Purpose. Definition of cervicogenic dizziness. SNAGs. Participants. Method

Transcription

1 THE TREATMENT OF CERVICOGENIC DIZZINESS AND PAIN WITH SUSTAINED NATURAL APOPHYSEAL GLIDES (SNAGS): A RANDOMIZED CONTROLLED TRIAL Purpose To determine the efficacy of SNAGs in the treatm of cervicogenic dizziness, pain and disability To provide sciific evidence for the treatm of cervicogenic dizziness Susan Reid Prof Darren Rivett Dr Michael Katekar A/Prof Robin Callister Definition of cervicogenic dizziness Dizziness: described as imbalance, disequilibrium or unsteadiness (not rotatory vertigo) AND related to either movems or positions of the cervical spine, or occurring with a stiff or painful neck SNAGs Sustained accessory glide combined with active movem Mulligan (99) proposed as treatm for cervical vertigo Nil research but recommended clinically (Exelby, Grieve 99, Wilson 99) Systematic review found limited evidence for manual therapy in treatm of cervicogenic dizziness (Reid & Rivett ) Participants Thirty-four participants with cervicogenic dizziness (and usually cervical pain) Recruited by referral from Neurologists and a press release Diagnosis of exclusion by neurologist Chronic dizziness (> months) Method Prospective, double-blind randomized, controlled trial Randomized to receive SNAG manual therapy (n=7) or a placebo (detuned laser) (n=7)

2 Primary outcome measures Dizziness Handicap Invory () Dizziness severity (VAS) Frequency of dizziness Neck pain/headache severity (VAS) Global perceived effect Secondary outcome measures Cervical range of motion Posturography/balance (sway index) Posturography (Chattecx balance system) SNAG treatm As per Mulligan (999) Used physiological movem or position causing dizziness: Extension/flexion: anterior glide to C spinous process Rotation: anterior glide to ipsilateral C transverse process. If no relief, contralateral transverse process. Treatm is symptom-free Intervion - treatms over four weeks SNAG treatm was progressed by increasing number of reps, sustaining SNAG, or adding a second indicated SNAG as per clinical reasoning Assessms pre-treatm, post-treatm, & weeks Assessms administered by blinded assistant

3 Analysis scores 8 Two-way repeated measures analysis of variance Each group evaluated over time for each outcome Pretreatm Two study groups compared at each assessm point using independ two-sample T-tests with equal variance lower scores post-treatm (p <.), at wk (p <.), and wk (p <.). : lower at wk (p =.) 7% improvem in at s; % for placebo group lower scores than placebo group post-treatm (p =.) and at s (p =.) VAS dizziness Pre-treatm (both grps): % of participants p reported mild handicap (scoring - on ), % moderate (score -) and 7% severe (score -). Post-treatm: 8% of participants reported mild handicap, % moderate and none severe. % reported mild, % moderate and % severe handicap Dizziness scores Pretreatm Posttreatm lower scores post-treatm (p =.), at wk (p <.) and wk (p <.). Placebo: lower scores at wk (p <.) % improvem in at wks; % placebo group lower scores than placebo group post-treatm (p =.) and at s (p =.) Frequency of dizziness VAS pain Scores scores follow -up follow -up Pre-treatm Pretreatm 8 % had dizziness daily lower scores post-treatm (p =.), at s (p =.) and s (p =.) had no significant change lower pain scores post-treatm (p <.), at s (p =.) and s (p =.). no change lower scores than placebo group post-treatm ( p =.) and at s (p =.8) had % decrease in pain post-treatm (8% is considered a clinically significant change [Mannion et al. 999])

4 Posturography: cervical extension Sway index 8 Conclusions SNAGs were shown to: have a clinically and statistically significant effect Pretrea tm e nt Posttreatm fo llo w -up have an immediate and sustained effect reduce dizziness, cervical pain and disability caused by cervical spine dysfunction lower SI at s (p =.). : no effect Clinical Implications Evidence for existence of cervicogenic dizziness Idification of people with this condition Sciific evidence for effectiveness of SNAGs in treatm A new evidence-based treatm option for people with this disabling condition Possible mechanism of action Inputs to vestibular nuclei that maintain balance (Cronin, 997; Furman & Whitney, ) Vestibular system Proprioceptors of the cervical joints and muscles Vestibular Nuclei Visual system Future research To evaluate the long-term effects of SNAGs and Self-SNAGs in reducing symptoms of chronic cervicogenic dizziness and pain To compare SNAGs to Maitland passive cervical joint mobilizations To compare the cost-effectiveness To assess any adverse effects To measure changes in the ability to reposition the head in space. Score Pati : 7 year old gardener REsults for Mr C Timeline Dizziness Dizziness -years After swimming, gardening, g, painting ceilings, stocktaking : looking up, frustrated, feels handicapped, reading, quick movems After treatms almost no dizziness or headache (pres weeks) You gave me my life back No dizziness or pain for. years after treatm

5 Pati : 7 year old lady Felt off balance would fall over 9 7 year history been to St Vincs, 8 had ear surgery 7 : Felt frustrated, restricts travel, restricted social activities, wouldn t go for a walk or leave the house, felt depressed, stress with family Post T: could go for a walk, leave the house alone, less stress, less depression, less handicap Dizzines Pati : 7 year old kayaker World long distance kayak record; km /wk Turn to right falls out of kayak; sold kayak years stiff, painful neck Post treatm fantastic only occassional dizziness, returned to sport TK Acknowledgems Scores Mr N results Dizziness Brian Mulligan Prof Kate D Este Geoff Evans The University of Newcastle Brawn Scholarship Timeline Physiotherapy gets more exciting as the years pass. Brian Mulligan 99