteoporosis kyphosis and a history of falls participated in a pilot cross-over study. Four randomized comparisons were carried out, including either soft, semi-rigid, and rigid trunk orthoses worn on the participants compared to “no orthosis” as the control condition. Kyphosis angle, Forward Reach Test, Timed Up and Go test, and postural stability during standing on a force plate were recorded and compared between study conditions using one-way repeated measures analysis of variance test.
Results
All orthoses significantly reduced the kyphosis angle (p<0.01). None of the orthoses has a significant change in the Timed Up and Go test (p>0.01). Rigid orthosis significantly reduced the forward reach compared to “no orthosis” (p=0.003, 95% CI: 1.08 to 6.3 cm). None of the orthosis induced a significant change in postural sway velocity in anteroposterior and mediolateral directions compared to the control condition (p>0.01).
Conclusion
These findings suggest that using rigid orthosis in older people with osteoporosis hyperkyphosis reduces the balance performance.
Objective
The purpose of this study was to compare craniocervical posture assessed by photogrammetry using 2 distinct palpation methods for locating the spinous process of the seventh cervical vertebra (C7SP).
Methods
This cross-sectional study was conducted in 2 phases. In phase I (n = 42), the assessor's accuracy in locating the C7SP using the flexion-extension and the modified thorax-rib static methods was compared to radiography. In phase II (n = 68), the craniocervical posture was analyzed with photogrammetry after palpation using the 2 methods. Neck pain intensity and disability were also determined.
Results
The accuracy in locating the C7SP was higher using the modified thorax-rib static method (67%, 95% confidence interval [CI], 55-79) compared to the flexion-extension method (38%, 95% CI, 26-50, P = .016). Lower values of the craniocervical angle were obtained with the flexion-extension method than the modified thorax-rib static method (mean difference = −1.1°, 95% CI, −1.6 to −0.6, P < .001). However, both palpation methods resulted in similar classifications of participants as with or without forward head posture (P = .096). Weak correlations were observed between the craniocervical angle and neck pain intensity (ρ = −0.088 and −0.099, respectively) and disability (ρ = −0.231 and −0.249, respectively).
Conclusion
Craniocervical angles obtained using palpation methods with different accuracies were different, although the magnitude of the difference was insufficient to lead to different classifications of a forward head posture in adults with mild neck pain and disability. Craniocervical posture was weakly correlated with neck-pain intensity and disability.
Objective
This study aims to examine the electromyographic activity of the regional spinal muscle between patients with forward head posture (FHP) and those with a normal cranio-vertebral (CV) angle.
Methods
We recruited 60 adult women aged between 18 and 29 years from a single institution. The CV angle was measured in the sagittal plane, which helped us to assign the participants in the FHP group (n = 30) with a large CV angle (53.1 ± 2.3) and the control group (n = 30) with a normal CV angle (43.0 ± 3.6). The surface electromyography (EMG) was used to measure the magnitude of normalised muscle activity of eight spinal muscles (cervical, lumbar, and thoracic levels) while standing and performing a specific manual handling task.
Results
The CV angle was significantly lower in the FHP group than in the control group (p = .001). The cervical erector spinae (CES) muscle activity was significantly increased in the FHP group compared to that in the control group. The right and left CES of those in the FHP group exhibited 73% and 87%, respectively, higher normalised muscle activity than those in the control group while performing the manual handling task (p = .001). No significant difference was detected for the thoracic or lumbar segment muscles between groups.
Conclusion
Our results indicate that greater neck muscle demands result from anterior head translation in FHP. This effect is a counterbalance to the reduced CV angle and to support the neck. The increased activity of the neck muscles in FHP could demand more support from the neck muscles and might increase the risk of spinal injuries. Management of FHP is essential to avoid overloading the spinal muscles.
