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Can Neck Exercises Enhance The Activation Of The Semispinalis Cervicis Relative To The Splenius Capitus At Specific Spinal Levels?

Schomacher, J. et al., Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.04.010.

Abstracted by: Russell Hanks, PT, COMT, Anchorage, AK — Fellowship Candidate, IAOM-US Fellowship Program & Jean-Michel Brismée, PT, ScD, Fellowship Director, IAOM-US Fellowship program.

Exercise has been shown to be an effective treatment for people with chronic neck pain but the neuromuscular changes in response to training are typically specific to the mode of exercise performed (Miller et al., 2010; Jull et al., 2008; Falla et al., 2012).  Patients with neck pain often display increased sternocleidomastoid activity and decreased deep cervical flexor activation (Jull et al., 2009).  Therefore, exercises to increase deep cervical flexors activity are often employed (Falla et al., 2004; O’Leary et al., 2011b).  It has also been shown that the deep cervical extensor, semispinalis cervicis, is relatively inactive in individuals with chronic neck pain while showing increased activation of the superficial extensor muscles including the splenius capitis (Schomacher et al., 2012b, 2013; Schomacher and Falla, 2013). This study attempted to demonstrate a method to activate the deep cervical extensor muscle, semispinalis cervicis, while relatively inhibiting the superficial cervical extensor, splenius capitis, as is done with deep cervical flexor exercises.


Using intramuscular electromyography (EMG), this study investigated the activity of the deep semispinalis cervicis and the superficial splenius capitis muscle at two spinal levels (C2 and C5) in ten healthy volunteers during a series of neck exercises:

  1. Traction and compression
  2. Resistance applied in either flexion or extension at the occiput, at the level of the vertebral arch of C1 and of C4.  
  3. Maintaining the neck in neutral while inclined prone on the elbows, with and without resistance at C4.

The ratio between semispinalis cervicis and the splenius capitis EMG amplitude was quantified as an indication of whether the exercise could emphasize the activation of the semispinalis cervicis muscle relative to the splenius capitis. Manual resistance applied in extension over the vertebral arch emphasized the activation of the semispinalis cervicis relative to the splenius capitis at the spinal level directly caudal to the site of resistance (ratio: 2.0 ± 1.1 measured at C5 with resistance at C4 and 2.1 ± 1.2 measured at C2 with resistance at C1).


Ten healthy volunteers (3 men and 7 women; age 30.7+/-7.4 years; height 170+/- 8.8 cm; weight 67.6+/-24.8 kg) without neck pain participated.  Intramuscular EMG, guided by ultrasound, was acquired from the semispinalis cervicis and splenius capitis muscles at the level of the 2nd and 5th spinous processes on the right side.  The subjects were placed in a prone position with the head slightly flexed.  The deep cervical artery, which lies in the fascia separating the semispinalis cervicis from the splenius capitis muscle, was visualized with Doppler sonography prior to the insertion of the needle.  The needle was inserted at the spinal levels of C2 and C5 vertically into the semispinalis cervicis and at a 45 degree angle into the splenius capitis.  Once the target muscles were identified by ultrasound, the needle was removed leaving the wire in the muscle belly for the duration of the experiment.  A reference surface electrode for each wire was placed adjacently (mastoid process, spinous process C7, and for the levels of C2 and C5) and a further common reference electrode was placed around the wrist.

The participants were then seated in a device to measure neck muscle force (Cervical-Multi unit, BTE technologies, USA).  Three maximum voluntary neck extension contractions were measured and the highest value of force was selected as the maximal force.  The subjects then performed isometric exercises against manual resistance in sitting resisting axial traction and compression (Figures 7, 8), extension and flexion (Figures 1-4), and standing in front of a table propped up on both forearms in extension (Figures 5, 6).  Each exercise was repeated twice for approximately 10 seconds during which EMG activity was recorded.  The intensity of the resistance was applied with the maximal force that each subject could counteract without discomfort from the investigators hands/fingers over the neck.  Manual resistance could not be standardized so the ratio between normalized root mean square (RMS – estimated amplitude of the EMG signal) of the semispinalis cervicis and splenius capitis was calculated and compared across conditions.

Figure 1: Subject retracts head and neck against the extension resistance at the occiput

Figure 2: Subject retracts head and neck against the extension resistance at C1.


Figure 3: Subject protracts head against the flexion resistance at the occiput.

Figure 4: Subject protracts head against the flexion resistance at C4

Fig 5: Propping on elbows with head aligned.

Figure 6: Propping on elbows with resistance in extension at the level of C4.

Figure 7

Figure 8

Figures 7-8: Compression and traction respectively while asking the patient to resist the downward or push upwards.

A three-way ANOVA (Analysis of Variance) was conducted on the normalized RMS values for semispinalis cervicis and splenius capitis, both at C2 and C5, with direction (flexion and extension), location of resistance (occiput, C1 and C4) and muscle (semispinalis cervicis and splenius capitis) as factors.  


This study evaluated and confirmed, for the first time, the ability to enhance the activation of the semispinalis cervicis muscle relative to the splenius capitis at different spinal levels with targeted exercise interventions.  

Resistance in cervical Flexion and Extension:

    • The activation of both muscles at both spinal levels was greatest when resistance was applied to the head, for flexion and extension, compared to resistance over the vertebral arches.
    • Resistance at C1 produced higher muscle activity at C2 compared to resistance at C4 which has no direct lever at the level of C2.
    • Resistance at C1 had the same level of muscle activity at C2 as it did at C5 indicating the other factors influence muscle activation.
    • The ratio between the semispinalis cervicis and splenius capitis recorded at C2 was highest when resistance was applied in extension at the level of C1 compared to resistance applied at the occiput or the level of C4.
    • The ratio of muscle activity at C5 was highest with resistance in extension at C4 compared to the occiput or C1.
  • Manual resistance applied over the vertebral arch can emphasize the activation of the semispinalis cervicis relative to the splenius capitis directly caudal to the location of the resistance compared to resistance applied at other locations.  
  • These concepts might be clinically relevant when movement dysfunction or structural changes are identified at specific segments.

Prone extension on elbows:

  • The aim of this exercise was to emphasize the lower cervical extensor muscles, so resistance was only applied at C4.  This may be helpful for patients presenting with a forward head posture.
    • As previously confirmed, resistance over the vertebral arch of C4 further increased the activity of both muscles at both levels but more so at C5 compared to C2.
  • The ratio between the deep and superficial muscles did not differ with this exercise, however the muscle activity recorded at C5 was higher compared to the exercises when the resistance was applied in flexion which suggests that extension on elbows is still an effective way to activate the semispinalis cervicis in the lower cervical spine.

Seated cervical traction and compression:

  • Higher muscle activity was recorded for both muscles at both levels during traction versus compression.
  • Cervical lordosis flattened during traction and increased during compression.  Flattening of the cervical lordosis occurs during traction (Panjabi et al., 1978) which may prompt activation of all extensor muscles.  Compression tends to increase cervical lordosis which cannot be limited by extensor muscle contraction.  The activation of both the semispinalis cervicis and splenius capitis during compression may reflect coactivation with the cervical flexor muscles which are likely more activated (Falla et al., 2007b).

Methodological considerations and limitations of the study:

    • The invasive nature of the experiment limited the sample size of the study but it is consistent with other invasive EMG studies.
    • The electrode wires may have moved during the exercise because the size of the wire and the inability to confirm its location once the needle was removed.  The hook at the end of the wire did limit its movement.
    • Pressure on the tissue near the wires may have caused EMG artifact but this was monitored continuously throughout the experiment.
    • The validity and reliability of the exercises selected have not been previously evaluated.
  • Both muscles were activated in all of the exercises.  Exclusive activation of the semispinalis cervicis was not found, however resistance applied over the vertebral arch did activate the semispinalis cervicis relative to the splenius capitis directly caudal to the site of resistance.  
  • The study was performed on pain-free subjects and the results may differ if performed on subjects with neck pain however previous studies have concluded a difference in semispinalis cervicis relative to splenius capitis in people with chronic neck pain when resistance was applied locally to the neck.


Since resistance applied over the vertebral arch was found to activate the semispinalis cervicis relative to the splenius capitis directly caudal to the site where the resistance was applied, this concept may prove to be useful if applied to people with neck pain who have shown to suffer from impairment to this muscle during clinical testing.

IAOM Comment:

What do we know about the semispinalis cervicis?  The fibers of semispinalis cervicis originate from the transverse processes of T1 to T5/T6 and insert on the spinous processes of C2 to C5 (Leonhard et al., 2003) respectively down to C7 (Schünke et al., 2006; Drake et al., 2010).  The deep semispinalis cervicis muscle is active predominately in extension with a small ipsilateral component (Schomacher et al., 2012b).  The activity of the semispinalis cervicis increases with increasing contraction intensity (Schomacher et al., 2012b), confirming observations for other neck muscles, such as the sternocleidomastoid, semispinalis capitis, splenius capitis and upper trapezius (Blouin et al., 2007; Falla et al., 2010; Lindstrøm et al., 2011).  This finding suggests that multiple muscles can be recruited at lower loads to generate a required force in a desired direction, while at higher loads the primary muscles are predominately recruited (Blouin et al., 2007).

