muskelskjelett - Manuellterapimanuellterapi.no › wp-content › uploads › 2018 › 06 › MS_1_2012_LR.pdf6 muskel&skjelett nr. 1, febr. 2012 AKTUELT Stor interesse for å utdanne

Nummer 1/2012 27. årgang Utgiver: Manuellterapeutenes Servicekontor

muskelmuskelmuskelmuskelmuskelmuskelmuskelmuskelmuskelmuskelmuskelmuskelskjelett

➥ Ber om autorisasjon av manuellterapeuterSide 23

➥ Program for fagseminar i marsSide 30

➥ Manuellterapi mot svimmelhet Side 10

Manuellterapeuter lærer muskel og skjelettultralyd Side 6-7

Manuellterapeutene beholder varemerket

Side 8-9

Møter, kurs og seminarer se side 3

Varmt klima bra for

revmatikereSide 6

“Stimula gir meg nye muligheter”

Slyngebehandling med Redcord Stimula

®

Redcord ASPB 55 , 4920 Staubø Tlf: 37 05 97 [email protected]

Neurac slyngebehandling gjenoppretter normal muskelfunksjon og reduserer smerte gjennom neuromuskulær stimulering og aktivering.

“Før hadde jeg ikke mulighet til å hjelpe mange mennesker fordi smerterne blokkerte for treningen. Nå kan en del av smerterne blokkeres ved hjelp av Redcord Stimula®, slik at klienten kan trene opp svak muskulatur etter lengre tids inaktivitet.”

Solveig Hauge, Fysioterapeut.Solveig Hauge, Fysioterapeut.

Gratis Gratis Gratis Gratis Gratis Gratis Neurac 2

Neurac 2

Neurac 2 Stimula kurs

Stimula kurs

Stimula kurs

Stimula kurs

Stimula kurs

Stimula kurs

Pris: 29 000,- eks mva Inkl. 1 gratis kursplass på Neurac 2 Stimula kurs ved kjøp og bestilling samtidig.

Stimula er effektiv i behandling av:

- Funksjonsforstyrrelser og avvik i muskel-skjelett apparatet- Smertetilstander relatert til dysfunksjon i muskel-skjelett apparatet- Problemer med rygg, nakke, skuldre og bekken

KURS, MØTER OG KONFERANSER

muskel&skjelett nr. 1, februar 2012 3

Mars2.-3. Oslo. Manuellmedisinsk smertebehandling (MMS), trinn III for fysioterapeuter. Arr.: Norsk Manuellterapeut-forening. Se www.manuellterapeutene.org/kurs/mms

10.-11. Oslo. Kurs i klinisk resonnering og manipulasjon for nye manuellterapeuter og manuellterapistudenter. Arr.: NMF. Se www.manuellterapeutene.org/kurs

22. Oslo. Kollegabasert veiledningsseminar for manuellte-rapeuter. Tema: Inkluderende arbeidsliv. Generalforsamling i Servicekontoret. Mer info og påmelding, se www.manuellterapi.no > Kurs og seminarer. Arr.: Manuellterapeutenes Servicekontor

23.-25. Oslo. Tverrfaglig seminar for manuellterapeuter, fysioterapeuter, leger, kiropraktorer og annet helseperso-nell. Mer info og påmelding, se www.manuellterapi.no > Kurs og seminarer. Arr. Manuellterapeutenes Servicekon-tor.

23.-25. Oslo. Landsmøte i Norsk Manuellterapeutforening.

April20.-21. Oslo. Manuellmedisinsk smertebehandling (MMS), trinn I for fysioterapeuter. Arr.: Norsk Manuellterapeut-forening. Se www.manuellterapeutene.org/kurs/mms

20.-21. april, Oslo. Dataregistre – fremmer de samhand-ling og tverrfaglighet, eller bare forskere? Arr.: Norsk forening for ryggforskning. Les se www.manuellterapi.no > Kurs og seminarer

20.-21. april, Oslo. Grunnkurs 2 – muskel og skjelett ultra-lyd. Les se www.manuellterapi.no > Kurs og seminarer

26.-28 Adelaide, Australia. NOI Neurodynamics andthe Neuromatrix conference. Arr.: Neuro Orthopaedic Institute. Mer info og påmelding, se www.noi2012.com

26.-29. Dublin, Irland. Active Release Technique Soft Tis-sue Management (ART) for ryggraden. Arr.: ART Europa For info og påmelding, se www.manuellterapi.no > Kurs og seminarer.

Agenda Oversikten over arrangementer er ikke fullstendig. Tips oss om aktuelle kurs, kongresser og seminarer, slik at oversikten blir mest mulig komplett. Kontakt redaksjonen, [email protected]. Tlf.: 913 00 403.

Generalforsamling i Servicekontoret

Det avholdes generalforsamling i Servicekontoret torsdag 22. mars kl. 17.00 på Radisson Blu Scandi-navia hotell i Oslo. Frist for innsending av saker: 22. februar.

Styret i Manuellterapeutenes Servicekontor

“Stimula gir meg nye muligheter”

Slyngebehandling med Redcord Stimula

®

Redcord ASPB 55 , 4920 Staubø Tlf: 37 05 97 [email protected]

Neurac slyngebehandling gjenoppretter normal muskelfunksjon og reduserer smerte gjennom neuromuskulær stimulering og aktivering.

Pris: 29 000,- eks mva Inkl. 1 gratis kursplass på Neurac 2 Stimula kurs ved kjøp og bestilling samtidig.

– din totalleverandør av fysikalsk utstyr

UniversalbenkEt sikkert valg i sitt segment. Finnes i mange varianter, valg av dropper, farger, versjoner og tilleggsutstyr. Universalbenken er veldig fleksibel i forhold til innstillinger, og gir derfor tera-peuten mange behandlings- muligheter. Benken er meget stabil med kraftig konstruksjon. Konstruert spesielt for behandling med hovedvekt på manipulasjons- teknikker, og tåler hard belastning.

Kvalitetsbenker til alle typer behandlinger

OsteoflexBenkene fra Gymna representerer funksjonalitet og unikt design. Gymna Stability Profile (GSP) garanterer en merkbar stabilitet. Den 7-delte Osteoflexbenken med sideklaffer er spesielt tilpasset tera-peuter som jobber mye med manuelle behandlingsteknikker. Sideklaffene gjør at du kommer nærmere pasienten, hvilket gir god arbeidsergonomi og sikrere behandlinger. Osteoflex er en toppmodell, som forener høy kvalitet og muligheten for best prestasjon.

Kontakt oss for mer informasjon. Tlf. 24 05 66 30. E-post: [email protected]. www.medinor.no

Quadroflex

Art.nr WA65MXPE-2Art.nr WA65MXPE-2

I tillegg til å være totalleverandør på utstyr, har vi også et bredt sortiment innenfor forbruk til helsesektoren. Ta gjerne kontakt med oss for en forbruksavtale.

Forbruk

Annonse Januar 1/1 side.indd 3 27.01.12 19:53

Innhold

Ansvarlig redaktørEspen MathisenNabbetorpveien 1381636 Gml [email protected] tlf.: 913 00 403

Utgiver Manuellterapeutenes ServicekontorBoks 797 , 8510 Narvik

RedaksjonskomiteGro Camilla [email protected].: 907 45 055

Bjørn Runar [email protected].: 922 59 017

Harald [email protected].: 915 94 788

AnnonserÅsmund Andersen, tlf.: 920 30 [email protected]

AbonnementTidsskriftet sendes ut fi reganger i året til medlemmer av Manuellterapeutenes Service-kontor. Medlemmer av Unge Fysioterapeuters Fellesskap får bladet gratis tilsendt i 2012. Andre kan tegne årsabonnement for 175 kroner.