Palpitation is an important component of a comprehensive musculoskeletal and neurologic examination of the cervical spine in individuals with neck pain, but examiners should not base diagnostic conclusions (eg, facetogenic pain) and interventional procedures on palpatory findings alone. A methodological approach to palpation of the posterior neck includes evaluation of the paraspinal musculature, the tissues that overlie the facet (zygapophyseal) joints, and the midline spinous processes. Although studies have shown low interexaminer reliability, palpation is an important component of the physical examination for determining general anatomic regions of symptoms and in establishing rapport with the examinee. In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, the diagnosis-related estimate (DRE) or injury method lists both muscle spasm and muscle guarding as potential physical exam findings by palpation. In this edition, the range-of-motion method for rating spinal impairment states that an examiner cannot find muscle spasm on exam and rate the individual's impairment on the same day because, by definition, the individual is not at maximum medial improvement. Despite acceptance by the AMA Guides, Fifth Edition, neither spasm nor guarding appears to be a reliable finding on palpation. The AMA Guides, Sixth Edition, provides a different method for determining spinal impairment, and the authors recommend limiting physical examination findings used in impairment rating to those with acceptable interrater reliability.
Introduction
Ultrasound was used to determine optimal needle insertion parameters and assess the vasculature of paraspinal muscles at C5‐T1 spinal levels across patients with different body mass indices (BMIs).
Methods
Thirty patients underwent ultrasound examination of the cervical paraspinal muscles at the C5‐T1 levels. Images were analyzed to determine the optimal distance and angle of needle insertion to reach the base of the right lamina. Color and spectral Doppler analysis was used to identify and map paraspinal blood vessels.
Results
Mean distances and angles varied from 35.1 mm and 17.27 degrees for the low BMI group at C5 to 65.1 mm and 9.85 degrees for the high BMI group at T1. Paraspinal blood vessel mapping revealed a random distribution of vasculature.
Discussion
Longer distances and steeper angles of needle insertion are required for patients with higher BMIs. Cervical paraspinal arteries vary in distribution and can be visualized with ultrasound.
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Background
Chronic pain is a growing global and economically costly problem leading the National Health Service (NHS) in the UK to actively search for novel strategies to improve health outcomes. Some trials have shown a benefit when practitioners use a positive communication style, however, much of the available literature investigating the use of positive language to alter patient expectation utilises subjective reports from patients.
Objectives
To demonstrate whether positive and negative communication before a high-velocity low amplitude (HVLA) thrust spinal manipulation of the C7-T1 spine segments, and within an osteopathic consultation setting, increases and decreases (respectively) pain pressure thresholds (PPT) to form contextual placebo and nocebo effects.
Study design
pre-test, post-test randomised controlled design.
Methods
35 asymptomatic participants were recruited and randomised into three separate condition arms using a repeated measures cross-over design; negative communication (NegC), neutral communication (NeuC), or positive communication (PosC). Each condition included spinal manipulation (HVLA thrust) to the C7-T1 segments. PPTs were measured by an algometer over the spinous process of C7 pre and post each condition setting.
Results
There was a significant effect of language style on PPT for the three conditions. Post-hoc tests demonstrated that positive communication had a significant effect on PPT (i.e., placebo effect), but the negative communication demonstrated no significant effect (i.e., no nocebo).
Conclusion
These results were discussed in the context of communication style used during an osteopathic clinical consultation to potentially improve health outcomes in NHS and other clinical settings (Clinical trial registry https://clinicaltrials.gov/number: NCT03855254).
Background: Prolonged standing and lifting heavy loads are risk factors for the appearance of low back pain in work. The aim of this study was to observe changes in the height, spinal sagittal alignment, and the lumbar and dorsal discomfort perception in assembly line workers. Methods: Cross-sectional study. 40 assembly line workers (6 females). Height, sitting height, grades of thoracic kyphosis and lumbar lordosis and perceived spine discomfort, before and after the working day, were determined. Thoracic and lumbar sagittal alignment was compared between discomfort developers and no developers. Results: There was a significant decrease in the height and sitting height of the workers at the end of the day. Thoracic and lumbar curvature increased significantly, as did perceived lumbar discomfort. Conclusion: Workers on the assembly line, in a prolonged standing work, suffer an increase in lumbar discomfort, and changes in height and thoracic and lumbar curvatures.
Practitioner Summary: Spinal shrinkage, sagittal alignment and back discomfort (upper and lower back), were analysed in assembly line workers in prolonged standing during a work day. Assembly line workers suffer a decrease in height, an increase in their thoracic and lumbar curvature, and in lumbar discomfort throughout their workday.
Objectives
A reliable detection of bony landmarks of the spine is necessary in order to determine rigid bodies and to reduce the variability of marker placement in a movement laboratory setting. In a first study on the thoracic and lumbar spine, we demonstrated that placing markers on their relative positions between two major landmarks was superior to palpation of specific bony landmarks. The aims of this study were to examine the intra-rater reliability when palpating for spinous processes (SPs) of the second (C2) and seventh cervical vertebrae (C7), to determine the distances between C2 and C7 and the relative position of C7 along the length between C2 and the posterior superior iliac spine (PSIS) level.