Schomacher and Falla, in 2013, found structural changes in the deep cervical extensors of patients with neck pain compared to healthy controls such as a higher concentration of fat within the muscle, variable cross-sectional area and higher proportions of type II fibers.  They postulated that these findings suggest that the behavior of the deep extensors may be altered in patients with neck pain.  On the contrary, fatty infiltration of muscle tissue has not been observed consistently in patients with insidious-onset neck pain (Elliott et al., 2008b).  The superficial cervical extensors typically show increased activation in patients with neck pain (Szeto et al., 2005; Kumar et al., 2007; Johnston et al., 2008; Lindstrøm et al., 2011) as well as delayed offset (relaxation) after activity (Johnston et al., 2008).  On the contrary, recent studies show that patients with neck pain display reduced activation of the deep extensor muscles, semispinalis cervicis and multifidus when assessed with muscle functional magnetic resonance imaging (mfMRI) (O’Leary et al., 2011a).

So, a good question to ask at this point is how do you know in clinical practice when the semispinalis cervicis is weak and is it weaker in patients with chronic neck pain?  The answers to these questions were alluded to in this abstracted study but no testing was performed to measure weakness because the test subjects in this study had no neck pain.  Can we make the assumption that weakness is occurring in muscles showing a higher concentration of fat, variable cross-sectional area and higher proportions of type II fibers?  I think we can, but is there a clinical test to show it?  Not that was shown in this study.

Quote from the previous IAOM CTL-Safe course: “The musculoskeletal system of the cervical spine is among the most complex of the human body.  Cervical muscles demonstrate marked morphological diversity to permit and control the wide variety of head movements that are possible.  Untrained individuals are unable to maximally activate cervical muscles (Conley ’97).”

With this in mind, it is important that we include appropriate stabilization training that encompasses the complete cervical spine.  This is the attempt of the Sensoimotor Control and Rehabilitation of the CT Spine (SenMoCOR) course taught Phil Sizer Jr., PT, PhD, OCS, FAAOMPT with the IAOM-US.  The information contained in this article is an effective precursor to the SenMoCOR program.  Emphasis in this article is placed on the semispinalis cervicis, a deep cervical postural stabilizing muscle, similar to the multifidus.  When used as a neuromuscular re-education (NMR) tool post cervical mobilization, it can be an effective means to keep the newly gained range of motion in addition to activating the appropriate deep cervical extensors that are important in the stability of the cervical spine.  This article studied the C2 and C5 levels but I believe that activation of the semispinalis cervicis could be emphasized at all cervical levels, especially as a NMR tool.  For activation of the semispinalis cervicis after mobilization, have the patient push gently retract (2-3 lbs. of force) while you are providing resistance at the vertebral arch.  A light force of resistance is recommended because as previously mentioned above, in the study by Blouin et al. 2007, multiple muscles can be recruited at lower loads to generate a required force in a desired direction, while at higher loads the primary muscles are predominately recruited.

Since resistance applied over the vertebral arch was found to activate the semispinalis cervicis relative to the splenius capitis directly caudal to the site where the resistance was applied, it is important that surface anatomy for the cervical spine be emphasized.  The IAOM recommends beginning with the Frankfurter position, which is performed when the dorsal-most part of the occiput is in line with the dorsal-most aspect of the thoracic spine and the lower part of the orbit is in line with the external auditory meatus.  C1 is then found between the mastoid and the posterior angle of the mandible, anterior and deep to the sternocleidomastoid muscle.  C2 is the first spinous process caudal to the external occipital protuberance, C3 is found at the level of the hyoid bone, C4 at the level of the v-notch of the thyroid cartilage, C5 is found at the 3plates of the thyroid cartilage and C6 is located at the level of the 1st ring of the cricoid cartilage.

While not mentioned in this article, a home exercise program could be used to apply these principles for strengthening the semispinalis cervicis.  A Mulligan strap or similar strap could be used as pictured below (figures 9 and 10).  I recommend an isometric resistance of 2-3 lbs. into extension against the strap for a 3-second hold for a total of 3 sets of 25 repetitions or as symptoms will allow (72 repetitions over a 15 minute period for 7 consecutive days was shown to improve long-term motor learning – Boudreau et al. 2010).  All cervical levels can be treated in this manner.  You can also implement proprioceptive training using guided imagery with “thinking” looking up and “thinking” looking right or left while maintaining the resistance to add an additional component to the exercises.


Blouin JS, Siegmund GP, Carpenter MG, Inglis JT, Neural control of superficial and deep neck muscles in humans. Journal Neurophysiology 2007; 98:920-8.

Boudreau SA, Hennings K, Svensson P, Sessle BJ, Arendt-Nielsen L.  The effects of training time, sensory loss and pain on human motor learning.  Journal of Oral Rehabilitation 2010; 37(9):704-18.

Conley MS, Stone MH, Nimmons M, Dudley GA.  Resistance training and human cervical muscle recruitment plasticity. Journal of Applied Physiology 1997; 83(6):2105-11.

Drake RI, Vogl WA, Mitchell AWM. Gray’s Anatomy. Philadelphia, PA: Churchhill Livingston Elsevier, 2010.

Elliott J, Sterling M, Noteboom JT, Darnell R, Galloway G, Jull G. Fatty infiltrate in the cervical extensor muscles is not a feature of chronic, insidious-onset neck pain. Clinical Radiology 2008b; 63(6):681-7.

Falla D, Jull G, Hodges PW.  Patients with neck pain demonstrate reduced electromyographic activity of the deep cervical flexor muscles during performance of the craniocervical flexion test.  Spine 2004; 29:2108-14.

Falla D, Jull G, Russell T, Vicenzino B, Hodges P. Effect of neck exercise on sitting posture in patients with chronic neck pain.  Physical Therapy 2007a; 87:408-17.

Falla D, Lindstrøm R, Rechter L, Farina D.  Effect of pain on the modulation in discharge rate of sternocleidomastoid motor units with force direction.  Clinical Neurophysiology 2010; 121:744-53.

Falla D, O’Leary S, Farina D, Jull G.  The change in deep cervical flexor activity after training is associated with the degree of pain reduction in patients with chronic neck pain. Clinical Journal of Pain 2012; 28:628-34.

Johnston V, Jull G, Souvlis T, Jimmieson N. Neck movement and muscle activity characteristics in female office workers with neck pain. Spine 2008; 33 (5): 555-63.

Jull G, Falla D, Vicenzino B, Hodges PW.  The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain.  Manual Therapy 2009; 14:696-701.

Jull G, Sterling M. Falla D, Treleaven J, O’Leary S.  Whiplash, headache and neck pain: research-based directions for physical therapies.  Edinburgh: Elsevier, Churchhill Livingston; 2008.

Kumar S, Narayan Y, Prasad N. Shuaib A, Siddiqui ZA.  Cervical electromyogram profile differences between patients of neck pain and control.  Spine 2007; 32 (8):E246-53.

Leonhard H, Tillmann B, Tondury G, Zilles K. Rauber/Kopsch. Anatomie des Menschen, Lehrbuch und Atlas. In: Tillmann B, editor. Bewegungsapparat, Band I. Stuttgart – New York: Georg Thieme Verlag: 2003.

Lindstrøm R, Schomacher J, Farina D, Rechter L, Falla D.  Association between neck muscle coactivation, pain, and strength in women with neck pain.  Manual Therapy 2011; 16 (1): 80-6.

Miller I, Gross A, D’Sylva J, Burnie SI, Goldsmith CH, Graham N, et al.  Manual therapy and exercise for neck pain: a systematic review.  Manual Therapy 2010; 15:334-54.

O’Leary S, Cagnie B, Reeve A, Jull G, Elliott JM.  Is there altered activity of the extensor muscles in chronic mechanical neck pain? A functional magnetic resonance imaging study. Archives of Physical Medicine and Rehabilitation 2011; 92(6): 929-34.

O’Leary S, Falla D, Jull G.  the relationship between superficial muscle activity during the craniocervical flexion test and clinical features in patients with chronic neck pain.  Manual Therapy 2011b; 16:452-5.

Panjabi MM, White III AA, Keller D, Southwick WO, Friedlaender G.  Stability of the cervical spine under tension. Journal of Biomechanics 1978; 11:189-97.

Schomacher J, Falla D.  Function and structure of the deep cervical extensor muscles in patients with neck pain. Manual Therapy 2013; 18:360-8.

Schomacher J, Farina D, Lindstroem R, Falla D.  Chronic trauma-induced neck pain impairs the neural control of the deep semispinalis cervicis muscle.  Clinical Neurophysiology 2012b; 123:1403-8.