TrykkLO MediaISSN 1503 6588

Opplag1.200 eksemplarer

Neste nummer Ca. 21.5.2012. Manusfrist: 24.4.2012

Internett Les fl ere saker om muskel og skjelett på www.manuellterapi.no

Tidsskriftet MuskelSkjelett

Manuellterapeutene kan avlaste fastlegeneDepartementets forslag til ny fastlegeforskrift inneholder mange gode intensjoner. Skal disse oppnås må fastlegene ha avlastning. Det kan ma-nuellterapeutene bidra til.

Ifølge forskriften skal fast-legene blant annet tilby time innen 48 timer, telefonhenven-delser skal besvares innen to minutter, alle på fastlegens liste skal følges opp – også de som ikke selv tar kontakt og fastle-gen skal på flere hjemmebesøk. Fastlegene har reagert med pro-test, og hevder at de ikke vil rek-ke over alle arbeidsoppgavene.

Tidligere undersøkelser viser at ca. 20 prosent av fast-legenes konsultasjoner skyldes sykdom og skade muskel- og skjelettapparatet. Dette er manuellterapeutenes faglige kompetanseområde. Samtidig har manuellterapeutene full-makter som ligner fastlegenes i kommunehelsetjenesten. Ved å implementere manuelltera-pireformen av 1.1.2006 bedre, kan manuellterapeutene avlaste fastlegene. Ved å bruke manuell-terapeutene til det de er gode på, kan fastlegene frigjøres til andre samfunnsviktige oppgaver.

muskel skjelett

3 Kalender med oversikt over kurs og møter5 InnholdLeder6 Stor interesse for å utdanneseg i muskel og skjelettultralyd8 Manuellterapeutene vant over NFF i merkesak10 Manual therapy with and without vestibular rehabilitation for cervicogenic dizziness

21 428 manuellterapeuter i 2010 NMF mer enn dobbel så stor som FFMT22 Slik behandles autorisasjonssaken Ber om manuellterapiautorisasjon Dette mener NMF Dette mener FFMT – Autorisasjon vil tvinge seg fram

28 Psykologer vil sykmelde

30 Program for tverrfaglig seminar, 23.-25. mars og kollegabasert veiledningsseminar 22. mars.

6

26

8

– din totalleverandør av fysikalsk utstyr

UniversalbenkEt sikkert valg i sitt segment. Finnes i mange varianter, valg av dropper, farger, versjoner og tilleggsutstyr. Universalbenken er veldig fleksibel i forhold til innstillinger, og gir derfor tera-peuten mange behandlings- muligheter. Benken er meget stabil med kraftig konstruksjon. Konstruert spesielt for behandling med hovedvekt på manipulasjons- teknikker, og tåler hard belastning.

Kvalitetsbenker til alle typer behandlinger

OsteoflexBenkene fra Gymna representerer funksjonalitet og unikt design. Gymna Stability Profile (GSP) garanterer en merkbar stabilitet. Den 7-delte Osteoflexbenken med sideklaffer er spesielt tilpasset tera-peuter som jobber mye med manuelle behandlingsteknikker. Sideklaffene gjør at du kommer nærmere pasienten, hvilket gir god arbeidsergonomi og sikrere behandlinger. Osteoflex er en toppmodell, som forener høy kvalitet og muligheten for best prestasjon.

Kontakt oss for mer informasjon. Tlf. 24 05 66 30. E-post: [email protected]. www.medinor.no

Quadroflex

Art.nr WA65MXPE-2Art.nr WA65MXPE-2

I tillegg til å være totalleverandør på utstyr, har vi også et bredt sortiment innenfor forbruk til helsesektoren. Ta gjerne kontakt med oss for en forbruksavtale.

Forbruk

Annonse Januar 1/1 side.indd 3 27.01.12 19:53

6 muskel&skjelett nr. 1, febr. 2012

AKTUELT

6 muskel&skjelett nr. 1, febr. 2012

Stor interesse for å utdanne seg i ultralyddiagnostikk

Muskel- og skjelettultralyd

Varmt klima bra for revmatikereSINTEF har evaluert ordningen med behandlingsreiser til utlandet. Evalueringen viser blant annet at behandlingsreiser til varmere klima for revmatikere er godt dokumen-tert.

Det er også godt dokumentert at personer med psoriasis kan ha nytte av slike reiser. For andre pasient-grupper, som for eksempel personer med nevromuskulær sykdom og postpolio, foreligger det få studier som dokumenterer nytten.

Det foreligger ingen publiserte studier av behandlingseffekt i var-mere klima for astma og lungesyk-dommer for barn og unge, mens det for barn med atopisk eksem bare er én randomisert kontrollert studie som viser positiv effekt.

SINTEF peker på at det ikke foreligger noen nyttekostnadsana-lyser for behandlingsreiser. For å kunne vurdere nytten av behand-lignsreiser opp mot andre helsteje-nester, anbefales det å gjennomføre fullstendige nyttekostnadsanalyser av diagnosegruppene innen dagesn ordning.

De første norske pasienter med revmatiske sykdommer og psoriasis fikk tilbud om offentlig finansiert behandlingsreise til utlandet i 1976.

Fra 1997 ble ordningen gjort permanent etter vedtak i Stortinget. I dag omfatter ordningen pasienter med betennelsesaktige revmatiske sykdommer, psoriasis, senskader et-ter poliomyelitt, barn og unge med astma og lungesykdommer og barn med atopisk eksem.

Behandlingen foregår i Tyrkia, på Kanariøyene, Montenegro, Spania og Lanzarote. n

Kilde: Evaluering av ordningen med be-handlingsreiser til utlandet, Sintef 2011.

Årets første kurs i diagnostisk ultralyd for muskel- og skjelett-systemet ble svært vellykket. Jørn Bjørnås (det lille bildet t.v.) tror ultralyddiagnostikk vil bli viktigere etter innføringen av Samhandlingsreformen. Det var stor interesse for å få delta på kurset i januar. Da deltakerne ble ønsket velkommen, var det fullt i Medinors lo-kaler i Oslo.

Kursledere var manuellterapeut Jørn Bjørnaas og fysioterapeut Frode Gar-mannsvik. De driver Ultralyd Trønde-lag, og er engasjert av Servicekontoret til å gjennomføre en kursrekke i løpet av året. Temaer er grunnleggende ultra-lydfysikk, ultralyddiagnostikk muskel-skjelett, ultralyd på nerver, ultralydstyrt nåling og injeksjoner, ultralydpatologi. I tillegg er det mye «hands on» og prak-tiske øvelser.

Neste kurs avholdes 20.-21. april 2012, mens siste kurs går av stabelen 21.-22.

Sjekker struktur. Manuellterapeut Kjersti Gundersen studerer ankelen til lege Helge Opøien ved hjelp av ultralydapparatet.

Kursledere. Jørn Bjørnaas og Frode Gar-mannsvik fra Ultralyd Trøndelag

september 2012. Det er mulig å ta enkelt-kurs.

SamhandlingsreformDen nye samhandlingsreformen påleg-ger kommunene å ta mer ansvar for di-agsnostikk og behandling.

– For kommunene vil det være øko-nomisk gunstig at mest mulig bildedia-gnostikk og prosedyrer foregår i kom-munehelsetjenesten, slik at sykehus eller røntgeninstitutt blir avlastet, sier Bjørnaas.

AKTUELT


Stor interesse for å utdanne seg i ultralyddiagnostikk

Muskel- og skjelettultralyd

– Dette, sammen med at ultralyd er blitt den fag-lig mest foretrukne tmetoden for billedundersøkel-se ved ulike typer muskel- og skjelettilstander, gjør at muskel- og skjelettultralyd vil bli mer etterspurt.

Revmatologi kan være et området som det kan samarbeides om.

