Dear Panos
You may recall my input on this topic. I feel it can be summarised as such.
Most of the tests I have seen for the cervical spine, applicable for serious
pathology are seriously provocative. As you will know Sharp Pursa is one of
the 7 upper cervical tests I mentioned. As well as VBI I do not use these
because of the danger the test itself holds. This is a conclusion I have
come to on my own without the benefit of sufficient evidencing.
For these reasons I do not feel confident to use velocity type or strong
combined movts on the Cx. That is to say the tests to determine the severity
of the cervical problem are either too inaccurate, insensitive or
provocative to perform; thus leaving an element of doubt in the patients
diagnosis.
I usually find there should be enough alarm bells ringing in a thorough
subjective exam to necessitate a consultation with a neuro surgeon and MRI.
This answer is more borne out of practice than science, but I hope it has
some value all the same
Warm Regards Kevin Reese UK PT.
-----Original Message-----
From: Panos Barlas <[log in to unmask]>
To: [log in to unmask] <[log in to unmask]>
Date: 06 April 2000 17:45
Subject: Pre Manipulative Neck Testing
Dear all,
it is with interest that I followed all the discussions on the past
week or so on Pilates, the role of physiotherapist as a reflective
practitioner and now with reference to pre-manipulative cervical
spine testing.
Coincidentally, my colleague and I are in the process of finalising a
paper (preliminary results have been already communicated on this:
Forrester, GA, Barlas P (1999) Reliability and validity of the
Sharp-Purser Test in the assessment of atlanto-axial instability in
patients with rheumatoid arthritis. Physiotherapy, 85 (7), pp. 376)
which refers to the accuracy of physiotherapists in diagnosing
Atlantoaxial instability on rheumatoid pain patients.
The results of this investigation are summarised below (straight from
the results section of the paper in question)
Table 4: Overall inter-therapist reliability
Overall Kappa Value Ko = 0.20
Standard Error = 0.05
95% Confidence Interval = 0.09 to 0.30
Z score = 3.72
(significant at 0.0002 level)
(Overall)
Sensitivity Specificity PPV NPV
0.43 0.77 0.34 0.89
Now, on the basis of these results, I would not like my neck to be in
the line (literaly!).
Althought the argument may be that these results may not be a true
reflection of the clinical reality [we used 6 MACP therapists with >3
years experience on 31 patients with an AAI incidence of 16% (5/31)],
it is my belief that this should raise significant questions as to
our beliefs of the results such tests as the Sharp-purser that was
tested here yield. Has anyone out there have any data of Sensitivity
and Specificity, PPV and NPV for any other tests (eg. Lachman, ULTT1
etc)? I have tried to locate some but my efforts were fruitless.
The main question I am trying to raise is this:
How comfortable are we as therapists with our current knowledge of
the usefulness of the tools that we use daily? If the study above is
the tip of the iceberg (and by no means I think that we broke new
heights of research here) how can we trust that what we do is right
for our patients in the first instance, but from a professional
ethics point of view also?
I am not aware of the MACP guidelines on premanipulative cervical
spine screening. I am aware however that the Sharp Purser test is one
of the most commonly used for that purpose. So, the question to be
asked is:
On what basis are any guidelines produced? How much are we to believe
them?
I hope my comments are seen in their true light, which is one of
exploration and not as personal attacks.
Looking forward to your contributions,
yours,
Panos
Date: Wed, 5 Apr 2000 10:22:54 +0100
From: Ralph Hammond <[log in to unmask]>
To: [log in to unmask]
Subject: VBI testing
Message-Id:
<[log in to unmask]>
Sorry to be a bit slow with this one.
The Manipulation Association of Chartered Physiotherapists and the
Society of Orthopaedic Medicine have produced guidance for
pre-manipulative testing of the cevical spine. The reference is:
Barker S et al (2000) Guidance for premanipulative testing of the
cervical spine Manual Therapy 5, 1, 37 - 40
Ralph Hammond MCSP
Professional Adviser
Research and Clinical Effectiveness Unit
The Chartered Society of Physiotherapy
14 Bedford Row
London WC1R 4ED
UK
Tel: 020 7306 6636
Fax: 020 7306 6611
Web: www.csp.org.uk
P. Barlas, BSc(Hons) PDD, DPhil, MCSP, SRP, Lic.Ac
Lecturer,
Physiotherapy Subject Group,
Coventry University,
Priory Street,
Coventry, CV1 5FB
Tel: 024-76-888980
Fax: 024-76-888020
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