Results
The intra-rater reliability in determining the distance between C2 and C7 was found to be substantial, with an intra-rater reliability of 0.75 (95% confidence limits 0.55–0.99) and a standard error of the measurement of 0.34 cm. The relative distance of C7 along the total C2–PSIS length was estimated to be 11.5%. The determination of the relative positions of spinal landmarks through measurement is considered superior to their palpation, because it relies on a reproducible and comparable definition of rigid bodies.
Background:
Hyperkyphosis is a common postural defect with high prevalence in the 20 to 50 year old population. It appears to compromise proximal scapular stability. Grip and pinch strength are used to evaluate general upper extremity function.
Objective:
The aim of this study was to compare pinch and grip strength between young women with and without hyperkyphosis.
Methods:
Thirty young women (18-40 years old) with hyperkyphosis and 30 healthy women matched for age and body mass index participated in the study. Hyperkyphosis was confirmed by measuring the kyphosis angle with a flexible ruler. Grip strength was measured with the Waisa method and a dynamometer. Pinch strength was assessed with a pinch meter.
Results:
Grip (P= 0.03) and pinch strength (P= 0.04) were significantly lower in women with hyperkyphosis compared to the control group. Kyphosis angle correlated weakly with grip (r= 0.26) and pinch strength (r= 0.23).
Conclusions:
Hyperkyphotic posture has led to decreased grip and pinch strength compared to people without hyperkyphosis.
Objective:
The purpose of this study was to assess the intra- and interexaminer reliability of the upper trapezius muscle and fascia thickness measured by ultrasonography imaging and strain ratio by sonoelastography in participants with myofascial pain syndrome.
Methods:
Thirty-two upper trapezius muscles were assessed. Two examiners measured the upper trapezius thickness and strain ratio 3 times by ultrasonography and sonoelastography independently in the test session. The retest session was completed 6 to 8 days later.
Results:
A total of 87.5% of participants had trigger points on the right side, and 22.5% had trigger points on the left side. For the test session, the average upper trapezius thickness, fascia thickness, and strain ratio measured by first and second examiners were 11.86 mm and 11.56 mm, 1.23 mm and 1.25 mm, and 0.94 and 0.99, respectively. For the retest session, the previously mentioned parameters obtained by first and second examiners were 11.76 mm and 11.39 mm, 1.27 mm and 1.29 mm, and 0.96 and 0.99, respectively. The intraclass correlation coefficients indicated good to excellent reliability for both within-intraexaminer (0.78-0.96) and between-intraexaminer (0.75-0.98) measurements. Also, the intraclass correlation coefficients and standard errors of measurement of interexaminer reliability ranged between 0.88 to 0.93 and 0.05 to 0.44 for both muscle and fascia thickness and 0.70 to 0.75 and 0.04 to 0.20 for strain ratio of upper trapezius, respectively.
Conclusion:
Upper trapezius thickness measurements by ultrasonography and strain ratio by sonoelastography are reliable methods in participants with myofascial pain syndrome.
Objective:
The aim of this study was to develop and validate a multivariate prediction model, guided by palpation and personal information, for locating the seventh cervical spinous process (C7SP).
Methods:
A single-blinded, cross-sectional study at a primary to tertiary health care center was conducted for model development and temporal validation. One-hundred sixty participants were prospectively included for model development (n = 80) and time-split validation stages (n = 80). The C7SP was located using the thorax-rib static method (TRSM). Participants underwent chest radiography for assessment of the inner body structure located with TRSM and using radio-opaque markers placed over the skin. Age, sex, height, body mass, body mass index, and vertex-marker distance (DV-M) were used to predict the distance from the C7SP to the vertex (DV-C7). Multivariate linear regression modeling, limits of agreement plot, histogram of residues, receiver operating characteristic curves, and confusion tables were analyzed.