Schomacher J, Petzke F, Falla D.  Localised resistance selectively activates the semispinalis cervicis muscle in patients with neck pain.  Manual Therapy 2012c; 17:544-8.

Schuenke M, Schulte E, Schumacher U. Thieme Atlas of Anatomy, General Anatomy and Musculoskeletal System. Stuttgart, Germany: Thieme, 2006.

Szeto GPY, Straker LM, O’Sullivan PB. A comparison of symptomatic and asymptomatic office workers performing monotonous keyboard work – 1: neck and shoulder muscle recruitment patterns.  Manual Therapy 2005; 10:270-80.

Fibular Malalignment in Individuals with Chronic Ankle Instability

Kobayashi T, Suzuki E, Yamazaki N, et al. Fibular malalignment in individuals with chronic ankle instability. J Orthop Sports Phys Ther. 2014;44(11):872-878.

Abstracted by:  Rebecca Sherwin, PT, COMT, West Monroe, LA – Fellowship Candidate, IAOM-US Fellowship Program & Jean-Michel Brismée, PT, ScD, IAOM-US Fellowship Program Director

Chronic ankle instability can be associated with ankle sprains and changes that occur at the distal tibiofibular joint (DTFJ) with injuries.  When there is increased movement at the DTFJ, there is naturally an increase in talar movement, which affects the mechanics of the entire foot.  This change also affects the load distribution that occurs at the ankle during weight-bearing and has been shown to lead to osteoarthritis of the ankle joint.1  This increased motion at the ankle is commonly assessed with radiography; however, computed tomography (CT) is superior to radiography.2,3

Many different fibular positions have been indicated with chronic ankle instability in 2-D studies; however, none of the studies are in full agreement with their findings. According to Kobayashi et al, studies utilizing CT scans found a posterior placement of the fibula while many radiographic studies found that there was an anterior placement of the fibula.  

This study was performed to analyze the 3-D position variations of the ankle with computed tomography in a non-weight bearing position in subjects with chronic ankle instability.  The study hypothesis was that the fibula of an ankle with chronic ankle instability would exhibit a posterior and lateral position in relation to the tibia.  The inclusion criteria were:  healthy male, at least 2 episodes of unilateral ankle sprain in the year prior to the study, multiple episodes of giving way unilaterally especially during sporting events, side-to-side differences on figure 8 hop test and side hop test and a contralateral ankle without dysfunction.  The exclusion criteria were: ankle sprain within the past 3 months on the lateral side, any history of a neurological deficit (CVA, neuropathy) or lower extremity injury, and any history of using medication that could affect balance. 

Seventeen participants were chosen for this study that exhibited unilateral chronic ankle instability (CAI).  All participants were tested with stress radiography bilaterally in order to screen for any type of mechanical instability that could be present.  The stress radiography included an Anterior Drawer test (Figure 1) and a Talar Tilt test (Figure 2).  The study’s definition of mechanical instability was equal to or greater than 3 mm difference with the anterior drawer test between affected and non-affected side as well as a talar tilt of 3 degrees or greater.

The participants had non-weight bearing CT scans performed in 1 mm slices from the distal 10 cm of the lower leg to the distal end of the calcaneus.  The ankles were held in a neutral position during the scanning.  From the CT imaging, bone models were formulated and measurements were taken 10 cm proximal from the lateral malleolus, 5cm proximal from the lateral malleolus and at the most prominent part of the lateral malleolus.  In this study, there was not a significant difference in the affected and non-affected ankle in anterior and posterior positioning of the fibula.  However, there was a significant difference in lateral positioning of the fibula as well as a slight difference in external rotation of the fibula when looking at the affected versus the non-affected limb at all three of the markers that were measured as previously mentioned.

Figure 1: Positive anterior drawer test on lateral radiographic view


Figure 2: Positive talar tilt test (image on left side of picture) on AP radiographic view

IAOM Commentary: The imaging in this study was performed in a non-weight bearing positioning where the widening of the distal tibiofibular joint is lessened in comparison to what would occur in a weight-bearing position.4  A disruption of the interosseous membrane that can occur with some lateral ankle instability dysfunctions will allow changed segmental mechanics, decreased weight distribution through the lower leg and resultant stability deficits4, which can occur up to 6 months post-injury.5  Many studies have shown that improvements in chronic ankle instability and postural sway can be made through strengthening, balance challenges as well as with ankle stabilization training.6,7,8  A study performed by Matsusaka et al reported that the addition of lateral ankle taping increases the joint awareness during ankle stabilization exercises.9  They also found that there was a reduction in recovery time and return to peak performance within 4 weeks versus 6 weeks.  Other studies discuss the effectiveness of challenging the brain’s ability to focus on a task in order to improve balance and reaction times.10  The following are examples of exercises to challenge balance, concentration on tasks as well as improve ankle stabilization.  One would want to progress their patient in training from a bilateral activity to a unilateral activity, progress from a static to a dynamic activity, from a firm surface to a softer, more unstable support.7

Figure 3: Taping a 1 cm strip of tape anterior and posterior to the malleolus with the addition of disc training has shown quicker improvement times.9


Figure 4: Bilateral balance exercise on dynadisc.6


Figure 5: Single leg stance balance exercise with dynamic activity with contralateral LE.


Figure 6: Single leg stance with rebounder activity to distract the brain and increase automatic responses in the ankle/foot complex.10


  1. Leeds HC, Ehrlich MG. Instability of the distal tibiofibular syndesmosis after bimalleolar and trimalleolar ankle fractures. J Bone. 1984;66(4):490-503.
  2. Harley JD, Mack LA, Winquist RA. CT of acetabular fractures: comparison with conventional radiography. Am J Roentgenol. 1982;138(3):413–417.
  3. Dikos GD, Heisler J, Choplin RH, Weber TG. Normal tibiofibular relationships at the syndesmosis on axial CT imaging. J Orthop Trauma. 2012;26(7):433–438.
  4. Wang Q, Whittle M, Cunningham J, Kenwright J. Fibula and Its Ligaments in Load Transmission and Ankle Joint Stability. Clin Orth Rel Res. 1996;330:261-270.
  5. Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC. Persistent Disability Associated with Ankle Sprains: A Prospective Examination of an Athletic Population. Foot Ankle Int. 1998;19(10):653-660.
  6. Eils E, Rosenbaum D. A multi-station proprioceptive exercise program in patients with ankle instability. Med Sci Sports Exerc. 33(12):1991-1998.
  7. Rozzi SL, Lephart SM, Sterner R, Kuligowski L. Balance training for persons with functionally unstable ankles. J Orthop Sports Phys Ther. 1999;29(8):478-486.
  8. Sekir U, Yildiz Y, Hazneci B, Ors F, Aydin T. Effect of isokinetic training on strength, functionality and proprioception in athletes with functional ankle instability. Knee Surg Sports Traumatol Arthrosc. 2007;15(5):654-664.
  9. Matsusaka N, Yokoyama S, Tsurusaki T, Inokuchi S, Okita M. Effect of ankle disk training combined with tactile stimulation to the leg and foot on functional instability of the ankle. Am J Sports Med. 2001;29(1):25–30.
  10. Ashton-Miller JA, Wojtys EM, Huston LJ, Fry-Welch D. Can proprioception really be improved by exercises? Knee Surg Sports Traumatol Arthrosc. 2001;9(3):128-136.

Daily Exercises and Education for Preventing Low Back Pain in Children: Cluster Randomized Controlled Trial

Hill JJ, Keating JL, Physical Therapy Journal, 95 (2015) 507–516.

Abstracted by: Russell Hanks, PT, COMT, Anchorage, AK — Fellowship Candidate, IAOM-US Fellowship Program & Jean-Michel Brismée, PT, ScD, Fellowship Director, IAOM-US Fellowship program.

This prospective multicenter cluster randomized controlled trial (RCT) compared education and regular specific back exercises with education alone on the incidence of low back pain (LBP) in children aged 8 to 11 years.  The research available1 appears to indicate that regular specific back exercises when combined with education may reduce episodes of LBP and lifetime first episodes of LBP when compared with education alone. This paper attempted to examine how children stay compliant to an exercise routine and whether or not they would make it an ongoing part of their daily practice. This study also examined the factors that lead to exercise compliance.

The prevalence of LBP increases with age, starting as young as 9 years of age and reaching similar prevalence as reported for adults by 15 years of age.2, 3  LBP in adolescence predicts LBP in adulthood, 4, 5 signaling a role for primary prevention of the lifetime first episode of LBP.3, 6  The only risk factor for LBP that has been validated in independent studies in adults is a history of previous LBP.3, 7-11 Exercise appears to be helpful in reducing the recurrence of LBP in adults,12 and may influence future spine health of young people with a history of LBP.13,14 Reviews of interventions to improve spinal knowledge, change movement behavior and reduce the prevalence of LBP in children showed potential benefits, but evidence to support their effects is limited.15, 16


This was an observational study of compliance to exercise. It was embedded in a prospective RCT comparing education and daily exercise with education alone on LBP in children (aged 8 to 11 years) in primary schools in New Zealand for 270 days between April and December 2011.  Schools were enrolled in the MySpine program and were allocated using randomization with concealment to an exercise and education group (intervention) or to education alone (control).