– Dersom ultralyd beherskes, er det fullt mulig å avlaste sykehusene med ultralydstyrte injeksjoner for revmatikerpasienter. – Dette vil være lønnsomt for kommunene, lettvint for pasientene, samt min-ske trykket på sykehusene, en vinn vinn situasjon for alle, sier Bjørnaas.

Mange yrkesgrupperSnaut halvparten av de 24 kursdeltakerne var ma-nuellterapeuter. Resten var leger og fysioterapeuter. Interessen for ultralyd er med andre ord stor i flere yrkesgrupper, og det relativt stor kursaktivitet på området.

– Det er bra at Servicekontoret ønsker at manu-ellterapeuter skal være i front av utviklingen, sier Bjørnaas.

Medlemmer av Servicekontoret får kursene til medlemspris. De som følger hele kursrekken får dermed kvalitetskurs, og sparer samtidig penger. n

Hands on. Det settes av rikelig med tid til praktiske øvelser på kursene. Hjelpelærer og manuellterapeut Geir Vollstad midt i bildet med briller og svart t-skjorte.

Sjekk neste kurs på manuellterapi.no

> Kurs

8 muskel&skjelett nr. 1, februar 2012

AKTUELT Bransjemerke

– Vi er tilfreds med utfallet, men samtidig oppgitt over at NFF gjennom sin innsigelse har forspilt tid og ressurser for begge parter, sier informasjons-medarbeider Espen Mathisen i Manuellterapeute-nes Servicekontor.

Servicekontoret søkte 24. november 2008 om å registrere manuellterapimerket som manuelltera-piprofesjonens merke. Av søknaden gikk det fram at alle manuellterapeuter tilknyttet Servicekontoret – uavhengig av fagpolitisk tilknytning – samt kon-toret selv, skal kunne benytte logoen.

Garanti– Bakgrunnen for søknaden var at vi ønsket at ma-nuellterapeutene skulle ha et felles bransjemerke som kunne tjene som en garanti for pasienter og samarbeidende personell at profesjonsutøverne er manuellterapeut etter forskrift, sier Mathisen.

Han peker på at det var viktig å varemerkebe-skytte logoen, da manuellterapeutbegrepet per i dag ellers ikke er beskyttet på noen som helst måte.

– Det er derfor mulig for andre å nyte godt av det arbeidet som er lagt ned for å bygge opp profesjo-nen og merkevarebetegnelsen «manuellterapi».

Ville slette registreringenDen 24. mars 2009 registrerte Patentstyret logoen som manuellterapeutenes varemerke. Dette ble behørig omtalt i Muskel&Skjelett 2/2009. Kort tid etter leverte Norsk Fysioterapeutforbund ved ad-vokatfirmaet Rohde Garder en innsigelse til Pa-tentstyret der de krevde registreringen slettet i sin helhet. NFF hevdet å eie logoen, og at forbundet verken ved avtale eller på annen måte hadde over-dratt merket til Servicekontoret da det ble opprettet i 2005.

Servicekontoret hadde da siden starten i 2005 brukt logoen for å bygge manuellterapi som mer-kevare.

Manuellterapeutene vant over NFF i merkesak

Patentstyret avviste Norsk Fysioterapeutforbunds innsigelse på registreringen av manuellterapilogoen som yrkesgruppens bran-sjemerke. Dermed er det slått fast at manuellterapeuter tilknyttet Manuellterapeutenes Servicekontor kan bruke bransjemerket slik som tidligere forutsatt.

Inngikk avtale med NFF Servicekontorets advokat Christine Schjerven viste i sine tilsvar i innsigelsessaken til at NFF umulig kunne eie et merke forbundet hverken hadde bestilt eller betalt. I tillegg ble det den 23. juni 2006 inngått en avtale mellom NFF og Servicekontoret der alle forhold mellom de to partene ble endelig opp- og avgjort. I avtalen heter det blant annet at «partene forplikter seg til ikke å rette ytterligere krav mot hverandre».

– Vi la derfor til grunn at Servicekontorets bruk av manuellterapilogoen, som var vel kjent for NFF, var uproblematisk. Da vi søkte om varemerkebe-skyttelse hadde ikke NFF nye faggruppe for manu-ellterapi noen gang brukt logoen.

Mathisen ønsker ikke å spekulere hva som kan være motivasjonen for NFFs ønske om å slette re-gistreringen av manuellterapilogoen.

– At den nye faggruppen skulle ønske å bruke logoen for seg og andre manuellterapeuter, faller på sin egen urimelighet. Faggruppen utviste ikke noen form for interesse for å bruke logoen før Ser-vicekontoret ville beskytte den som varemerke. Pa-tentstyret har nettopp lagt avgjørende vekt på dette i sin avgjørelse.

Manuellterapeuter fra alle forbund som organi-serer manuellterapeuter, også Norsk Fysioterapeut-forbund, har adgang til å bruke logoen.

– Servicekontoret er fagpolitisk uavhengig, men vi vil arbeide mot alle forsøk på å slette merker og kjennetegn på manuellterapi, selv om det skulle være et fagforbund som organiserer manuelltera-peuter som står bak, sier Mathisen.

Tiltak på ventHan forteller at innsigelsessaken har hatt negative konsekvenser for Servicekontoret.

– Markedsføringstiltak, som for eksempel nytt design på nettsiden, har blitt utsatt, fordi innsigel-

Manuellterapi-logoen. Bransjens kjennemerke.

AKTUELT


Bransjemerke

Manuellterapeutene vant over NFF i merkesak

sessaken ikke var avklart. Design tar som regel utgangspunkt i en logo både når det gjelder farge- og formbruk. Det ville være uklokt å bruke mange penger på et nytt design, hvis logoregistreringen måtte slettes. n

«Vi ønsker å bruke logoen»NFFs faggruppe for manuellterapi skriver i sin års-melding til egne medlemmer at manuellterapilo-goen var et viktig identitetssymbol for manuellte-rapeuter, og at NFF ønsker at det fortsatt skal være det.

Ifølge faggruppen har den hele tiden ønsket å bruke logoen for sin faggruppe, og samtidig tillate alle manuellterapeuter, enten de er medlemmer av faggruppen eller ikke, å bruke det i sin virksom-het. n

Servicekontor med god forretningsskikkServicekontoret hadde en aktuell og beretti-get interesse i å levere en søknad om registre-ring av manuellterapilogoen som bransjens varemerke. Søknaden var i også i tråd med god forretningsskikk, fremgår det av Paten-styrets avgjørelse.

Patentstyret skriver at det ikke er doku-mentert klare uenigheter mellom NFF og Ser-vicekontoret om logoen da søknad ble levert. Dette til tross for at det var kontakt mellom partene. Videre heter det at

«Når en tar partenes forhold og historie i be-traktning, sammenholdt med innsigers (NFF, red. anm.) passivitet, kunne det etter Patentstyrets syn ikke med rimelighet forventes av innehaver (Ser-vicekontoret, red. anm.) å avstå fra å levere inn en søknad. Etter Patentstyrets vurdering foreligger det ikke opplysninger i saken som samlet sett gir et kvalifisert grunnlag for å slå fast at søknaden ble levert i strid med standarden for god forretnings-skikk».

Patentstyret ville derfor ikke slette regis-treringen av logoen som varemerke for ma-nuellterapi, slik NFF ba om. n

En logo for manuellterapeuterBruk logoen for å vise at du er manuellterapeut. Patentstyret har nå, drøyt tre år etter at søknad ble sendt, endelig stadfestet at manuellterapilogoen er profesjonens kjennemerke. Brukere av merket er ifølge logobestemmelsene manuellterapeut i hen-hold til forskrift.

Medlemmer kan laste ned logoen her: manuellterapi.no > For medlemmer > Drift > Markedsfø-ring > Manuellterapilogo (krever innlogging). n

NFF ba Patentstyret slette registreringen av manuellterapilogoen, men fikk ikke medhold (faksimile).

