Assessment of in vivo 3D kinematics of cervical spine manipulation: Influence of practitioner experience and occurrence of cavitation noise

Highlights

• 3D kinematics was assessed during cervical manipulation for different practitioners.

• No influence of the side or the level on the kinematics was demonstrated.

• Most parameters were dependent on the practitioner.

• Cavitation occurrence seems to be related to particular kinematics features.

Background

Investigations on 3D kinematics during spinal manipulation are widely reported for assessing motion data, task reliability and clinical effects. However the link between cavitation occurrence and specific kinematics remains questionable.

Objectives

This paper investigates the 3D head-trunk kinematics during high velocity low amplitude (HVLA) manipulation for different practitioners with respect to the occurrence of cavitation.

Methods

Head-trunk 3D motions were sampled during HVLA manipulation in twenty asymptomatic volunteers manipulated by four practitioners with different seniority (years of experience). Four target levels were selected, C3 and C5 on each side, and were randomly allocated to the different practitioners. The data was recorded before, during and after each set of trial in each anatomical plane. The number of trials with cavitation occurrence was collected for each practitioner.

Results

The manipulation task was performed using extension, ipsilateral side bending and contra-lateral axial rotation independent of side or target level. The displayed angular motion magnitudes did not exceed normal active ROM. Regardless cavitation occurrence, wide variations were observed between practitioners, especially in terms of velocity and acceleration. Cavitation occurrence was related to several kinematics features (i.e. frontal ROM and velocity, sagittal acceleration) and practitioner experience. In addition, multilevel cavitation was observed regularly.

Conclusions

Kinematics of cervical manipulation is dependent on practitioner and years of experience. Cavitation occurrence could be related to particular kinematics features. These aspects should be further investigated in order to improve teaching and learning of cervical manipulation technique.

Introduction

Neck pain is an important health problem with various societal and economic implications (Hurwitz et al., 2008, Driessen et al., 2012). Most reviews agree that manipulation is significantly better than placebo, exercise alone or no treatment in reducing pain immediately or shortly after treatment (Gorrell et al.,, Miller et al., 2010).

Although there have been many studies on manipulation, its definition remains imprecise. Some features are regularly proposed to be included in the description of this technique (Evans and Lucas, 2010). One of them is the use of an external force in a specific direction that should be perpendicular to the joint surface to achieve the thrust manipulation. According to this model an audible “noise” should be produced caused by the occurrence of a cavitation at the target joint.

Ngan et al. (2005) have demonstrated a fairly high intra-rater reliability of pre-manipulative head-trunk parameters (i.e. motion range and speed) for a rotational manipulation Dugailly et al. (2010) and Gianola et al. (2015) confirmed intra- and inter-rater consistency of regional kinematic and primary axial rotation respectively while manipulating the upper cervical spine in vitro (Dugailly et al., 2010, Gianola et al., 2015).

Concerning motion magnitude, Salem and Klein (2013) found a lower range in axial rotation and lateral bending compared to the physiological range of motion (ROM) during pre-manipulative positioning. Indeed, the ROM of the gesture is likely to be related to the technique used and the subsequent neck positioning. For instance Williams and Cuesta-Vargas (2013) showed a large variation between upslope and downslope techniques in terms of head-trunk axial rotation magnitude for pre-manipulative position. Additionally, Cattrysse et al. (2015) studied rotational atlanto-axial thrust and observed unintended motion components in other directions and in the adjacent level. Wu et al. (2012) demonstrated significant intra-discal pressure variations during simulated cervical manipulative techniques related to the neck positioning (from 20° of flexion to 20° of extension), the velocity and the manipulated segment (C3 to C5) (Wu et al., 2012). However, due to the scarcity of knowledge about the kinematics of High Velocity Low Amplitude (HVLA) manipulations, the variations observed could not be explained.

Manipulating in the seated position, Klein et al. (2003) observed that neither the side nor the target level (C3 or C5) influenced 3D head-trunk kinematics when applied by the same experienced practitioner. The first leverage was lateral bending, and the range of motion was higher in the frontal plane (close to AROM). Note that cavitation occurrence was not analysed.

To our best knowledge, investigation of 3D kinematics during cervical manipulation including analysis of practitioner expertise and cavitation noise is lacking.

The objectives of the present study were 1) to assess 3D head-trunk kinematics during HVLA manipulation between four different practitioners, 2) to analyse influence of expertise (years of practice) on ROM, velocity and acceleration and 3) to investigate the occurrence of cavitation and its link with kinematics.