The children in the study ranged in age from 8 to 11 years and were able to follow simple instructions, complete a child-friendly survey and whose parents gave their informed consent. Children were excluded if they were not able to do the exercises due to spinal pathologies, neurological disorders, injuries, or physical disabilities for which movement was a contraindication or prevented standing unilaterally safely and independently.

The primary researcher, a physical therapist, visited each group in the study (intervention or control) seven times over the 270-day period.  A randomization officer assigned the students to each of the groups.  Figure 1 summarizes the intervention (MySpine program) and control conditions, along with the 4 exercises shown to the intervention group.  Back awareness and taking responsibility for “MySpine” were taught and reinforced at each session within each of the control and intervention groups.  The range of motion exercises encouraged movement, could be performed without supervision, were meant to be easy to remember and could be added to any existing exercise routine.  Students were encouraged to perform the exercises three times per day.  Instruction was also provided to encourage compliance to the exercise program.

Children were given surveys to determine a history of low back pain (day 1) or episode of low back pain when the researcher visited the schools on days 7, 21, 49, 105, 161, and 270.  The duration of low back pain was tracked and categorized in shorter episodes (1-2 days) and longer episodes (> 3 days).  They were also asked about their compliance to the exercise, the frequency of performance and their reasons for non-adherence.  

MySpine Program

Both Groups:

  1. Introduction to the MySpine program (15 minutes)
  2. Baseline Survey
  3. Back awareness education session. “Taking responsibility for your spine.” (15 minutes)
  • Anatomy of the spine
  • What is low back pain?
  • Movement versus static postures
  • Taking responsibility for your spine – “It’s about what you can do.”
  • Handy hints – advise children to “stand tall, shoulders square, chin in, keep moving, don’t slouch.”
  1. Question time (5 minutes)

Intervention Group:

  1. Demonstrate 4 back exercises (see below)
  2. Emphasize moving the back through the full range of flexion, extension, and lateral flexion movements, repetition, and awareness of back movement.  Advise to repeat 3x/day.
  3. Children demonstrate exercises
  4. Exercises checked
  5. Performance difficulties addressed using feedback and demonstration

Figure 1: MySpine Program (may be used without permission by the authors)


There were 764 children in 7 participating schools meeting the criteria for the study.  There were no significant differences between the groups in regards to age, episodes of LBP, or response attrition.  During the trial, 35% of the intervention group and 28% of the control group reported on LBP episodes.  Children with a history of LBP had greater odds of reporting pain during the study.  Short duration LBP (1-2 days) occurred in 72% in the control groups and 62% in the intervention groups.  There were no significant differences between groups for LBP episode durations and there was no significant effect on the frequency of exercises performed for episodes of LBP.


Children in the exercise group reported fewer episodes of LBP and fewer lifetime first episodes of LBP than those in the control group.  At the start of the study, 47% of the children reported a previous episode of LBP. The researchers observed a decrease of 23% at day 7 in episodes of LBP to 13% at day 270 in the intervention group and 33% to 24% in the control group, respectively.  Children in the exercise group were also less likely to report a lifetime first episode of LBP and experience a longer time to onset of a first episode when one did occur.

It has been suggested that it may be inappropriate to apply adult definitions of LBP when assessing children17 and that children may conceptualize pain in ways that differ from adults.18  A reduction in LBP was reported across both groups in spite of compliance to the exercises declining across the study.  The researchers could not confidently attribute the results to exercise participation.  They stated that likely there was not a physiological effect from the four exercises but felt that paying attention to the children, educating them about the spine and LBP and talking about the importance of movement had a therapeutic effect on the children.

In conclusion, the program presented in this study may reduce episodes of LBP in children ages 8-11 years, however it is unlikely the results can be attributed to the exercises alone but also the education provided.  Additional studies are needed to validate these findings.


IAOM Comment:

Low back pain in children is becoming more common and as indicated in the references of this study, it is often a predictor of LBP in adulthood.4,5  I think the important point made in this study was that it wasn’t either exercise or education that made the difference, it was both.  I don’t think it comes as a surprise to anyone with children that compliance to the exercises declined over time.  In fact, I think we could safely assume that happens with all age groups.  We don’t need a study to prove what most of us have seen in our practices.  

Increasing activity levels in children is important.  It is disturbing that LBP is becoming more common but not surprising given the trends seen with children spending more time in front of screens.19  I think it is important to note that any exercise will become routine for most people over time.  Regardless of the effectiveness of the 4 exercises in this program, asking a child to be compliant over a 6-month period, especially if they didn’t have back pain, seems unlikely.  I think it is a challenge for physical therapists to have our patients stay compliant with their home exercise programs.  In this study, education was also an important component in the success of reducing the onset of back pain.  I try to ask myself the following four questions when prescribing a home program: (1) What does the patient need to know?  (2) Why do they need to know it? (3)   What do they need to do?; and (4) Why do they need to do it?

Education is important, but ultimately, what does the patient need to know about what is going on with their body?  This will be dependent on what the patient wants to know.20  Some patients want to know everything and others, not so much.  Once you have determined what they need to know, it is important to help them understand why.  This makes the information relevant.  It the information stays irrelevant, then it is not a felt need and will be ignored.  Next, what do they need to do?  This is the exercise, or whatever else makes up your home program.  Is it easy to follow?  Have you included a picture, or video from their phone, or handout of some kind?  This helps with compliance.21  Lastly, why do they need to do it?  Assisting patients with understanding why they are doing a home program helps them understand the relevance of the exercise.  It also helps them engage in what problem is being addressed and how to measure their improvement.  Compliance is a challenge but I’ve found asking these four questions helps my patients be more successful.



1 Hill JJ, Keating JL. Daily exercises and education for preventing low back pain in children: cluster randomized controlled trial. Phys Ther 2015; 95:507–16.

2 Hill JJ, Keating JL. A systematic review of the incidence and prevalence of low back pain in children. Phys Ther Rev 2009; 14:272–84.

3 Burton AK, Balague F, Cardon G, Eriksen HR, Henrotin Y, Lahad A, et al. How to prevent low back pain. Best Pract Res Clin Rheumatol 2005; 19:541–55.

4 Hestbaek L, Leboeuf-Yde C, Kyvik KO, Manniche C. The course of low back pain from adolescence to adulthood: eight-year follow-up of9600 twins. Spine 2006; 31:468–72.

5 Jeffries LJ, Milanese SF, Grimmer-Somers KA. Epidemiology of adolescent spinal pain: a systematic overview of the research literature. Spine 2007; 32:2630–7.

6 Cardon G, Balague F. Low back pain prevention’s effects in school children. What is the evidence. Eur Spine J 2004; 13:663–79.

7 Hestbaek L, Leboeuf-Yde C, Manniche C. Low back pain: what is the long-term course? A review of studies of general patient populations. Eur Spine J 2003; 12:149–65.

8 Jones GT, Macfarlane GJ. Epidemiology of low back pain in children and adolescents. Arch Dis Child 2005; 90:312–6.

9 Hestbaek L, Leboeuf-Yde C, Kyvik KO, Hestbaek L, Leboeuf-Yde C,Kyvik KO. Is comorbidity in adolescence a predictor for adult low backpain? A prospective study of a young population. BMC Musculoskel Dis 2006; 7:29.

10 Harreby M, Neergaard K, Hesselsoe G, Kjer J, Harreby M, Neergaard K, et al. Are radiologic changes in the thoracic and lumbar spine of adolescents’ risk factors for low back pain in adults? A 25-year prospective cohort study of 640 school children. Spine 1995; 20:2298–302.

11 Hill JJ, Keating JL. Risk factors for the first episode of low back pain in children are infrequently validated across samples and conditions: a systematic review. J Physiother 2010; 56:237–44.

12 Hayden JA, van Tulder MW, Malmivaara AV, Koes BW. Meta-analysis: exercise therapy for nonspecific low back pain. [Summary for patients in Ann Intern Med 2005;142: I71]. Ann Intern Med 2005; 142:765–75.

13 Jones M, Stratton G, Reilly T, Unnithan V. The efficacy of exercise as an intervention to treat recurrent nonspecific low back pain in adolescents. Pediatr Exerc Sci 2007;19:349–59.

14 Fanucchi GL, Stewart A, Jordaan R, Becker P. Exercise reduces the intensity and prevalence of low back pain in 12–13-year-old children: a randomized trial. Aust J Physiother 2009; 55:97–104.

15 Steele EJMPHB, Dawson APGB, Hiller JEP. School-based interventions for spinal pain: a systematic review. Spine 2006; 31:226–33.