FORSKNING


Svimmelhet

REVIEW Open Access

Manual therapy with and without vestibularrehabilitation for cervicogenic dizziness: asystematic reviewReidar P Lystad*, Gregory Bell, Martin Bonnevie-Svendsen and Catherine V Carter

Abstract

Background: Manual therapy is an intervention commonly advocated in the management of dizziness of asuspected cervical origin. Vestibular rehabilitation exercises have been shown to be effective in the treatment ofunilateral peripheral vestibular disorders, and have also been suggested in the literature as an adjunct in thetreatment of cervicogenic dizziness. The purpose of this systematic review is to evaluate the evidence for manualtherapy, in conjunction with or without vestibular rehabilitation, in the management of cervicogenic dizziness.

Methods: A comprehensive search was conducted in the databases Scopus, Mantis, CINHAL and the CochraneLibrary for terms related to manual therapy, vestibular rehabilitation and cervicogenic dizziness. Included studieswere assessed using the Maastricht-Amsterdam criteria.

Results: A total of fifteen articles reporting findings from thirteen unique investigations, including five randomisedcontrolled trials and eight prospective, non-controlled cohort studies were included in this review. Themethodological quality of the included studies was generally poor to moderate. All but one study reportedimprovement in dizziness following either unimodal or multimodal manual therapy interventions. Some studiesreported improvements in postural stability, joint positioning, range of motion, muscle tenderness, neck pain andvertebrobasilar artery blood flow velocity.

Discussion: Although it has been argued that manual therapy combined with vestibular rehabilitation may besuperior in the treatment of cervicogenic dizziness, there are currently no observational and experimental studiesdemonstrating such effects. A rationale for combining manual therapy and vestibular rehabilitation in themanagement of cervicogenic dizziness is presented.

Conclusion: There is moderate evidence to support the use of manual therapy, in particular spinal mobilisationand manipulation, for cervicogenic dizziness. The evidence for combining manual therapy and vestibularrehabilitation in the management of cervicogenic dizziness is lacking. Further research to elucidate potentialsynergistic effects of manual therapy and vestibular rehabilitation is strongly recommended.

Keywords: Cervicogenic dizziness, Vertigo, Manual therapy, Vestibular rehabilitation, Spinal manipulation,mobilisation

BackgroundDizziness is a non-specific symptom that is commonlyencountered by primary health care practitioners [1],and the prevalence has been reported to be between11.1% and 28.9% [2-5]. It can be experienced as faint-ness, unsteadiness, perception of spinning and

disorientation [6-8]. The mechanisms producing thesesymptoms are multiple and can involve several differentorgan systems. Ardc, Topuz and Kara [9] reported themost frequent diagnosis of patients suffering from dizzi-ness to be benign paroxysmal positional vertigo, endo-lymphatic hydrops, migraine, central decompensation,acute vestibulopathy and autonomic dysfunction.Furthermore, it is not uncommon for patients experien-cing dizziness to have more than one diagnosis.* Correspondence: [email protected]

Department of Chiropractic, Macquarie University, Sydney, Australia

Lystad et al. Chiropractic & Manual Therapies 2011, 19:21http://chiromt.com/content/19/1/21 CHIROPRACTIC & MANUAL THERAPIES

© 2011 Lystad et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.

REVIEW Open Access

Manual therapy with and without vestibularrehabilitation for cervicogenic dizziness: asystematic reviewReidar P Lystad*, Gregory Bell, Martin Bonnevie-Svendsen and Catherine V Carter

Abstract

Background: Manual therapy is an intervention commonly advocated in the management of dizziness of asuspected cervical origin. Vestibular rehabilitation exercises have been shown to be effective in the treatment ofunilateral peripheral vestibular disorders, and have also been suggested in the literature as an adjunct in thetreatment of cervicogenic dizziness. The purpose of this systematic review is to evaluate the evidence for manualtherapy, in conjunction with or without vestibular rehabilitation, in the management of cervicogenic dizziness.

Methods: A comprehensive search was conducted in the databases Scopus, Mantis, CINHAL and the CochraneLibrary for terms related to manual therapy, vestibular rehabilitation and cervicogenic dizziness. Included studieswere assessed using the Maastricht-Amsterdam criteria.

Results: A total of fifteen articles reporting findings from thirteen unique investigations, including five randomisedcontrolled trials and eight prospective, non-controlled cohort studies were included in this review. Themethodological quality of the included studies was generally poor to moderate. All but one study reportedimprovement in dizziness following either unimodal or multimodal manual therapy interventions. Some studiesreported improvements in postural stability, joint positioning, range of motion, muscle tenderness, neck pain andvertebrobasilar artery blood flow velocity.

Discussion: Although it has been argued that manual therapy combined with vestibular rehabilitation may besuperior in the treatment of cervicogenic dizziness, there are currently no observational and experimental studiesdemonstrating such effects. A rationale for combining manual therapy and vestibular rehabilitation in themanagement of cervicogenic dizziness is presented.

Conclusion: There is moderate evidence to support the use of manual therapy, in particular spinal mobilisationand manipulation, for cervicogenic dizziness. The evidence for combining manual therapy and vestibularrehabilitation in the management of cervicogenic dizziness is lacking. Further research to elucidate potentialsynergistic effects of manual therapy and vestibular rehabilitation is strongly recommended.

Keywords: Cervicogenic dizziness, Vertigo, Manual therapy, Vestibular rehabilitation, Spinal manipulation,mobilisation

BackgroundDizziness is a non-specific symptom that is commonlyencountered by primary health care practitioners [1],and the prevalence has been reported to be between11.1% and 28.9% [2-5]. It can be experienced as faint-ness, unsteadiness, perception of spinning and

disorientation [6-8]. The mechanisms producing thesesymptoms are multiple and can involve several differentorgan systems. Ardc, Topuz and Kara [9] reported themost frequent diagnosis of patients suffering from dizzi-ness to be benign paroxysmal positional vertigo, endo-lymphatic hydrops, migraine, central decompensation,acute vestibulopathy and autonomic dysfunction.Furthermore, it is not uncommon for patients experien-cing dizziness to have more than one diagnosis.* Correspondence: [email protected]

Department of Chiropractic, Macquarie University, Sydney, Australia

Lystad et al. Chiropractic & Manual Therapies 2011, 19:21http://chiromt.com/content/19/1/21 CHIROPRACTIC & MANUAL THERAPIES

© 2011 Lystad et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.

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Dizziness is commonly seen in whiplash patients, affect-ing 20-58% of individuals with flexion-extension injuries[10].One specific type of dizziness is cervicogenic dizziness.

The disorder was first described as “cervical vertigo” byRyan and Cope in 1955 [11]. Other terms used for thesame disorder are proprioceptive vertigo, cervicogenicvertigo and cervical dizziness [12-14]. Although thediagnosis has remained controversial since its introduc-tion, several observations have led to the proposal of aplausible pathophysiological mechanism. The deep inter-vertebral muscles in the cervical spine possess a highdensity of muscle spindles and are assumed to play animportant role in postural control [15-18]. Cervicalafferents are known to be involved in the cervico-collicreflex, the cervico-ocular reflex and the tonic neckreflex, which work in conjunction with other reflexesinfluenced by visual and vestibular systems to stabilisethe head, the eyes and posture [19]. Vestibular and pro-prioceptive input is linearly combined for computingegocentric, body-centred coordinates [20].Several authors have demonstrated that anaesthetic

injections to the upper cervical dorsal nerve roots canproduce dizziness and nystagmus [21-23]. Electrical sti-mulation to cervical muscles has also been shown toinduce a sensation of tilting or falling [24]. Brandt andBronstein [25] proposed a mechanism where changedfiring characteristics of cervical somatosensory receptorsdue to neck pain lead to a sensory mismatch betweenvestibular and cervical input, resulting in cervicalvertigo.Several authors have proposed manual therapy inter-

