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Produce a systematic literature review of a specific intervention for a musculoskeletal (MSK) condition. The chosen therapy or combination of therapies can be from any of the categories listed below:

  • Manual therapy
  • Exercise
  • Complementary and alternative medicine therapies
  • Nutraceutical
  • Pharmacological
  • Electrophysiological
  • Surgical  
  • Psychological

Students are to prepare the systematic literature review in accordance with the PRISMA documents and any relevant extension documents:

Students must carefully choose a topic in which there is sufficient research to warrant performing a systematic literature review.


Title: Usefulness of Manual Therapy for Individuals with Cervicogenic Dizziness (CD); A Systematic Literature Review and Metal Analysis

Participants were randomly allocated to the sustained Glides and placebo groups. Every participant received up to five treatments by a professional physiotherapist over 42 days over the discretion of treating therapists used clinical judgement to identify the dosage as per the client’s response. The treatments stopped when the participants that the condition was adequately improved or when where was o further improvement over two continuous visits.

90 participants with CD were recruited in Canada through press release as well as radio interviews/ newspaper blogs, via advertisement in daily newspaper, plus referral from healthcare professionals like neurologists. Hence forth, exclusion and inclusion criteria were summarised as shown in the table below.


Exclusion criteria: Conditions that would put an individual at risk of CD

Exclusion criteria

Inclusion criteria

Inflammatory joint disease

Has CD described as imbalance related to neck movement /positions

Marked osteoporosis

Has the symptoms present for more than three months

Cervical spine cancer

18 to 90 years old

Pathology of the spinal cord

Dislocation of the neck

Acute nerve root symptoms

Marked cervical spine disc protrusion

A process of three steps was used in identifying those with CD. First, an initial screening of phone was done by a physiotherapist. Second, for the potential participants who were perceived to posses the condition following a discussion regarding the phone, were physically tested by a professional physiotherapist. Lastly, those not excluded by a physiotherapist at this stage had an examination which was clinical and it was performed by a neurologist like function testing of peripheral vestibular.

In this process, history of the individual was taken by a physiotherapist to identify that the client did have CD. If the client had other types of dizziness like orthostatic hypotension and vertigo they were left out. In cases where dizziness was termed as CD (unsteadiness or imbalance) it was noted that the later was not as a result of another cause suck as musculoskeletal or neuromuscular complications. However, it was noted that there was a related past of neck stiffness or pain. The poor balance or lack of steadiness was also due to cervical spine positions or movements.

The Dix-Hall pike manoeuvre was conducted to know whether the individual had their phones screened and those thought to be CD positive if they underwent a physical examination done by a physiotherapist. The examinations were;

  1. The Dix-Hall pike manoeuvre conducted to know whether the individual haddysfunction of semi-circular canals. Here, the participants sat on an examination table and the health care proffesional the participant head to an angle of degree 45 and quickly laid the participants with their back straight such that the head was extended below the horizontal.  Ideally, the nystagmus formation was a presence of benign paroxysmal vertigo.
  2. A hypertension test was done in sitting and upright position using a sphygmomanometer. However, the normal response of pressure to positional change was an indication that neurocardiogenic syncope was not likely a cause of CD.
  3. Smooth visual pursuit movement was also done to track slow moving objects.  The one examining looked for eye movement asymmetry which may show the presence of cerebella lesion.
  4. The cervical range of motion was also done to know if the participants have a limitation of movement which might be a good indication of cervical spine dysfunction with CD. Here, participant was requested to sway the neck into a reflexion, right and left rotation, extension as well as right and left lateral reflexions as well as report in case of symptoms like pain or dizziness.
  5.  Palpation on the upper cervical spine was also tested to identify painful or stiff joints. In case of these symptoms, there would be an indication of complication in the upper cervical spine.
  6.  Lastly, a decrease of balance was shown in individuals with CD.   For assessing balance, the participants were balance used to assess posture steadiness in a heel to toe posture. They were asked to be in tandem posture for 30 second. This is a standing balance of clinical measure used to test steadiness in a heel to toe posture.

For the participants who were not excluded in the performance of previous screening, were also tested by a neurologist to eliminate the CNS and vestibule. The examination included tests of vestibule-ocular and spinal function as well as testing of balance   

Participants who were not eliminated in process of screening were allocated randomly to either placebo or Mulligan SNAGS. A statistician who was independent produced a pattern generated using a computer which was then put in envelopes sealed in sequential numbers. This pattern contained participant’s number for every group.

Intervention was performed by a manual therapy specialised professional physiotherapist experienced in a period of 10 yrs at minimum.

A participants group had placebo interventions comprising of infrared therapy laser that the manufacturer had deactivated.  Physiotherapists use medical lasers to treat symptoms of musculoskeletal. To the participants, the device of the laser seemed to function normally with the flashing light as well as sound of beeping but did not give effective emissions. However, the laser which was deactivated that appeared to show a strong effect of placebo was applied for 120 seconds for each neck’s side, with a pen at a distance of one centimetre from the skin.