16 Cardon G, Balague F. Low back pain prevention’s effects in school children. What is the evidence? Eur Spine J 2004; 13:663–79.

17 Balague´ F, Dudler J, Nordin M. Low-back pain in children. Lancet. 2003; 361:1403–1404.

18 Burton AK, Mu¨ller G, Balague´ F, et al; on behalf of the COST B13 Working Group on Guidelines for Prevention in Low Back Pain. European guidelines for prevention in low back pain. November 2004. Available at: http://www.backpaineurope.org/web/files/WG3_Guidelines.pdf. Accessed September 2014.

19 American Academy of Pediatrics. Children, adolescents, and television. Pediatrics 2001; 107:423–426 [PubMed]

20 Shekhawat L et.al. Does the cancer patient want to know? Results from a study in an Indian tertiary cancer center. South Asian J Cancer 2013; 2:57-61.

21 Zhabenko O. et.al. Supporting Homework Compliance in Cognitive Behavioral Therapy: Essential Features of Mobile Apps. JMIR Ment Health 2017 4:e20. 10.2196/mental.5283

The prevalence of osteoarthritis of the sternoclavicular joint on computed tomography

Abstracted by: Dale Gerke, PT, ScD, COMT, Mequon, Wisconsin — Fellowship Candidate, IAOM-US Fellowship Program & Jean-Michel Brismée, PT, ScD, Fellowship Director, IAOM-US Fellowship Program.

Lawrence CR, East B, Rashid A, Tytherleigh-Strong GM. The prevalence of osteoarthritis of the sternoclavicular joint on computed tomography. J Shoulder Elbow Surg. 2017; 26:e18-e22.

The shoulder girdle is comprised of 3 synovial joints with the sternoclavicular joint (SCJ) likely the least commonly involved (Figure 1). The authors acknowledged that the most common pathology of the SCJ is osteoarthritis (OA) as previously determined through cadaveric observation. Therefore, the dual purpose of this study was to determine if there was a similar pattern of OA severity and prevalence in the SCJ.

Figure 1. Sternoclavicular Joint (source: Wikipedia)

The investigators retrospectively viewed CT scans from patients who underwent imaging for adjacent trauma or systemic pathologies such as cancer. None of the scans were ordered to evaluate the SCJ, but the image was reconstructed to use a minimum of 18 slices. This is significant because the scans were not ordered secondary to a painful SCJ. The authors acquired at least 20 patients in each decade of adult life. A total of 232 patients and 464 SCJ scans were used in the study. Definitive signs of OA were used to grade the joints including obvious presence of an osteophyte, subchondral cyst or cortical sclerosis. Each finding was given one point with the greatest severity receiving a score of 3 points per joint. Three separate reviewers reviewed the images to eliminate a deadlocked decision.

OA was identified in 137 (59%) patients and 107 (46%) patients had bilateral involvement.  Interestingly, a majority of the signs occurred on the clavicular side of the joint with less than 2% having isolated OA on the sternal side of the joint. The average age without any signs of OA was 41.4 years. Conversely, the average age for those patients with OA of the SCJ being 73.1 years of age. Eighty-nine percent of patients who were older than 70 years of age had at least 3 signs of OA in one joint. The presence of OA in the SCJ was not different between genders or hand dominance. Furthermore, there was an open physis in the younger patients between the ages of 20-25 years of age and an absence of OA.

The presence of OA in the SCJ appears to be a normal degeneration of the joint beginning as early is the mid 30’s. By age 50, nearly 90% of individuals will have some sign of OA. It is also important to remember that OA could be a normal variant as none of these subjects were scanned for discomfort in the SCJ.

IAOM Comment:

According to the information from the authors, the SCJ is prone to typical degeneration especially as we age. It would be easy to consider this information as inconsequential, but this is beneficial for several reasons. It is important to remember that we do not treat imaging alone. Identifying OA in the SCJ coupled with the results from the examination would be more meaningful. If the SCJ is symptomatic, the IAOM advocates pain would be present in the C4 distribution1. It is also possible to see signs of degeneration such as osteophytes on the medial aspect of the clavicle with observation. Some authors have also advocated that a common characteristic of SCJ arthritis is a larger prominence with possible subtle anterior dislocation5.The basic examination includes an assessment of shoulder girdle motions.  This may allow the clinician to compare sides for pain provocation or subtle hypomobility. Similarly, the capsular pattern for the SCJ is pain at the end of shoulder elevation requiring end range shoulder girdle motion to be evaluated as well. In summary, a cluster of pain in the C4 region, provocation or hypomobility with shoulder girdle motions, anteromedial clavicular prominence and pain at the end of shoulder elevation should warrant a local investigation of the SCJ. The IAOM advocates specific joint play testing to determine if the joint is hypermobile or hypomobile (Figure 2).to direct the appropriate intervention. If it is determined that the SCJ is a pain generator, traction mobilizations up to tissue resistance can be used for pain relief with acute injury (Figure 3).

Figure 2. The examiner grasps the lateral aspect of the shoulder with the lateral clavicle. While stabilizing the thorax, the examiner will pull the right shoulder girdle in a direction of retraction. The examiner will simultaneously monitor the ipsilateral SCJ play with the index finger of the contralateral hand.

Figure 3. To perform traction, the patient is positioned supine with a towel medial to the involved scapula to allow for slight retraction. Another towel is placed over the middle sternum of the patient prior to the clinician stabilizing the sternum with their forearm. Failure to stabilize the sternum will create a rocking or tipping of the trunk during the mobilization technique. Then the clinician will apply a traction up to tissue resistance for acute pain in the SCJ or a manipulative thrust through tissue resistance for a non-painful SCJ. The direction of force is in line with the clavicle.

Moreover, a hypomobility may warrant joint specific mobilization (Figure 4) to improve mobility. The clinician may identify the hypomobility as part of an active arthritis in the SCJ. However, it may also be important to consider mobilizations through tissue resistance to improve end range limits with overhead elevation for pathologies such as external impingement3. In a study of 18-60 year old asymptomatic and symptomatic adults, the authors found that SCJ elevation and posterior rotation were decreased in the symptomatic population2. Identifying pain or limitations is important for the orthopedic manual physical therapist as there is evidence suggesting SCJ mobilizations can help decrease shoulder pain2,3. Furthermore, dysfunction in the SCJ may also warrant additional screening of the ACJ and scapular kinematics during humeral elevation2.

Figure 4. Caudal glide of the SCJ can be performed to address end range shoulder girdle limitations identified in the SCJ. The clinician will first pre-position the shoulder at or near the end range humeral elevation (4a). The clinician will then orient themselves in a position lateral and inferior to the side being treated in a position ready to pull the clavicle in a caudal, ventral and slightly lateral direction (4b). The examiner will position the head in ipsilateral sidebending and contralateral rotation to allow muscular relaxation and maximal purchase on the clavicle (4c). The opposite hand can be used to reinforce the mobilizing hand or to provide a more diffuse grip. An alternative position for the clinician is to push the clavicle in the same direction (4d) whereby the clinician will orient themselves in a position cranial to the involved SCJ. The direction of the mobilization is the same. In each scenario, the mobilization force will be performed to a point of tissue resistance.


  1. Hasset G, Barnsley L. Pain referral from the sternoclavicular joint: a study in normal volunteers. Rheumatology. 2001;40(8):859-62.
  2. Lawrence RL, Braman JP, LaPrade RF, Ludewig PM. (2014). Comparison of 3-Dimensional shoulder  complex Kinematics in Individuals with and without shoulder pain, part I: SCJ, ACJ and STJ. JOSPT; 44(9):636-645.
  3. Mischke JJ, Emerson-Kavchak AJ, Courtney CA. Effect of sternoclavicular mobilization on pain and function in a patient with massive supraspinatus tear. Physiother Theory Pract. 2016;32(2):153-8.
  4. Van Tongel A, MacDonald P, Leiter J, Pouliart N, Peeler J. A cadaveric study of the structural anatomy of the sternoclavicular joint. Clin Anat. 2012;25(7):903-10.
  5. Van Tongel A, Valcke J, Piepers I, Verschueren T, DeWilde L. Relationship of the medial clavicular head to the manubrium in normal and symptomatic degenerated sternoclavicular joints. J Bone Joint Surg Am. 2014;96(13):e109.

The Reliability of the Cervical Relocation Test on People with and Without a History of Neck Pain

Burke S, Lynch K, Moghul Z, Young C, Saviola K, Schenk R. The reliability of the cervical relocation test on people with and without a history of neck pain. J Man Manip Ther. 2016;24(4):210-214.