ventions for the treatment of dizziness of a cervical ori-gin [26-28]. Indeed, it has been suggested that themanagement of cervicogenic dizziness should be thesame as for cervical pain [25]. In a systematic review ofthe literature, Reid and Rivett [29] concluded that thereis limited evidence to support manual therapy treatmentof cervicogenic dizziness. Moreover, it was recom-mended that further research be conducted, especiallyrandomised controlled trials (RCTs), to provide moreconclusive evidence of the role of manual therapy forcervicogenic dizziness.Another treatment modality that is advocated for cer-

vical pain is sensorimotor rehabilitation exercises[19,30]. These exercises fall under the scope of exercisesincluded in vestibular rehabilitation therapy. Vestibularrehabilitation emerged as a group of exercises for per-ipheral vestibular disorders, aiming to maximise centralnervous system compensation to vestibular pathology[31,32]. These exercises are usually movement based,and can be further subcategorised according to differentphysiological rationales: (i) compensatory responsesusing motion to habituate activity in the vestibular

nuclei; (ii) adaptation for visual-vestibular interactionand possibly eye/hand coordination, using repetitive andprovocative movements of the head and/or eyes; (iii)substitution which promotes the use of individual orcombinations of sensory inputs to bias use away fromdysfunctional vestibular input; (iv) postural control exer-cises, falls prevention, relaxation training, reconditioningactivities and functional/occupational retraining, whichare based on motor learning principles [33,34].Hillier and Hollohan [34] concluded that there was

moderate to strong evidence that vestibular rehabilita-tion is safe and effective in the management of unilateralperipheral vestibular disorders. Moreover, severalauthors encourage the implementation of vestibularrehabilitation in treatment of dizziness of a cervical ori-gin [10,32,35], and published case studies have reportedpositive outcomes when combining manual therapy andvestibular rehabilitation [36,37].To the authors’ knowledge, the evidence of imple-

menting vestibular rehabilitation with manual therapy inthe management of cervicogenic dizziness has not beensystematically reviewed. Thus, the purpose of this sys-tematic review was: (i) to provide an updated systematicreview of manual therapy for cervicogenic dizziness byincluding higher level evidence published since the pre-vious review by Reid and Rivett [29], and (ii) to comparethe evidence of (a) manual therapy with vestibular reha-bilitation for cervicogenic dizziness with (b) manualtherapy without vestibular rehabilitation for cervicogenicdizziness.

MethodsThis systematic review adhered to the guidelines out-lined in the Preferred Reporting Items for SystematicReviews and Meta-Analyses (PRISMA) Statement [38].

Eligibility criteriaThis systematic review was limited to prospective, con-trolled or non-controlled intervention studies publishedin peer-reviewed journals. Retrospective study designs,case reports, case series, commentaries, letters to theeditor, and expert opinions were excluded from thisreview. No language restrictions were applied in thisreview.Eligible studies had to investigate a cohort of patients

diagnosed with cervicogenic dizziness. Cervicogenic diz-ziness was defined as the presence of dizziness, imbal-ance or unsteadiness related to movements or positionof the cervical spine, or occurring with a stiff or painfulneck [29]. Studies investigating populations diagnosedwith cardiovascular disorders, central nervous systemdisorder (e.g. cerebellar ataxia, stroke, demyelination),Mal de Debarquement syndrome, migraine-associatedvertigo, psychogenic dizziness, vestibular disorders (e.g.

Lystad et al. Chiropractic & Manual Therapies 2011, 19:21http://chiromt.com/content/19/1/21

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benign paroxysmal positional vertigo, Meniere’s disease,peripheral vestibulopathy), were not included in thisreview. Studies were also excluded if the study popula-tion was comprised of patients with a history of activeinflammatory joint disease, spinal cord pathology, cervi-cal spine cancer or infection, bony disease or markedosteoporosis, marked cervical spine disc protrusion,acute cervical nerve root symptoms, fracture or disloca-tion of the neck, or previous surgery to the upper cervi-cal spine.This review considered two possible interventions,

namely manual therapy alone and manual therapy inconjunction with vestibular rehabilitation. For the pur-poses of this review, manual therapy was defined asspinal manipulation (high velocity, low amplitude tech-niques) or mobilisation (low-velocity, small or largeamplitude techniques) [29]. Vestibular rehabilitation wasdefined as an exercise-based group of approaches withthe aim of maximising the central nervous system com-pensation for vestibular pathology [39]. Vestibular reha-bilitation techniques included habituation (movementprovoking) with gaze stabilising (adaptation), sensorysubstitution, and balance and gait/activity training [34].

Search StrategyA comprehensive search of the literature was conducted,including electronic searches of the Scopus, Mantis, andCINAHL databases from January 1955 to June 2010. Inaddition, the Cochrane Library was searched frominception (1993) to June 2010 to identify any relevantCochrane Reviews. Keywords used in the literaturesearch included “cervicogenic dizziness” and “manualtherapy”. Alternative spellings, synonyms and relatedterms, and truncated versions of both the condition andthe intervention were included. In addition, bibliogra-phies of included studies and relevant review articleswere hand searched to indentify potentially eligible stu-dies not captured by the electronic searches.

Study selectionCitations from the electronic searches were combined ina single list and duplicate records were discarded. Tworeviewers screened all titles and abstracts to identify andremove obviously irrelevant citations. Full text versionsof all potentially eligible articles were retrieved and eval-uated by two independent reviewers to determine elig-ibility for inclusion in this review. Any differences wereresolved by mutual consensus with a third independentreviewer.

Data extraction processData from eligible studies were extracted and compiledin a spreadsheet. For the purposes of this systematicreview the following data were extracted: (i) study

population (e.g. age, gender, diagnosis, and sample size);(ii) study design; (iii) intervention; (iv) outcome mea-sures; and (v) main findings.

Data analysisOwing to the clinically heterogeneous nature of theincluded studies (i.e. varying study designs, interven-tions, outcome measures, and quality of data), a meta-analysis was deemed unfeasible. Thus, in this reviewonly a qualitative analysis of included studies was under-taken. As per the previous review by Reid and Rivett[29], qualitative analysis was achieved by attributinglevels that rate the scientific evidence, i.e. Level 1:Strong evidence (provided by generally consistent find-ings in multiple higher quality RCTs); Level 2: Moderateevidence (provided by generally consistent findings inone higher quality RCT and one or more lower qualityRCTs); Level 3: Limited evidence (provided by generallyconsistent findings in one or more lower quality RCTs);and Level 4: No evidence (if there were no RCTs or ifthe results were conflicting).

Assessment of methodological qualityThe methodological quality of the included studies wasassessed using the Maastricht-Amsterdam criteria [40].The Maastricht-Amsterdam criteria list, which consistsof 19 items assessing patient selection, interventions,outcome measures and statistics, is included in Addi-tional file 1. Two independent reviewers assessed meth-odological quality and any differences were resolved bymutual consensus with a third independent reviewer.Each item was answered “yes”, “no”, or “don’t know”,and one point was assigned for each “yes” (fulfilleditem). The assessed studies were categorised as eitherpoor, moderate or good based on the percentage of ful-filled items from the Maastricht-Amsterdam criteria list.In accordance with other authors using similar qualityassessment methods, the cut-off percentage values werearbitrarily set at < 50% (poor), 50-80% (moderate), and> 80% (good) [41-43].