Another participants group received SNAGS as Brian Mulligan presented. A participant in a sitting posture was asked to sway his head in a direction that emits the symptoms. As the head of the participant moved, a physiotherapist glided the C2 or Ca vertebra anteriorly plus sustained the glide via the movement. During the glide application, the participant was supposed to be symptom free as well as allowed to stop in case dizziness was produced. Ideally, the movement was repeated severally during the initial recommended treatment session by Brian. In the other treatments where there we no dizziness, an apophyseal Glides was performed done severally and pressure applied. The other sustained glide in a different showed that the direction of movement would be included to the treatments. Following this treatment, the participants were asked to perform a self apophyseal Glides daily as a workout plan where the participants were asked to do home exercises once daily for a period of one year.

Social-demographic data of the participant was gathered at the baseline which included the participants’ gender, age as well as time following the start of dizziness. Both outcomes (primary and secondary) were measured at the baseline following the final treatment at 6, 12 and 24 weeks respectively plus one year upon completion of the treatment. Follow up assessment was done by analysts blinded to participant’s group allocation. 

The extent of CD was measured with 100mm VAS, visual analogue scale. The scale had measure dizziness in other studies successfully.

  1. The rate of dizziness was determined using a 6-point point scale that included the following; 0 to mean no dizziness, one was dizziness less than once per month, two to mean one to four episodes of dizziness in a month, three to mean one to four episodes of CD a week, four to mean one dizziness in a day, and five dizziness constant dizziness. This scoring technique had been used by multiple researchers to measure the rate of dizziness.
  2. Disability due to dizziness was assessed using DHI, a dizziness handicap inventorytool. It measured the type of life using a subscale to show the effect of CD on a person’s day to day activities. Ideally, 100 was the highest score and represented the limit self perceive handicap.
  3. The seriousness of neck pain was examined using a 100mm visual analogue scale. However, there is lots of evidence holding to a greater validity of scale for assessing the level of pain.
  4. Neck repositioning sense was assessed using a cervical range of motion device. This was aimed at testing a person’s capability to reposition both the neck and the head. However, the participants sat with heads in a neutral posture.  Then they were advised to close the eyes as well as rotate their head. However, at a half range rotation, they were ordered to stop, held their head steadily thought about the position, a target position. After five seconds, they returned to the initial posture where a reading was taken. The difference in degree between the target posture as well as the attempt to get it was determined. This was done three times for left and right rotation plus the mean obtained for every direction of rotation.
  1. Sample Size (N) Calculation

The needed sample measurement was based on analysis, with t-tests for the variation of treatments group pairs and alpha set of 5%.  A comparison between the placebo and SNAG group was made. Sample size calculation was based on variation of the above groups which would be important for the results, supported by findings of other studies where there were applicable data. This was done by biostaticians from Newcastle University using VAS and DHI as the outcome measures. The later was an outcome measure for calculation of the sample size since it is a great measure of perceived disability as well as impact of dizziness on function. However presuming that the s.d of dizziness handicap inventory score was 14 and then about thirty participants in every group would give the study an eighty percent power to find the variation of eleven units in every group. The participants (30), in every group were also required basing on the zero to ten VAS scale with a s.d of 3.2 plus a significant variation of two and a 80% power plus 5% C.I

  1. Statistical Methods.

For the primary outcomes measures of dizziness handicap inventory, the resulting variables were the dizziness handicap inventory while predictors were treatment groups and time. A probability value for the interaction term would represent in case of difference in variation in the dizziness handicap inventory overtime of the groups.  However, a “gate keeper’s technique” was employed to check for the different testing plus limit the whole type 1 error. This implies that a SNAG intervention would be tested for the placebo. Both primary and secondary outcomes were also compared in the treatments at every point with t-tests.

  1. Economic Assessment

Exclusion and Inclusion Criteria

Economic assessment varies from one outcome to the other. There is a possibility that variation in effectives would exist, hence a cost utility and effective analysis would be necessary. In the event an intervention was very useful but cheap, the incremental cost effectiveness ratio would not require any calculations since the most efficient effective intervention is usually preferred.   In case the results showed that one intervention was more effective than the other, a cost minimisation analysis would be necessary. However, in the scenario presented, there was no difference in the efficacy hence the analysis was a comparison of the costs.

To limit bias randomisation certain exclusion and inclusion criteria, blind data analysis, and concealed allocation would be employed.  Besides, it is very hard to blind physiotherapists during intervention. 

Discussion and Conclusion

Participants experienced increased dizziness and neck pain in the baseline phase thus making it hard to interpret the results. Besides, a self perceived disability was very stable in the baseline despite the fact that it increased in the final measurement. The cervical range of motion declined during the baseline phase apart from rotation to the left which increased. Considering the unstable baseline, it is evident that one should be keen enough when interpreting the results. Therefore, it appeared be a tendency of the intensity dizziness as well as perceived disability to lower in later treatment section with the reduction in intensity being clinically and not statistically of essence plus the reduction in perceived stability being statistically and not clinically important. Neck pain was considered minimal in the last treatment with the decline being clinically significant. All in all, the decline wasn’t statistically significant neither was it kept at follow-up. Also, the treatment did not appear to have any effect of on active cervical range of motion.

In conclusion, this review has outlined the usefulness of MT treatment for individuals having CD as well as neck pain to some extent. It has compared its efficacy plus cost effectiveness of placebo and SNAG intervention in lowering CD symptoms plus its pain over one year. The aim of the review was to show which manual therapy treatment is very effective for such conditions (CD) and if manual therapy is efficient in the long run. Ultimately, the review and Meta analysis has contributed to evidence based MT to improve decision making during clinical practice


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