Abstracted by:  Rebecca Sherwin, PT, COMT, West Monroe, LA – Fellowship Candidate, IAOM-US Fellowship Program & Jean-Michel Brismée, PT, ScD, IAOM-US Fellowship Program Director

Neck pain is a common disorder in the United States.  This complaint affects millions of people per year with costs equaling billions of dollars in the United States alone.1  Neck pain can be present due to a chronic problem as well as acute dysfunction from whiplash.  With neck pain, a dysfunction in the proprioceptive sense of the neck and errors in repositioning of the head on the neck can occur.2,3  According to Manchikanti et al, “54-60% of people present with chronic neck pain following a whiplash injury.”4 Changes in position sense of the head and neck is clearly evident in whiplash injury patients as well as other dysfunctions.5  While people seek treatment for the pain, the position sense may remain an untreated condition.  

One test that is utilized to assess position sense in the cervical spine is the Cervical Relocation Test (CRT).3,6  Many studies have been performed to assess position sense with the ability to return the head to a neutral position; however, none have looked at the utilization of a CROM device with this test.  Studies have shown the ability of utilizing the cervical relocation test with various instruments in assessing position sense.  There are many studies that have shown the differences between the position sense of subjects with and without symptoms when utilizing the cervical relocation test (CRT).  One study was performed with the use of a CROM in order to assess cervical position sense and found that relocation accuracy differed between symptomatic and asymptomatic subjects.7  Another study found that a relative head on trunk rotation, which activated cervical proprioceptors without activating the vestibular afferents, produced more position errors for those with symptoms versus the asymptomatic subjects with use of the laser and Fastrak measurement tools.8  Treatment for the neck for not only pain relief but for improving the proprioceptive system seems to be indicated due to the increase in joint position sense in those with neck pain.  Much research has been done on the laser, Fastrak and US measurement tools; however, there is limited research on the reliability of the use of CROM with the cervical relocation test with either intertester or intratester reliability.  

This study was performed to determine the intertester and intratester reliability of utilization of the CROM device in comparison with a laser for measuring cervical relocation in those with and without neck pain. The CROM is an inexpensive and easily accessible tool in the clinic.  

This study included two groups of 25 subjects.  The groups were split into two groups based on convenience.  Each group was paired with each tester to perform the following tests utilizing the CROM and a laser. The 25 subjects in each group were analyzed independently of the other subjects.  The exclusion criteria were:  1) being under the age of 18; 2) previous spinal surgery; 3) pregnant currently; 4) receiving care for neck pathology.  The groups were split and tested with 2 testers where one tester utilized a laser and the other tester utilized the CROM.  The subject was blindfolded (not in picture – subject is with her eyes closed) to inhibit visual input thereby forcing the subject to utilize their proprioception system in the cervical spine.  The test began with the utilization of the CROM.  The subject was asked to turn the head to the right (figure 1), pause at end-range (to allow documentation of the ROM) then return to their perceived neutral head position (NHP) and a recording of this rotation ROM was documented.  Three trials were documented to the right then performed and documented to the left.

The same test was repeated with a laser system.  The subject was blindfolded (not in picture – subject is with her eyes closed) then the laser was placed on the subject’s head with the light at the forehead (figure 2). The subject was placed 3 feet from a wall with a target placed in front of the them.  The return to perceived neutral position was recorded based on the laser projection on the target. This was done with 3 trials to the right and then 3 trials to the left with a brief pause at end-range and then returning to NHP.  

The reliability of the CRT to assess position sense has been established throughout the literature as previously discussed.  This study determined that the interrater reliability using the CROM to measure CRT had ICC values > 0.75 showing a good reliability between testers with the same instrument.  The intertester reliability with the laser was not as good as the CROM with an ICC value of 0.67.  This could possibly be due to the challenging equipment fit of the laser as it was attached in the study with a one-sized bike helmet.   A paired t-test showed no difference in the accuracy to relocate using the CROM in subjects with and without a history of neck pain.  The CROM is a relatively inexpensive and accurate tool to utilize in the clinic to measure a patient’s proprioceptive sense in the cervical spine after trauma.

IAOM Commentary:

Many patients present to the clinic with neck pain after various types of injuries whether traumatic or non-traumatic events.  These patients will usually present with changes in their cervical position sense due to these painful events.  When there is a dysfunction of the position sense in the cervical spine, there will be dysfunction up and down the chain, which can lend to multiple dysfunctions ranging from stiffness, headaches, ROM deficits, muscular tightness and dizziness to name a few.  There are many exercises that can improve position sense in the cervical spine.  Peterson et al report that position sense can be improved through DNF activity, coordination exercises, including eye-head-neck exercises, as well as manual therapy techniques for improving segmental mobilization with the coordination exercises producing the largest effects on position sense.9  The following pages give various exercises as examples of what will improve these different areas previously mentioned.

Figure : Deep Neck Flexion with Beach Ball Roll – Instructions are to perform DNF then rotate the head left and right.


Figure : Deep Neck Flexion with Inclinometers – Pt head is rotated in 10˚, 20˚ and 30˚ degree increments in one direction and patient is asked to replicate this motion. The move is then increased to a full arc from left to right.


Figure: Laser with Figure 8 motion — moving in a clockwise and counterclockwise direction.


Figure: Laser with Clover with a clockwise and counterclockwise movement.


Figure: Laser with horizontal movement; and with vertical movement


Progression with utilization of various surfaces:

Figure: Challenges with various surfaces or positions — from left to right. Top row: single leg stance with rows, squat with rows, wedge surface with rows. Bottom row: theradisc with rows, theradisc squat with rows, BOSU with lats


Segmental Mobilization:

Figure: Segmental Extension Gliding — Lock the caudal segment by stabilizing it (pushing it in a ventral direction), then bring cranial segment into rotation and side-bending away from the treating clinician. Mobilization force through the cranial hand is in a caudal and dorsal direction with rotation away from the treating clinician.


Figure: Segmental Flexion Gliding — Lock the caudal segment with a 90˚ angle from the line of the zygapophyseal joint (pushing in a ventral and caudal direction), then bring cranial segment into rotation and side-bending towards the treating clinician. Mobilization force through the cranial hand is in a cranial and ventral and rotation towards the treating clinician.


  1. Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain Off J Am Pain Soc. 2012;13(8):715-724.
  2. Armstrong BS, McNair PJ, Williams M. Head and neck position sense in whiplash patients and healthy individuals and the effect of the cranio-cervical flexion action. Clin Biomech. 2005;20(7):675-684.
  3. Pinsault N, Vuillerme N, Pavan P. Cervicocephalic Relocation Test to the Neutral Head Position: Assessment in Bilateral Labyrinthine-Defective and Chronic, Nontraumatic Neck Pain Patients. Arch Phys Med Rehabil. 2008;89(12):2375-2378.
  4. Manchikanti L, Singh V, Rivera J, Pampati V. Prevalence of cervical facet joint pain in chronic neck pain. Pain Physician. 2002;5(3):243–249.
  5. Sizer PS, Poorbaugh K, Phelps V. Whiplash associated disorders: pathomechanics, diagnosis, and management. Pain Pract. 2004;4(3):249–266.
  6. Pinsault N, Vuillerme N. Degradation of cervical joint position sense following muscular fatigue in humans. Spine. 2010;35(3):294–297.
  7. Wibault J, Vaillant J, Vuillerme N, Dedering Å, Peolsson A. Using the cervical range of motion (CROM) device to assess head repositioning accuracy in individuals with cervical radiculopathy in comparison to neck- healthy individuals. Man Ther. 2013;18(5):403-409.
  8. Chen X, Treleaven J. The effect of neck torsion on joint position error in subjects with chronic neck pain. Man Ther. 2013;18(6):562-567.
  9. Petersen CM, Zimmermann CL, Tang R. Proprioception interventions to improve cervical position sense in cervical pathology. Int J Ther Rehabil. 2013;20(3):154-163.

Ligamentum teres tears and femoroacetabular impingement: prevalence and preoperative findings

Chahla J, Soares EA, Devitt BM, Peixoto LP, Goljan P, Briggs KK, Philippon MJ. (2016). Ligamentum teres tears and femoroacetabular impingement: prevalence and preoperative findings. Arthroscopy: The Journal of Arthroscopic and Related Surgery, 32(7): 1293-1297

Abstracted by: Dale Gerke, PT, ScD, COMT, Mequon, Wisconsin — Fellowship Candidate, IAOM-US Fellowship Program & Jean-Michel Brismée, PT, ScD, Fellowship Director, IAOM-US Fellowship program.

While the hip is generally considered a very stable joint because of the deep seated congruency of the acetabulum, there is growing evidence that hip microinstability does exist. The purpose of the article by the authors was to identify the prevalence of Ligamentum Teres (LT) injuries and identify clinical examination findings that fit the diagnosis.