ResultsThe electronic searches returned 658 hits, whichincluded 335 duplicate records and 323 unique citations.After removing duplicate records and screening titlesand abstracts to discard obviously irrelevant citations, atotal of 42 potentially eligible studies were identified. Ahand search revealed four additional studies that werenot captured by the electronic search. Thus, a total of46 potentially eligible studies were evaluated for inclu-sion in this systematic review. Thirty-one studies[29,36,44-72] did not meet the inclusion criteria andwere excluded from this review. See Additional file 2 fora list of excluded studies including reasons for


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exclusion. Figure 1 contains a flow diagram of the studyselection process. Two articles [26,73] reported datafrom the same RCT, and the results from one cohortstudy were published in two separate articles [74,75]Thus, this review included reports from a total of thir-teen unique investigations. See Table 1 for a descriptionof included studies.The included studies comprised five RCTs [26,76-79]and eight prospective, non-controlled, cohort studies[75,80-86], with samples sizes ranging from 12 to 168.One study [81] did not report on the gender distributionof recruited participants, however all but one of the

remaining studies included more females, ranging from52% to 88%.Six studies [75-77,80-82], including two RCTs [76,77],

used only spinal manipulation or mobilisation, or both,as the intervention. The remaining seven investigations[26,78,79,83-86], including three RCTs [26,78,79] uti-lised a multimodal approach consisting of several differ-ent interventions (e.g. spinal manipulation andmobilisation, soft tissue therapy, electrotherapy, andmedications) and home exercise programs. However,none of the included studies used manual therapy inconjunction with vestibular rehabilitation.

Figure 1 PRISMA flow diagram.


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exclusion. Figure 1 contains a flow diagram of the studyselection process. Two articles [26,73] reported datafrom the same RCT, and the results from one cohortstudy were published in two separate articles [74,75]Thus, this review included reports from a total of thir-teen unique investigations. See Table 1 for a descriptionof included studies.The included studies comprised five RCTs [26,76-79]and eight prospective, non-controlled, cohort studies[75,80-86], with samples sizes ranging from 12 to 168.One study [81] did not report on the gender distributionof recruited participants, however all but one of the

remaining studies included more females, ranging from52% to 88%.Six studies [75-77,80-82], including two RCTs [76,77],

used only spinal manipulation or mobilisation, or both,as the intervention. The remaining seven investigations[26,78,79,83-86], including three RCTs [26,78,79] uti-lised a multimodal approach consisting of several differ-ent interventions (e.g. spinal manipulation andmobilisation, soft tissue therapy, electrotherapy, andmedications) and home exercise programs. However,none of the included studies used manual therapy inconjunction with vestibular rehabilitation.

Figure 1 PRISMA flow diagram.


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Table 1 Included studies

Study Participants Interventions Outcome measures Main findings Quality

Manualtherapy

Vestibularrehabilitation

Randomised controlled trials:

Karlberg etal. 1996[26];Malmströmet al. 2007[44]

n = 34 (88%females)Mean age: 37Age range:25-55Country:SwedenSetting:primary carecenters and atertiaryreferralcenter

Mobilisation;Soft tissue therapy(relaxation techniques,stabilisation techniques);Home training program;Ergonomic changes at work

Nil Dizziness frequency;Dizziness intensity;Posturography

- Significantly improved dizzinessintensity and neck pain post-treatment (p < 0.05).- Significantly improved posturalsway post-treatment (p < 0.2).- 14 patients (82%) reportedimprovements at 6 months post-treatment.†

- 11 patients (65%) reportedimprovements in dizziness at 2year post-treatment.†

Moderate

Reid et al.2008 [47]

n = 34 (62%females), 1drop-outMean age:63.5Age range:not reportedCountry:AustraliaSetting:University ofNewcastle

Mobilisation (SNAGs) Nil DHI;Dizziness severity (VAS);Dizziness frequency;Neck pain (VAS);Posturography

- Significantly reduced DHI,dizziness severity, dizzinessfrequency and neck pain in thetreatment group at 6 and 12weeks post-treatment (p < 0.05).- No difference in dizzinessseverity at 12 weeks post-treatment.- No difference in dizzinessfrequency at either 6 or 12 weekspost-treatment.

Good

Kang, Wangand Ye2008 [48]

n = 76 (49%females)Mean age:32.4Age range:18-45Country:ChinaSetting:hospital

Group A:Spinal manipulationGroup B:Acupressure

Nil TCD-US;TCM syndromediagnostic criteria

- Significantly reduced VBA bloodflow velocity post-treatment inboth groups (p < 0.01).- Significantly larger reduction inleft and right vertebral arteryblood flow velocity in Group Bcompared with Group A (p <0.01).- Group differences remainedstatistically significant at a 6-month follow-up.

Moderate

Fang 2010[49]

n = 168 (73%females)Mean age:37.5Age range:not reportedCountry:ChinaSetting:hospital

Treatment group:Spinal manipulation;Soft tissue therapyControl group:TCM medication

Nil CVSFAS;Colour Dopplerultrasonography

- Significant improvements indizziness (p < 0.01), shoulder/neckpain (p < 0.05), and headache (p< 0.01) post-treatment.- Significant reduction of cervicalartery spasm index andatlantoaxial displacement index inthe treatment group post-treatment (p < 0.05).

Moderate

Du et al.2010 [50]


Treatment group:Spinal manipulation;Soft tissue therapyControl group:Traction;Medication

Nil CVSFAS;Radiography;TCD-US;TCM syndromediagnostic criteria

- Significant improvements indizziness scores, vertebraldisplacement post-treatment (p <0.01).- Significantly reduced left andright vertebral artery blood flowvelocity post-treatment (p < 0.01).- Significantly improved clinicaloutcomes six months post-treatment (p < 0.01).

Moderate

Prospective cohort studies:


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Table 1 Included studies (Continued)

Konrad andGerencser1990 [51]

n = 54 (74%females)Mean age:34.7Age range:not reportedCountry:HungarySetting:hospital

Mobilisation;Manipulation

Nil Dizziness (instrumentnot specifically stated);Electronystagmography

- 40 patients (74%) experiencedimprovement of dizziness post-treatment.†

Poor

Mahlstedt,Westhofenand König1992 [52]

n = 28(genderdistributionnot reported)Mean age:not reportedAge rangenot reportedCountry:GermanySetting: notreported

Spinal manipulation Nil No information provided - 19 patients (68%) reportedreduced dizziness post-treatment.†

Poor

Uhlemannet al. 1993[53]

n = 12*(genderdistributionnot reported)Mean age:40.7Age range:not reportedCountry:GermanySetting: notreported

Mobilisation;Spinal manipulation(traction)

Nil Cervical turn test - 5 out of 9 patients went fromtesting positive to testing negativeon the cervical turn test post-treatment.

Poor

Bracher etal. 2000 [54]

n = 15 (80%females), 3drop-outsMean age: 41Age range:27-82Country:BrazilSetting:chiropracticclinic

Spinal manipulation;Soft tissue therapy;Electrotherapy;Labyrinth sedationmedication;sEMG biofeedback;Exercise program

Nil Dizziness (instrumentnot specifically stated;“improvement ofsymptoms was based onpatient’s reports”)

- 9 patients (60%) reportedcomplete remission of dizziness, 3patients (20%) reported consistentimprovement with rare recurrenceof episodes of mild intensity, and3 patients (20%) reported nochange.†

Poor

Hülse andHölzl 2000[55]

n = 67 (52%females)Mean age: 49Age range:18-66Country:GermanySetting: notreported

Soft tissue therapy (tractionmassage, PIR,occipital-base-releasetechnique, atlas-impulse-therapy)

Nil Craniocorpography;Posturography

- Significant improvements inpathological vestibulospinalreactions found post-treatment (p< 0.001).

Poor

Chen andZhan 2003[56]


Spinal manipulation;Soft tissue therapy

Nil TCD-US;Radiography;TCM syndromediagnostic criteria

- 14 patients (87.5%) reportedmarked improvement or completeremission of symptoms.- Significantly decreased vertebralartery mean blood flow velocitypost-treatment (p < 0.05).- Significantly reduced vertebraldisplacement post-treatment (p <0.05).