Results:
The multivariate linear prediction model for DV-C7 (in centimeters) was DV-C7 = 0.986DV-M + 0.018(mass) + 0.014(age) - 1.008. Receiver operating characteristic curves had better discrimination of DV-C7 (area under the curve = 0.661; 95% confidence interval = 0.541-0.782; P = .015) than DV-M (area under the curve = 0.480; 95% confidence interval = 0.345-0.614; P = .761), with respective cutoff points at 23.40 cm (sensitivity = 41%, specificity = 63%) and 24.75 cm (sensitivity = 69%, specificity = 52%). The C7SP was correctly located more often when using predicted DV-C7 in the validation sample than when using the TRSM in the development sample: n = 53 (66%) vs n = 32 (40%), P < .001.
Conclusions:
Better accuracy was obtained when locating the C7SP by use of a multivariate model that incorporates palpation and personal information.
Objectives:
The aim of this study was to assess the thorax-rib static method (TRSM), a palpation method for locating the seventh cervical spinous process (C7SP), and to report clinical data on the accuracy of this method and that of the neck flexion-extension method (FEM), using radiography as the gold standard.
Methods:
A single-blinded, cross-sectional diagnostic accuracy study was conducted. One hundred and one participants from a primary-to-tertiary health care center (63 men, 56 ± 17 years of age) had their neck palpated using the FEM and the TRSM. A single examiner performed both the FEM and TRSM in a random sequence. Radiopaque markers were placed at each location with the aid of an ultraviolet lamp. Participants underwent chest radiography for assessment of the superimposed inner body structure, which was located by using either the FEM or the TRSM.
Results:
Accuracy in identifying the C7SP was 18% and 33% (P = .013) with use of the FEM and the TRSM, respectively. The cumulative accuracy considering both caudal and cephalic directions (C7SP ± 1SP) increased to 58% and 81% (P = .001) with use of the FEM and the TRSM, respectively. Age had a significant effect on the accuracy of FEM (P = .027) but not on the accuracy of TRSM (P = .939). Sex, body mass, body height, and body mass index had no significant effects on the accuracy of both the FEM (P = .209 or higher) and the TRSM (P = .265 or higher).
Conclusions:
The TRMS located the C7SP more accurately compared with the FEM at any given level of anatomic detail, although both still underperformed in terms of acceptable accuracy for a clinical setting.
The objective was to examine inter-tester reliability and validity of two therapists identifying the spinous processes (SP) of C7 and L5, using one predefined surface palpation procedure for each level. One identification method made it possible to examine the reliability and the validity of the procedure itself. Two manual therapists examined 49 patients (29 women). Aged between 26 and 79 years, 18 were cervical and 31 lumbar patients. An invisible marking pen and ultraviolet light were used, and the findings were compared. X-rays were taken as an objective measure of the correct spinal level. Percentage agreement and kappa statistics were used to evaluate reliability and validity. The best inter-therapist agreement was found for the skin marks. Percentage agreement within 10mm and 20mm was 67% and 85%, respectively. The inter-tester reliability for identifying a radiological nominated SP by palpation was found to be poor for C7 and moderate for L5, with kappa of 0.18 and 0.48, respectively. The results indicated acceptable inter-therapist surface palpation agreement, but the chosen procedures did not identify the correct SP. This indicates that the procedures are not precise enough. Future reliability studies should test other non-invasive palpation procedures, both individually and in combination, and compare these with radiological investigation.
This comprehensive, authoritative text presents the scientific foundations and clinical practice of neural blockade in both regional anesthesia and the management of pain. The descriptions and illustrations of pain mechanisms are considered classic examples. The Fourth Edition has been refined for clarity and flows logically from principles and pharmacology, to techniques for each anatomic region, to applications. This edition has two new co-editors and several new chapters on topics including neurologic complications, neural blockade for surgery, treatment of pain in older people, and complications in pain medicine. A companion Website will offer the fully searchable text and an image bank. © 2009 by Lippincott Williams & Wilkins, a Wolters Kluwer business. All rights reserved.
This study aimed at determining the standing spinal landmark that corresponds to the inferior tip of the scapula and determining the accuracy of experienced palpators in locating a spinous process (SP) 3 levels above and below a given SP.
The study participants were 34 asymptomatic or minimally symptomatic chiropractic students. An experienced palpator located the inferior scapular tip on each and then positioned a 2-mm lead marker about 5 cm lateral to the nearest SP. Two more markers were placed at levels intended to be 3 levels above and below the first marker placed. The locations of the scapular tip and the spinal targets were determined by comparison with a radiological criterion standard.