The research was a retrospective analysis of arthroscopic findings for patients with hip pain. The authors completed a prospective examination of the hip to establish a pre-operative diagnosis on patients over the age of 18. The examination was completed less than one month before the hip arthroscopy and included Passive Range of Motion (PROM), Apprehension Test (See Figure 1) Impingement Test, FABER, and Dial Tests for each patient. Radiographs of the hip were also analyzed and measured for each patient. The results of the arthroscopic findings were assessed retrospectively by one orthopedic surgeon. The LT was inspected arthroscopically and the findings were recorded.  The arthroscopic evaluation allowed the surgeon to classify the LT as normal, partially torn, or completely torn. A total of 3,158 hip arthroscopies were performed by the Physician over the 10-year period.  

A total of 2,213 patients met the inclusion criteria for undergoing primary hip arthroscopies on skeletally mature adults being treated surgically for chondrolabral dysfunction associated with Femoroacetabular Impingement (FAI). The results demonstrated 88% of the patients had fraying or tearing of the LT and were classified as partially torn. Eleven percent of the subjects had a normal LT and 1.5% of the patients were identified as having a completely torn LT.

Odds ratios were performed using SPSS. Gender, size, hip morphology, PROM and impingement tests were related to LT tears.  Additional arthroscopic findings also demonstrated chondral tears and coxafemoral joint capsular laxity. The authors found women were more than 3x likely to experience a tear in the LT than men. Radiographic analysis demonstrated a center edge angle (CEA) less than 25 was also associated with LT injury.


IAOM Comment:

Previous authors have identified LT injuries during arthroscopy. However, this is the first study to quantify the severity of an LT injury. The authors should be applauded for their work in identifying the very elusive hip instability with clinical examination.

The clinical examination is one of the underpinnings of the IAOM. Identifying the 5 questions of who, what, when, where, why, and to what extent helps shape the clinical hypothesis and subsequent interventions. The article helps us identify that adult women with low BMI are more likely to experience hip instability with LT injury. It should also be considered that women may be more likely to experience generalized laxity more often than men. Radiographic imaging for a small CEA can be helpful, but it is imperative that these findings are also considered in the context of the clinical examination. According to Byrd et al. (2004) 44% of all athletes with LT lesions had an atraumatic etiology preventing the diagnosis from being detected prior to arthroscopy. Similarly, individuals who experienced a traumatic injury did not receive surgery until an average of 28 months following the trauma.1 Delayed identification of the ligament laxity further indicates the need for greater suspicion during the clinical examination. A history of trauma can be helpful to consider an underlying instability, but the repetitive microtraumatic tears of LT are even more challenging to uncover in the clinical examination if there is an absence of pain. Injury to the LT should be considered for post-operative hip surgery as iatrogenic interference has also been suggested as a mechanism of injury to the LT.3

Numerous authors have identified that hip flexion can be limited as a result of the FAI, but hip IR was suggested to be increased by these authors. Assessing hip rotation may be one of the findings to help differentiate hip instability. The authors did not describe the patient position where hip IR was assessed. Alternatively, the IAOM advocates assessing hip IR in both the supine and prone positions. It would be interesting to compare hip IR in each of these positions to determine if motion loss would be different. Similarly, previous authors have used the Dial Test to differentiate instability.11, 12

The authors of the current study found the frequently used Dial Test was not as helpful to detect instability. (See Figure 2) This is understandable because the LT may not be fully elongated in this neutral hip position. Placing the hip in a flexion position brings the attachment of LT posterior to the axis of rotation adding length to the LT. The authors also noted that hip IR was greater in patients with partially torn or completely torn LT, but motion changes were considered controversial and not statistically significant in this article. Nonetheless, hip IR or ER with a soft end feel could increase clinical suspicion for instability. Moreover, a positive impingement test was frequently encountered with hip instability in this article. Several authors have suggested that a position of hip flexion, hip adduction and internal rotation can strain the LT, while others have advocated the hip flexion, adduction and external rotation elongate the LT. Therefore, identifying symptom location and carefully evaluating the end feel during the impingement test can be useful. Furthermore, patients experiencing laxity from a partially torn LT may have a softer end feel that could be limited by diffuse pain. Additionally, patients were recognized as having an isolated cam or pincer impingement more frequently when a partially torn or completely torn LT was identified. It is important to consider the morphology of the cam or pincer lesions because the bone lesions could have been present for many years. Traumatic hip instability certainly is a realistic concern, but many patients could be experiencing repetitive microtraumatic events leading to the subtle instability.

A thorough understanding of hip instability will be helpful for all clinicians. O’Donnell et al. (2013) suggested a novel test for LT insufficiency whereby the examiner places the hip in submaximal flexion.9 In this position, the examiner assesses hip IR and hip ER for total motion and end feel. A painful rotation with soft end feel that is consistently relieved with rotation in the opposite direction can be indicative of LT insufficiency. (Sn: 90, Sp: 85, (+) LR: 6.5, (-) LR 0.11) 9. (See Figure 3) The current authors also suggested using the previously described Dial Test FABER Test. It is believed that the LT has free nerve endings and is capable of having a nociceptive role.10

The authors suggest that early symptom identification can be helpful for surgical considerations. This is understandable considering the morphological differences, labral tears, capsuloligamentous laxity and chondral defects identified via arthroscopy.  A recent study by Devitt et al (2017) suggested that LT involvement was more common in individuals with arthroscopically evaluated capsular slimness.5  They also found that a Beighton Test Score (BTS) ≥ 4 was more predictive of a hypermobility and LT pathology. Devitt also found the average BTS for men and women was 1 and 4 respectively. Identifying more joint hypermobility and LT involvement in women was similar to the current research findings.

No statistical information is available to identify the accuracy of detecting a partial or full tear of LT. Therefore, interpreting results of the entire clinical exam will be meaningful. Considerations for younger women with a BTS > 4/9 experiencing diffuse hip pain with soft end feels into Hip IR or ER warrant judicious investigation for LT pathology.  Limited passive motion has been suggested with LT tears and should continue to be investigated2. Adding atypical findings from the LT Test according to O’Donnell, Impingement, Apprehension, Dial, and FABER Tests can be used cautiously. Identification of chondrolabral pathology through imaging or arthroscopic evaluation should also encourage investigation of ligamentous instability. Furthermore, association of abnormalities in bone morphology such as hip dysplasia or a pincer lesion were also associated with the presence of an LT tear.9

Having a better understanding of clinical hip instability can be beneficial for the manual physical therapist. Early identification of hip instability can lead us to implement appropriate somatosensory motor control exercises that incorporate the deeper stabilizing muscles of the hip to prevent the premature microtraumatic tissue damage in the coxafemoral joint. Hodges et al (2014) identified the role of obturator Internus (OI), piriformis and Quadratus Femoris (QF) with early active hip External Rotation and Abduction.8 To encourage activation of the deep rotators, the load should be low and slow to prevent over activation of the gluteal musculature. The therapist can assist light eccentric activation of the deep external rotators in prone (See Figure 4) while palpating the gluteus maximus (GM) to ensure GM inactivation during the exercise. The clinician may progress to a sidelying position (See Figure 5) after appropriate motor control has been successful in the prone position.

Distal motion deficits such as a lack of ankle dorsiflexion or knee flexion8,9 would also encourage hip adduction and internal rotation during functional activity. These hip positions create a position where the LT can be elongated with repetitive motions or one large traumatic event. Therefore, the clinician needs to look distal to the hip for secondary motion limitations and restore the motion when retraining functional movements such as squatting, jumping or landing.  A lack of improvement despite conservative care may warrant surgical intervention. Surgery could involve the repair of the LT in combination with labral repairs, capsular plication or capsulorrhaphy.

A limitation of the study was the authors failed to distinguish the difference between tears of traumatic and microtraumatic origin. While the authors acknowledged both trauma and microtrauma play a role in LT involvement, it is difficult to ascertain which is more common in this study. However, an individual will frequently remember a traumatic event in the history. Imaging results were also not reported by the authors. Previous investigators have suggested Magnetic Resonance (MR) Imaging to have poorer diagnostic utility (Sn: 41, Sp: 75, PPV: 32) while MR Arthrography would have greater diagnostic power (Sn: 83, Sp: 93, PPV: 76) if there is suspicion for partial LT pathology failing conservative management.4    There is no significant difference between MR Imaging and MR Arthrography when complete tears are identified.