Poor


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Twelve studies, including all five RCTs, reportedimprovements in dizziness and associated symptoms (e.g. neck pain) following manual therapy intervention.The remaining study measured skull spatial offset repo-sitioning ability, and found a significant improvementfollowing soft tissue manipulation [75]. In addition toreduction in dizziness and associated symptoms, twoRCTs [77,79] reported significant changes in vertebroba-silar artery blood flow velocity post-treatment, and afurther two RCTs [26,76] found improvement in balanceperformance measured with posturography.The methodological quality of the included studies

was generally poor [75,80-85] to moderate [26,77-79,86].However, one study [76] was found to be of good meth-odological quality. Not surprisingly, there was a trendtowards more robust study designs (i.e. RCTs) and morerecently published studies attaining higher qualityscores. Overall, common methodological weaknessesincluded: lack of control group; failure to provide infor-mation allocation concealment and participant, provider,and assessor blinding; omitting performing appropriatestatistical analysis; omitting reporting on patient compli-ance and drop-outs; and including long-term follow-upmeasurements. A tabulated overview of methodologicalquality scores is provided in Additional file 3.Only three studies commented on adverse reactions.

Two RCTs [26,76] reported no adverse reactions, andone prospective cohort study [86] found minor adverse

reactions associated with the interventions in eight ofnineteen participants.

DiscussionIn a previous review of the literature, Reid and Rivett[29] concluded there was limited (Level 3) evidence formanual therapy in the treatment of cervicogenic dizzi-ness. The current systematic review has identified addi-tional studies published since the previous review,including: four RCTs [76-79], three prospective cohortstudies [75,85,86], and a long-term follow up [73] of theintervention group from the RCT published by Karlberget al. [26].The RCT by Reid et al. [76], which was deemed to be

of good methodological quality, assessed the effective-ness of a specific type of spinal mobilisation known assustained natural apophyseal glides (SNAGs). Reid et al.[76] found significant improvement in dizziness severityand frequency, lower scores on the Dizziness HandicapInventory (DHI), and decreased neck pain in the treat-ment group at both six and twelve weeks post-treat-ment. In comparison the placebo group had significantchanges only at the 12-week follow-up in three outcomemeasures (dizziness severity, DHI, and neck pain). Theremaining four RCTs [26,77-79] were deemed to be ofmoderate methodological quality. The findings from theRCT by Karlberg et al. [26] (including the long-term fol-low-up by Malmstrom et al. [44] appear to corroborate

Table 1 Included studies (Continued)

Wu et al.2006 [45];Wu et al.2008 [46]

n = 121 (73%females)Mean age:not reportedAge range:20-71Country:ChinaSetting:hospital

Tuina manipulation therapy(pressing-kneadingmanipulation appliedcontinuously to bilateralvertebrae for 5 minutes)

Nil Custom-madeinstrument to measureskull 3D motion andhead repositioning.

- Significant improvements in skullspatial offset repositioning abilitypost-manipulation (p < 0.01).

Poor

Strunk andHawk 2009[57]

n = 21 (63%females), 2drop-outsMean age: 70Age range:44-85Country: USA(California)Setting:ClevelandChiropracticCollege

Spinal manipulation;Soft tissue therapy(myofascial release, PIR, andheat or cold therapy)

Nil DHISF-BBSNDI

- Improved DHI and SF-BBSscores.†

- Improved balance.†

- Decreased dizziness and neckpain.†

Moderate

CVSFAS: cervical vertigo, symptoms and functional assessment scale; DHI: Dizziness Handicap Inventory; NDI: Neck Disability Index; HVLA: high-velocity, lowamplitude; PIR: post-isometric relaxation; RCT: randomised, controlled trial; ROM: range of motion; SF-SSB: Berg Balance Scale (short form); sEMG: surfaceelectromyography; SNAGs: sustained natural apophyseal glides; TCD: transcranial Doppler ultrasonography; TCM: traditional Chinese medicine; VAS: VisualAnalogue Scale.

* Of the 42 patients that were recruited for this study only 12 patients were included in the manual therapy group, of which only 9 patients actually testedpositive on the cervical turn test pre-treatment.

† No inferential statistics reported


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the evidence provided by Reid et al. [76]. The RCTs byKang, Wang and Ye [77], Fang [78], and Du et al. [79]all utilised spinal manipulation in the intervention groupand reported improvements in clinical outcomes.In addition to five RCTs the current systematic review

identified eight prospective cohort studies, of whichseven [80-86] reported improvements in dizziness fol-lowing manual therapy. Although these were generallyof poor methodological quality they also reportedimprovements in additional outcome measures, includ-ing: neck pain [86], reduction of pathological vestibu-lospinal activity [84], balance [86], and reduced vertebraldisplacement and vertebrobasilar artery blood flow velo-city [85] The remaining cohort study [75] reportedimprovements in skull spatial offset repositioning abilitypost treatment. Collectively, these findings providefurther rationale for the use of manual therapy in thetreatment of cervicogenic dizziness. Overall, the evi-dence evaluated in the current systematic review sug-gests that there is moderate (Level 2) evidence in afavourable direction to support the use of manual ther-apy for cervicogenic dizziness.Although positive clinical outcomes have been demon-

strated, the underlying biological mechanism remains acontroversial subject. It has been theorised that distur-bances to the afferent input from cervical spine mechan-oreceptors may lead to a sensory mismatch betweenvestibular and cervical input subsequently resulting insymptoms such as dizziness, unsteadiness, and visualdisturbances [25]. There is an experimental body of evi-dence indicating that the biomechanical forces of spinalmanipulation and mobilisation impacts primary afferentneurons in paraspinal tissues, which in turn leads tophysiological consequences such as gating of nocicep-tion at the spinal cord and spinal reflex activity to altermuscle activity [87,88]. Thus it is believed that manualtherapy serves to normalise disturbances to the afferentinput from deep neck proprioceptors and their subse-quent reflex arcs (e.g. cervico-collic, cervico-ocular, andtonic neck), which in turn restores the ability to utiliseinternal vestibular orienting information to resolve inac-curate information from the somatosensory and visualsubsystems (i.e. reducing sensory mismatch) [89].Alas, no experimental or observational studies report-

ing the effect of combining manual therapy and vestibu-lar rehabilitation in the management of cervicogenicdizziness could be identified. Collins and Misukanis [36]and Schenk et al. [90] have published case studies inwhich they argue that manual therapy combined withvestibular rehabilitation may be superior in the treat-ment of cervicogenic dizziness. Notwithstanding thepaucity of such investigations, consideration of vestibu-lar dysfunction is paramount in patients with dizziness.Unilateral peripheral vestibular dysfunction can be

characterised by complaints of dizziness, visual or gazedisturbances and balance impairment [34]. In a recentmeta-analysis of vestibular rehabilitation for unilateralperipheral vestibular dysfunction is was concluded thatvestibular rehabilitation is a safe and effective therapy[34].The original vestibular rehabilitation protocols were

developed by Cooksey [91] in 1946. These included:mental exercise, occupational therapy, physical exercisewith the aim of restoring balance and joint positionsense, and training of the eyes, to compensate for per-manent vestibular dysfunction [91]. More recently, Hil-lier and Hollohan [34] stated vestibular rehabilitationmay include: learning to coordinate eye and head move-ments, improving balance and walking skills, learning tobring on the symptoms to desensitize the vestibular sys-tem, patient education, coping strategies, and physicalactivity. There are four mechanisms of vestibular rehabi-litation techniques that may contribute to its benefits,namely: (i) the compensatory response, (ii) adaptation,(iii) substitution, and (iv) postural control exercises. Thecompensatory responses are applied using motion tominimise the responsiveness to repetitive stimuli and torebalance tonic activity within the vestibular nuclei.Adaptation for visual-vestibular interaction uses repeti-tive and provocative movements of the head and/or eyesto minimise error and restore vestibulo-ocular reflexgain. Substitution encourages the use of other sensoryinputs to compensate for dysfunctional afferent systems.Postural control exercises and functional retraining areapplied for movement behaviour and fitness.The four mechanisms canvas a rationale for the inclu-