The standing inferior scapular tip corresponded to the T8 SP on average (SD = 0.9). Having placed the first lead marker, examiners on average overshot the upper marker by 0.26 (SD = 0.51) vertebral levels and undershot the lower marker by 0.21 (SD = 0.48) vertebral levels. The modes for the placement of the 3 markers were at T5, T8, and T11.
Approximately 68% of patients would be palpated to have their inferior scapular tips at T7, T8, or T9. An experienced palpator can quite accurately locate vertebral levels 3 above or below a given landmark. Chiropractors and other health professionals using the typical rule of thumb linking the inferior scapular tip to the standing T7 SP have likely been applying clinical interventions at spinal locations different from those intended.
Precise placement of thoracic epidural catheters is required to optimize postoperative analgesia and minimize adverse effects. Previous research demonstrated that anesthesiologists are inaccurate when using surface anatomy to locate vertebral levels. In this study, we compared the accuracy of two different landmarks to identify the seventh thoracic (T7) spinous process.
Two-hundred-ten patients referred for chest radiography were randomized to two groups. With patients in the anatomic (upright) position, one investigator identified and placed a radioopaque marker over the presumed T7 spinous process using either the vertebra prominens (C7) or the inferior scapular tip as a surface landmark. A radiologist, blinded to the identification technique, reported the spinous process corresponding to the radioopaque label. Marker positions were then compared using the Fisher's exact test. The influence of patient characteristics (age, gender, Body Mass Index [BMI], and height and weight) on accuracy was also examined.
Patient characteristics were similar between groups. The T7 spinous process was identified correctly 29% of the time with the C7 landmark and 10% of the time with the scapular landmark (P < 0.001). Accuracy improved for T7 +/- 1 level to 78% and 42%, respectively (P = 5.84 x 10(-8)). Errors were more common in the caudal direction (i.e., T8 or T9 identified). The C7 landmark was more accurate among those with a BMI <25 (P = 6.51 x 10(-5)). In those with a BMI >or=25, both landmarking methods were frequently inaccurate (P = 0.312).
For patients with a BMI <25, the T7 spinous process can be reliably identified to within one interspace in 78% of patients using the C7 (vertebra prominens) surface landmark. Neither the vertebra prominens nor the tip of scapula is a reliable landmark to identify T7 in patients with a BMI >or=25.
This paper describes a technique for analyzing movement of the cervical spine. The method consists of superimposition of two films representing the cervical spine in the end positions of the movement under investigation (e.g., flexion and extension). From tracings of selected structures, movement is represented in the form of movement diagrams. Knowledge of cervical spine dynamics is helpful in understanding muscle and ligament function as well as the shape of components in various postures.
To measure the distances from the skin to the epidural space (DSES) of the lower cervical and upper thoracic intervertebral spaces.
Retrospective review of films of the cervical spine as obtained by magnetic resonance imaging (MRI).
Health care facility that provides diagnosis and treatment of patients with chronic pain.
MRI sagittal films of 100 patients, who had diagnostic studies for chronic headaches and cervicobrachial radiculopathy, were reviewed. Measurements were made of DSES, the dural sac, and the spinal cord by centimeter ruler. Estimates were also made of the width of the epidural space by measuring the distance from the ligamentum flavum to the dural sac. The longest DSES were noted at C6-7 and C7-T1 levels, with a mean of 5.7 cm, but they decreased to a mean of 5.4 cm at the T1-2, and to 4. 7 cm at the T2-3 intervertebral spaces. One of the major factors in this variability was the presence of an accumulation of fatty tissue along the lower cervical and upper thoracic area, which the authors named the "hump pad." This accumulation appears to be thicker in obese patients, with a slight correlation coefficient with the patient's weight. The distances from ligamentum flavum to dural sac, representing the depth of the epidural space, averaged 0.3 cm, 0.4 cm, 0.5 cm, and 0.4 cm, respectively.
In the cervical spine, DSES varies from space to space. In obese individuals, the fat pad may increase DSES at the lower cervical intervertebral spaces. The longest mean distances from the ligamentum flavum to the dural sac and to the spinal cord were found at the T1-2 and T2-3 levels, precisely where DSES is shorter. All things being equal, the upper thoracic intervertebral spaces appeared to provide a greater margin of safety for insertion of epidural catheters to treat cervicobrachial radiculopathies.
