Background-There is no disease specific, reliable, and valid clinical measure of Achilles tendinopathy. Objective-To develop and test a questionnaire based instrument that would serve as an index of severity of Achilles tendinopathy. Methods-Item generation, item reduction, item scaling, and pretesting were used to develop a questionnaire to assess the severity of Achilles tendinopathy. The final version consisted of eight questions that measured the domains of pain, function in daily living, and sporting activity. Results range from 0 to 100, where 100 represents the perfect score. Its validity and reliability were then tested in a population of non-surgical patients with Achilles tendinopathy (n = 45), presurgical patients with Achilles tendinopathy (n = 14), and two normal control populations (total n = 87). Results-The VISA-A questionnaire had good test-retest (r = 0.93), intrarater (three tests, r = 0.90), and interrater (r = 0.90) reliability as well as good stability when compared one week apart (r = 0.81). The mean (95% confidence interval) VISA-A score in the non-surgical patients was 64 (59-69), in presurgical patients 44 (28-60), and in control subjects it exceeded 96 (94-99). Thus the VISA-A score was higher in non-surgical than presurgical patients (p = 0.02) and higher in control subjects than in both patient populations (p<0.001). Conclusions-The VISA-A questionnaire is reliable and displayed construct validity when means were compared in patients with a range of severity of Achilles tendinopathy and control subjects. The continuous numerical result of the VISA-A questionnaire has the potential to provide utility in both the clinical setting and research. The test is not designed to be diagnostic. Further studies are needed to determine whether the VISA-A score predicts prognosis. (Br J Sports Med 2001;35:335-341)

In the lumbar spine, SMT was accurate about half the time. However, because most procedures were associated with multiple cavitations, in most cases, at least one cavitation emanated from the target joints. In the thoracic spine, SMT appears to be more accurate.

Objective This project determined the location and distribution of cavitations (audible sounds producing vibrations) in the lumbar zygapophyseal (Z) joints that were targeted by spinal manipulative therapy (SMT). Methods This randomized, controlled, clinical study assessed 40 healthy subjects (20 male, 20 female), 18–30 years of age, that were block randomized into SMT (Group 1, n=30) or side-posture positioning only (Group 2, control, n=10) groups. Nine accelerometers were placed on each patient (7 on SPs/sacral tubercles of L1–S2 and 2 placed 3 cm left and right lateral to the L4/L5 interspinous space). Accelerometer recordings were made during side-posture positioning (Groups 1 and 2) and SMT (Group 1 only). The SMT was delivered by a chiropractic physician with 19 years of practice experience and included 2 high-velocity, low-amplitude thrusts delivered in rapid succession. Comparisons using chi-square or McNemar’s test were made between number of joints cavitating from: Group 1 vs. Group 2, up-side (contact side for SMT) vs. down-side, and Z joints within the target area (L3/L4, L4L5, L5/S1) vs. outside the target area (L1/L2, L2/L3, sacroiliac). Results Fifty-six cavitations were recorded from 46 joints of 40 subjects. Eight joints cavitated more than once. Group 1 joints cavitated more than Group 2 joints (p<0.0001), up-side joints cavitated more than down-side joints (p<0.0001), and joints inside the target area cavitated more than those outside the target area (p<0.01). Conclusions Most cavitations (93.5%) occurred on the up-side of SMT subjects in segments within the target area (71.7%). As expected, SMT subjects cavitated more frequently than side-posture positioning only subjects (96.7% vs. 30%). Multiple cavitations from the same Z joints had not been previously reported.

Background Context No clinical trial of spinal manipulation for chronic neck pain, either for single or multiple intervention session(s), has employed an effective sham-manipulation control group. Purpose Validate a practical sham cervical high velocity, low amplitude (HVLA) spinal manipulation. Study design/Setting Randomized, experimental validation study in an institutional clinical research laboratory Patient Sample Eligible subjects were males and females, 18–60 years of age with mechanical neck pain (as defined by the International Association for the Study of Pain Classification) of at least 3 months duration. Subjects with arm pain, any pathologic cause of neck pain or any contra-indication to spinal manipulation were excluded. Outcome Measures The primary outcome was the patient’s self-report or “registration” of group allocation following treatment. Secondary outcomes were NRS-101 for neck pain, range of motion (by goniometer), tenderness (by pressure algometry). Methods Eligible subjects were randomly allocated to one of two groups: “real” or sham cervical manipulation (RM or SM). All subjects were given two procedures in sequence, either RM+SM or SM+SM. Immediately following the two procedures, subjects were asked to register any pain experienced during the procedures and to identify their treatment group allocation. Force-time profiles were recorded during all procedures. Secondary clinical outcome measures were obtained at baseline, 5 and 15 minutes after the intervention including range of motion, self-report of pain and local spinous process tenderness. Data for each variable were summarized and tested for normality in distribution. Summary statistics were obtained for each variable and statistically tested. Funding for this study was obtained from the National Institutes of Health (NCCAM: R21 AT004396-01A1) and the Canadian Institutes of Health Research (BMT91926). No conflicts of interest exist in this study. Results Sixty-seven subjects were randomized. Data from 64 subjects (32 per group) were available for analysis. There were no significant differences between the groups at baseline. One adverse event occurred in the “real” group which was a mild post- treatment pain reaction lasting < 24 hours. In the RM group, 50% of subjects incorrectly registered their treatment allocation; in the sham group, 53% did so. For the SM group, none of the procedures resulted in cavitation while in the RM group, 87% of procedures resulted in cavitation. There were no significant changes between groups on pain, tenderness or ROM. Force-time profiles of the RM and SM procedures demonstrated fidelity with significant differences between components as intended. Conclusions The novel sham procedure has been shown to be effective in masking subjects to group allocation and to be clinically inert with respect to common outcomes in the immediate post-treatment stage. Further research on serial applications and for multiple operators is warranted.

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