sion of vestibular rehabilitation in the management ofpatients with cervicogenic dizziness. Stability and pos-ture of the cervical spine is achieved by a combinationof reflexes mediated by vestibular, visual and cervicalsensory input [19]. The cerebellum plays an importantrole in integrating this sensory information [92]. It canbe hypothesised that a well-integrated vestibulo-cerebel-lar system would be more capable of compensating forthe altered cervical sensory input in cases of cervico-genic dizziness. Thus, one can argue that when normalcervical afferent input is compromised, vestibular reha-bilitation may strengthen the vestibulo-cerebellar systemto improve the ability to adapt to the situation. Furtherresearch to elucidate the effectiveness of manual therapyin conjunction with vestibular rehabilitation for cervico-genic dizziness is strongly recommended.There are insufficient data to provide guidelines on

dosage and frequency of manual therapy in general, andspinal manipulation in particular, especially in the con-text of management of cervicogenic dizziness. With thisin mind, it is recommended that caution is taken whendelivering any sensory stimulation in the form of


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manual therapy or vestibular rehabilitation, or both, toaffect dysfunctions in the afferent system in patientswith cervicogenic dizziness. Further research is neces-sary to determine appropriate treatment dosage, sche-duling of interventions, and which manual therapy andvestibular rehabilitation techniques are most effective inmanaging patients with cervicogenic dizziness.Methodological limitations of this systematic review

included lack of blinding during the quality assessmentand the quality and utility of the quality assessment toolitself. Meta-analysis of the finding was precluded by thelack of robust research methodologies and heterogeneityof outcome measures in the studies included in this sys-tematic review.

ConclusionThis systematic review has found that there is moderate(Level 2) evidence in a favourable direction to supportthe use of manual therapy (spinal mobilisation and/ormanipulation) for cervicogenic dizziness. The evidencefor combining manual therapy and vestibular rehabilita-tion in the management of cervicogenic dizzinessremains inconclusive due to no observational andexperimental studies investigating manual therapy inconjunction with vestibular rehabilitation. However,there is a reasonable rationale for utilising manual ther-apy in conjunction with vestibular rehabilitation for cer-vicogenic dizziness, and further research to elucidate thepotential synergistic effects is strongly recommended.

Additional material

Additional file 1: Maastricht-Amsterdam criteria list. The Maastricht-Amsterdam criteria list is an instrument developed by van Tulder et al.[40] to assess methodological quality clinical trials. It consists of nineteenitems that can be rated individually using one of three options: yes, no,or don’t know. The overall methodological quality score is determined byadding up all of the ‘yes’ ratings, with a maximum score of nineteen.

Additional file 2: Excluded studies. Alphabetic list of excluded studies,including the reasons for exclusion.

Additional file 3: Methodological quality assessment scores ofincluded studies. Methodological quality assessment scores of includedstudies.

AcknowledgementsWe sincerely thank Lee-Lian Yeo who translated the Chinese languagearticles to English. We also thank Marius Monssveen for his contributions tothe conception and design of the study in its early stages.

Authors’ contributionsMBS, CVC and GB conceived of the study, participated in the design of thestudy, and helped to draft and edit the manuscript. RPL participated in thedesign and coordination of the study, helped to draft, edit and revise themanuscript. All authors read and approved the final manuscript.

Competing interestsThe authors declare that they have no competing interests.

Received: 25 April 2011 Accepted: 18 September 2011Published: 18 September 2011

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41. Olmos M, Antelo M, Vazquez H, Smecuol E, Maurino E, Bai JC: Systematicreview and meta-analysis of observational studies on the prevalence offractures in coeliac disease. Digestive and Liver Disease 2008, 40(1):46-53.

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43. Swain MS, Lystad RP, Pollard H, Bonello R: Incidence and severity of neckinjury in Rugby Union: A systematic review. Journal of Science andMedicine in Sport 2011, 14(5):383-389.

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doi:10.1186/2045-709X-19-21Cite this article as: Lystad et al.: Manual therapy with and withoutvestibular rehabilitation for cervicogenic dizziness: a systematic review.Chiropractic & Manual Therapies 2011 19:21.

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Svimmelhet

AKTUELT


Manuellterapi

Helfo har utarbeidet en analyserapport som viser takstbruken blant fysioterapeuter og manuelltera-peuter i 2010. Denne viser at 428 terapeuter utløste takst A8 Manuellterapi i 2010.

Hvem som er manuellterapeut er regulert i for-skrift. Alle manuellterapeuter kan utløse takst A8, men alle som kan utløse takst A8 er ikke nødven-digvis manuellterapueter etter forskrift. Det nøy-aktige tallet på manuellterapeuter etter forskrift i 2010, er derfor usikkert.

Rapporten gir en oversikt over gjennomsnittlig bruk av alle takstene som blir brukt av fysiotera-peuter og manuellterapeuter. Analysen omfatter totalt 2.793 fysioterapeuter, 428 manuellterapeuter (brukere av A8-taksten) og 292 psykomotorikere. Analysen henter opplysninger fra Kuhr, Helfos oppgjørssystem for behandlere. Ifølge rapporten har 4263 fysioterapeuter og manuellterapeuter av-tale med Helfo. Det vil si at ca 82 prosent av tera-peutene er med i analysen. Terapeuter som leverer manuelle oppgjør er ikke med i datagrunnlaget.

428 manuellterapeuter i 2010

Ifølge Helfo utløste 428 terapeuter takst A8 i 2010. Bare 270 utløste L-takst samme år.

I gjennomsnitt ble det utbetalt 574 417 kroner i refusjon til hver manuellterapeut i 2010. Fysiote-rapeuter fikk i snitt utbetalt 365 728 kroner, mens psykomotorikere fikk 293 477 kroner. Rapporten inneholder imidlertid ingen opplysninger om prak-sisomfang. Tidligere undersøkelser viser at manu-ellterapeuter arbeider lengre arbeidsuker enn fysio-terapeuter generelt og psykomotorikere spesielt.

Rapporten viser at fysioterapueter har en kost-nad per regning på 211 kroner i 2010, manuelltera-peuter 262 kroner og psykomotorikerne 332 kroner per regning. Fysioterpaueter har i snitt 3,33 takster per regning, mens manuellterapeuter har 2,83 og psykomotorikere 1,4 takster per regning.

Tallet på manuellterapeuter som utløste L-takst 1 (utfylling av sykmeldingsblankett) i 2010, er kun 270. Det tyder på at ca. 160 fysioterapeuter med A8-kompetanse ikke arbeider som primærkontakter i helsetjenesten, men kun behandler henviste pasi-enter som allerede sykmeldt av andre yrkesgrupper eller som er trygdet. o

NMF mer enn dobbel så stor som NFFs faggruppeIfølge Norsk Manuellterapeutforenings (NMF) års-rapport har foreningen nå 339 medlemmer med takst A8-kompetanse. Faggruppen for manuellte-rapi i NFF (FFMT) opplyser i sin årsberetning at den har 164 medlemmer med A8-kompetanse per 18.1.2012. NMF er dermed mer enn dobbel så stor som FFMT når det gjelder medlemmer med A8-kompetanse.

NMF og FFMT organiserer til sammen noe over 500 medlemmer. I forhold til 2010 er det kommet

til flere nye manuellterapeuter fra Universitetet i Bergen, og fra utenlandske læresteder. Det kan også være manuellterapeuter som er medlemmer i begge organisasjonene.

I fjor oppga NMF å ha 303 medlemmer med A8-kompetanse. Det betyr at foreningen har hatt en tilvekst på 36 me

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