Anaesthetists' ability to identify correctly a marked lumbar interspace was assessed in 100 patients undergoing spinal magnetic resonance imaging scans. Using ink, one anaesthetist marked an interspace on the lower spine and attempted to identify its level with the patient in the sitting position. A second anaesthetist attempted to identify the level with the patient in the flexed lateral position. A marker capsule was taped over the ink mark and a routine scan performed. The actual level of markers ranged from one space below to four spaces above the level at which the anaesthetist believed it to be. The marker was one space higher than assumed in 51% of cases and was identified correctly in only 29%. Accuracy was unaffected by patient position (sitting or lateral), although it was impaired by obesity (p = 0.001) and positioning of the markers high on the lower back (p < 0.001). The spinal cord terminated below L(1) in 19% of patients. This, together with the risk of accidentally selecting a higher interspace than intended for intrathecal injection, implies that spinal cord trauma is more likely when higher interspaces are selected.
Successful thoracic epidural analgesia depends on the sensory blockage of specific dermatomes following appropriate placement of the epidural catheter. This study aimed to ascertain how accurately anaesthesiologists identify thoracic intervertebral spaces, and whether counting from the prominent vertebra is easier than using the iliac crest as an anatomical landmark.
Five anaesthesiologists attempted to locate one out of five consecutive intervertebral spaces (Th7-Th8 to Th11-Th12) on patients referred for magnetic resonance imaging of the vertebral column. The intended thoracic interspace and the counting reference point (C7-Th1 or L3-L4) were marked with oil capsules. The body mass index, gender and position of the patient were recorded. The exact capsule positions were determined by a radiologist after the study.
In 92 patients, 26.7% of the thoracic interspaces were correctly identified. The counting reference point was the only variable studied with a significant influence on error. The accuracy increased when the iliac crest was used as an anatomical landmark rather than the prominent vertebra (odds ratio, 0.29). The majority (76.4%) of all the incorrectly placed capsules were found cephalad to the intended level.
We recommend that the caudal of two to three possible interspaces should be used when placing an epidural catheter in the thoracic spine. Because of the inaccurate localization of the thoracic intervertebral spaces, documentation should state the site of puncture as being in the upper or lower thoracic spine instead of claiming to be in an exact interspace.
The level of Tuffier's line was assessed on 200 standing and 60 prone lumbar radiographs. Sex, height, weight, and body mass index (BMI) were correlated with the radiograph findings.
To determine whether the level of Tuffier's line is associated with sex, height, weight, or BMI.
Tuffier's line (intercristal line) is a commonly used landmark for identification of the L4-L5 interspace; however, multiple studies have identified that this landmark is unreliable.
The level of Tuffier's line was assessed retrospectively on 200 standing anteroposterior lumbar radiographs and correlated with sex. Prospectively, the level of Tuffier's line was assessed on 60 prone posteroanterior lumbar radiographs and correlated with sex, height, weight, and BMI.
In men, the intercristal line most often intersected the L4 body or inferior endplate. In women, the intercristal line most often intersected the L5 body or superior endplate. Weight and BMI had no correlation with Tuffier's line. Subjects with a Tuffier's line through L4 were taller than those with a Tuffier's line through L5.
Tuffier's line demonstrated predictable sex-related differences: men had an intercristal line that most often intersected the L4 body or inferior endplate whereas the women's intercristal line most often intersected the L5 body or superior endplate. However, because the actual level of Tuffier's line may vary from the L4 body to the L5 body, the intercristal line is insufficient to use as the sole landmark for assessing spinal segmental level.
Musculoskeletal Manual Medicine: Diagnosis and Treatment
- J Dvořák
- V Dvořák
- W Gilliar
- W Schneider
- H Spring
- T Tritschler
Dvořák J, Dvořák V, Gilliar W, Schneider W, Spring H,
Tritschler T. Musculoskeletal Manual Medicine: Diagnosis and
Treatment. New York: Thieme, 2008:331
Cousins and Bridenbaugh's Neural Blockade in Clinical Anesthesia and Pain Medicine
- Q Hogan
Hogan Q. Anatomy of the neuraxis. In: Cousins MJ, Carr DB,
Horlocker TT, Bridenbaugh TH, eds. Cousins and Bridenbaugh's Neural Blockade in Clinical Anesthesia and Pain
Medicine. 4th ed. Philadelphia: Lippincott Williams & Wilkins,
2009:181-212