  1. Byrd JW, Jones KS. Traumatic rupture of the ligamentum teres as a source ofhip pain. Arthroscopy; 2004;20:385–91.
  2. Cerezal L, Kassarjian A, Canga A, Dobado MC, Montero JA, Llopis E, Rolon A, Perez-Carro L. (2010) Anatomy, biomechanics and management of ligamentum teres injuries. Musculoskel Imaging; 30(6): 1638-1651.
  3. Cerezal L, Arnaiz J, Canga A, Piedra T, Altonaga JR, Munafo R, Perez-Carro L. (2012). Emerging topics on the hip: ligamentum teres and hip microinstability. Eur J Radiolog; 81:3745-3754.
  4. Datir A, Xing M, Kang J, Harkey P, Kakarala A, Carpenter WA, Terk MR. (2014). Diagnostic utility of MRI and MR arthrography for detection of ligamentum teres tears: a retrospective analysis of 187 patients with hip pain. Am J Roentgenol; 203(2):418-423.
  5. Devitt BM, Smith BN, Stapf R, Tacey M, O’Donnell JM. (2017). Generalized joint hypermobility is predictive of hip capsular thickness. Orthop J Sports Med; 5(4):1-7.
  6. Fong CM, Blackburn JT, Norcross MF, McGrath M, Padua DA. (2011). Ankle-dorsiflexion range of motion and landing biomechanics. J Athl Train; 46(1):5–10
  7. Hagins M., Pappas E., Kremenic I., Orishimo K. F., Rundle A. (2007). The effect of an inclined landing surface on biomechanical variables during a jumping task. Clin Biomech;22(9):1030–1036.
  8. Hodges PW, McLean L, Hodder J. (2014). Insight into the function of the obturator internus muscle in humans: observations with development and validation of an electromyography recording technique. J Electromyog Kinesiol; 24(4):489-496.
  9. O’Donnell J, Economopoulos K, Singh P, Bates D, Pritchard M. (2014). The ligamentum teres test: a novel and effective test in diagnosing tears of the ligamentum teres. Am J Sports Med; 42(1): 138-43.
  10. O’Donnell J, Pritchard M, Salas AP, Singh PJ. (2014). The ligamentum teres – its increasing importance. J Hip Preservation Surg; 1(1):3-11.
  11. Philippon MJ, Zehms CT, Briggs KK, Manchester DJ, Kuppersmith DA. Oper Tech Sports Med; 2007;15:189-94.
  12. Phillipon MC, Briggs KK, Goljian P, Peixoto LP. (2013). The hip dial test to diagnose symptomatic hip instability. Arthroscopy; 29(10):e123.
  13. Shu B &  Safran M. Hip instability: anatomic and clinical considerations of traumatic and atraumatic instability. Clin Sports Med. 2011; 30: 349–67.

Abstract: Clustered clinical findings for diagnosis of cervical spine myelopathy

Cook C, Brown C, Isaacs R, Roman M, Davis S, Richardson W. J Man Manip Ther. 2010;18(4):175-80.

Abstracted by:  Rebecca Sherwin, PT, COMT, West Monroe, LA – Fellowship Candidate, IAOM-US Fellowship Program & Jean-Michel Brismée, PT, ScD, IAOM-US Fellowship Program Director

Cervical spine myelopathy (CSM) is a disorder that involves progressive compression of the spinal cord in the cervical area.  This compression can be caused by degenerative changes due to intervertebral disc disease, spondylosis, or other pathologies that cause degeneration.1  It has been referred to as one of the most common spinal cord disorders in the older populations.1  Many patients complain of stiffness in the neck, radiculopathy, and sometimes shoulder pain.2  According to Northover et al,  C5 and C6 are the most common levels for cord compression.3  With progression of cervical degenerative changes, one often begin experiencing  a loss of strength in the upper extremities and atrophy of the hand intrinsic musculature.4   CSM can best be identified through magnetic resonance imaging (MRI).  It is the best tool for definition of CSM as it demonstrates high sensitivity and specificity for cord compression.5   

No cluster of tests has proven to be more beneficial than any singular test for identifying cervical spine myelopathy.  This study attempted to find a cluster of predictive clinical findings using imaging confirmation after making a clinical diagnosis in hopes of developing a reference standard for CSM.  Many tests have been studied that have a high degree of specificity and can rule in the diagnosis of CSM; however, not many have a high sensitivity, which would help rule this diagnosis out.  The tests with a high specificity are clonus,6 Hoffman sign,7-9 hyper-reflexic deep tendon responses,7,8,10 inverted supinator signs,7,11 and Babinski sign.12  When these tests are used alone, they may lead to false negatives and occasionally false positives.7  When tests are clustered together, they can help overcome the weakness of stand-alone tests.  

Data was taken from 249 patients with cervical spine dysfunction from multiple conditions seen at Duke University from 2006 to 2009.  All participants were diagnosed with CSM by an orthopedic surgeon dependent on a patient’s history and physical examination.  The patient’s history consisted of deep aching pain in the neck, arm or shoulder joint that can be unilateral or bilateral, gait dysfunction resulting in clumsiness or stiffness, loss of dexterity in the hands and stiffness in the neck.  The patients also presented with “multisegmental weakness, losses during coordination testing, and variable losses of sensation and proprioception.”  When a clinical diagnosis was suspected, an MRI was done to confirm or deny the diagnosis of cervical spine myelopathy.  Each participant in this study had positive MRI findings to confirm diagnosis of CSM.  According to many studies, the diagnosis of CSM by MRI is confirmed with a reduction in the anterior-posterior width, signal changes noted in the cord, complete obstruction of the subarachnoid space, and cord compression noted with cross-sectional views on imaging.13-17  Patient’s demographic information, pain scale, neck disability index (NDI) and SF12, which is an outcome measure used to determine a person’s quality of life, were recorded and utilized as descriptive variable.  The predictive variables for the study included gait disturbances (abnormally wide-based gait, spastic gait, or ataxic gait), increased reflexes at the C5-6 level, abnormal brachio-radialis reflex (an inverted supinator sign), increased lower extremity reflexes, Hoffman, Spurling’s test or Babinski, the distraction test, clonus, and pain scores.  

Results and Conclusions:

Thirteen clinical findings were studied including:  pain score, pain consistency, age > 45 years old, hyper-reflexia of the lower extremity reflexes (quadriceps and achilles) as well as C5,6 reflexes in the upper extremity (biceps and inverted supinator sign of brachioradialis), Spurling’s test, Hoffman’s test, clonus, Babinski, distraction test, and gait deviation.   Five clinical findings were identified in the study (gait deviation, Hoffman’s test, inverted supinator sign, Babinski test and age > 45 years old) to be good predictors of CSM.  The patients in this study displayed high specificity for ruling in CSM when 3-4 of these 5 identifiers were present.  Also, there was high sensitivity for ruling out CSM when only 1 of the 5 clinical findings was present.  These clusters may be useful in helping a clinician identify patients with CSM.

IAOM-US commentary:

Many patients present to physical therapy for gait disturbances, which can be one of the initial complaints with a patient with cervical spine myelopathy.  Clinicians should to be aware of certain questions and objective measures to clear patients with this diagnosis.  The consistency of the IAOM-US evaluations, based on Cyriax’s teachings, is to perform a systematic evaluation every time while performing the least amount of testing for the most amount of information.  In doing the same evaluations each time, it is much easier to quickly identify discrepancies with these patients.  When performing a cervical evaluation, it is already recommended to perform upper extremity and lower extremity reflex testing as well as a Babinski as a quick screen.  Adding the performance of the Hoffman’s test can help rule in CSM.  In addition to the objective findings, the patient can quickly be assessed for gait deviations as he/she walks into your clinic for the initial examination.  Very easily and quickly, these 5 clinical findings that form a cluster with high specificity for a diagnosis of cervical spine myelopathy can be identified and the patient can be referred back to the physician for appropriate treatment.    

Hoffman’s Test

  • Grasp the patient’s middle phalanx of the 3rd digit then flick the patient’s distal phalanx into flexion.
  • A positive test is flexion of the interphalangeal joints of the thumb and index finger.

Inverted Supinator Sign

  • The arm is placed in a neutral position, allowing the natural ulnar deviation to occur.  Strike the brachioradialis tendon near the radial styloid process.
  • A positive test is flexion of the fingers.



  • Use the pointed end of the reflex hammer along the plantar surface of the foot then swipe lateral to medial across the ball of the foot.
  • A positive test is great toe extension and splaying of the other digits.



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  3. Northover JR, Wild JB, Braybrooke J, Blanco J. 2012. The epidemiology of cervical spondylotic myelopathy. Skeletal Radiol 41:1543–6.
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  13. Matsuda Y, Miyazaki K, Tada K, Yasuda A, Nakayama T, Murakami H, et al. Increased MR signal intensity due to cervical myelopathy — analysis of 29 surgical cases. J Neurosurg 1991;74:887–92.
  14. Matsumoto M, Toyama Y, Ishikawa M, Chiba K, Suzuki N, Fujimura Y. Increased signal intensity of the spinal cord on magnetic resonance images in cervical compressive myelopathy —Does it predict the outcome of conservative treatment? Spine 2000;25:677–82.
  15. McCormick WE, Steinmetz MP, Benzel EC. Cervical spondy- lotic myelopathy: make the difficult diagnosis, then refer for surgery. Cleve Clin J Med 2003;70:899–904.
  16. Al-Mefty O, Harkey LH, Middleton TH, Smith RR, Fox JL. Myelopathic cervical spondylotic lesions demonstrated by magnetic resonance imaging. J Neurosurg 1988;68:217–22.
  17. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine (Phila Pa 1976) 2003;28:52–62.
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