Defining and measuring objective and subjective spinal stiffness

Defining and measuring objective and subjective spinal stiffness:

A scoping review

Joel Ranui Moses

A 90-credit thesis submitted in partial fulfilment of the requirements

for the degree of Master of Osteopathy,

Unitec Institute of Technology, 2020

ii

Declaration

Name of candidate: Joel Moses

This thesis entitled “Defining and measuring objective and subjective spinal stiffness: A

scoping review” is submitted in partial fulfilment for the requirements for the Unitec degree of

Master of Osteopathy.

Principal Supervisor: Sylvia Hach

Associate Supervisor: Jesse Mason

Candidate’s declaration:

I confirm that:

• This thesis represents my work;

• The contribution of supervisors and others to this work was consistent with the Unitec

Regulations and Policies.

• Research for this work has been conducted in accordance with the Unitec Research

Ethics Committee Policy and Procedures and has fulfilled any requirements set for this

project by the Unitec Research Ethics Committee.

Candidate Signature: Date: 23/03/2020

Student number: 1458167

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Dedication/He mihi

Tihei mauri ora!

Te manu ka i te miro, nōna te ngahere, Te manu ka ii te mātauranga

Ko Tainui te Waka

Ko Hoturoa te Tangata

Ko Taupiri me Maungatautari te Māunga

Ko Waikato te Awa

Ko Waikato Tainui me Raukawa ngā Iwi

Ko Ngati Werokoko me Ngati Waenganui ngā Hapu

Ko Parawera te Marae

Ko Taneirangikapua te tupuna whare

Ko Sally rāua ko Rawhiti ōku mātua

Ko Joel Ranui Moses taku ingoa

Kua tau te mihi whakamana, ki a Waikato Tainui, mo te tautoko e pa ana ki taku kaupapa.

Tenei te mihinui mō tō rātou putea tautoko me tō rātou manaaki a Pai marire.

Waikato-taniwha-rau

He piko, he taniwha

He piko, he taniwha.

I also dedicate this thesis to my whanau who have shown endless support and encouragement

throughout this journey to completing my thesis.

I also dedicate this thesis to my best friend and partner, thank you for your endless love and

support.

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Acknowledgements

This thesis is the product of much collaboration. I would like to thank my supervisors, for

without their guidance, it would not have been possible to pull this thesis together. Sylvia, I

thank you for your persistence, dedication and assistance from the get-go. Your contributions

and research expertise have been invaluable. Jesse, I thank you for your great sense of humour

and for pulling me up at times on my discursive writing style. Your contributions and

perspectives have been an asset. It has been an absolute privilege and honour to work with you

both on this research project. I cannot thank you enough for the time you have put into the

preparation of this thesis.

I would like to make a special mention to Dipti Vora, Library Knowledge Specialist for her

expertise and guidance in the development of the search strategy.

To my lecturers and tutors, I thank you for providing me with a well-balanced perspective of

osteopathic principles, clinical expertise and evidence-based practice. These tools will be

invaluable as I begin my journey as a clinician.

To my classmates and now colleagues, what a privilege it has been to learn and develop

alongside you.

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Preface

The notion of stiffness is a well-known entity within the clinical context. Despite this, there is

little agreement on the fundamental question – what the word ‘stiffness’ is specifically referring

to and how can it be assessed in the clinic. A diverse range of measures are used across different

research settings. However, these quantitative approaches appear to be poorly comparable to

the realities of patients and the pragmatics of clinical practice.

The purpose of this thesis is to examine the nature, range and extent of definitions and measures

of spinal stiffness in the existing literature. This is a critical first step, as it will provide a basis

for researchers to investigate how patients or clinicians understand stiffness, in a meaningful

and informed way. This thesis contributes to the understanding of what definitions and

measures are used in the literature. It will provide important future research directions and is

aimed at facilitating the development of a fuller understanding of how stiffness can be defined

and measured in the clinical context.

This thesis is presented in three sections. Section one contains the literature review. Here, the

consensus statement and standardised definition of pain is used as a reference point to allow

the reader to consider why stiffness might also benefit from a definition that provides a common

understanding for researchers, patients and clinicians. The historical evolutionary perspective

of stiffness and its subsequent adoption into the clinical context is described. This provides an

explanation of key concepts related to the origins and characterisation of stiffness.

Consideration is given to the role of primary care and rehabilitation professionals in the

assessment, evaluation and implementation of clinical interventions for patients that present

with stiffness. Following this, the quantitative and qualitative approaches to measuring stiffness

are explained and operational definitions employed in this thesis are described. This section

concludes by making the case that more clarity is needed regarding how stiffness is both

defined and measured.

Section two contains an outline of the methodology. This section begins by describing how the

philosophical perspective – positivism and the epistemological underpinnings of this review

are integrated into the chosen methodology – scoping review. The following will cite where

the chosen methodology is situated within the evidence hierarchy and establish why this

methodology was implemented to address the guiding research question. Subsequently, the key

characteristics of scoping reviews are compared to the more well-known systematic review.

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Finally, the methodological framework is outlined and described within the context of how this

scoping review was conducted

Section three contains a manuscript of the present project for submission to a peer-reviewed

journal for publication. Note, that a scoping review of this type required a broad scope, and

consequently yielded a large volume of data pertaining to the research question. For the purpose

of this thesis it was therefore determined that a detailed results section should be included,

irrespective of the word limitations of the target journal for the manuscript. This provides a

platform by which the reader may benefit from a more comprehensive coverage of the findings,

than could be achieved in a published manuscript. That is, a thorough and accurate

representation of the results could not have been achieved by adhering to the guidelines for the

purpose of a published manuscript. The intention is to abbreviate the manuscript following the

examination of the thesis in preparation for submission to the target journal.

Section four contains all appended resources including, for example, evidence of ethics

approval exemption and detailed data structure matrices. A scoping review protocol was

developed and registered prospectively on the open science framework which encourages

transparency during the review process and can also be found cross-referenced in the

appendices.

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Table of contents

Declaration............................................................................................................................................. ii

Dedication/He mihi ................................................................................................................................ iii

Acknowledgements ................................................................................................................................ iv

Preface .................................................................................................................................................... v

Table of Contents .................................................................................................................................. vii

List of Figures ........................................................................................................................................ ix

List of Tables ......................................................................................................................................... ix

Section 1: Literature review ................................................................................................................. 1

Definition of pain ............................................................................................................................... 2

Historical evolution of stiffness ........................................................................................................ 4

Considerations for primary care ..................................................................................................... 6

Considerations for rehabilitation .................................................................................................... 6

The importance of measuring stiffness ........................................................................................... 9

Objective measures of spinal stiffness ............................................................................................. 9

Subjective measures of spinal stiffness .......................................................................................... 11

Conclusion ............................................................................................................................................ 14

Section 2: Methodology ...................................................................................................................... 15

Philosophical perspective ............................................................................................................... 16

Comparison of key characteristics of scoping reviews and systematic reviews ......................... 18

Methodological approach ............................................................................................................... 20

Framework Stage 1: Identifying the research question ............................................................... 21

Framework Stage 2: Identifying the relevant studies .................................................................. 21

Grey literature .............................................................................................................................. 21

Clarification of terminology ........................................................................................................ 22

Framework Stage 3: Study selection ............................................................................................. 23

Framework Stage 4: Charting the data ........................................................................................ 23

Framework Stage 5: Collating, summarising and reporting the results .................................... 24

Framework Stage 6: (optional) Consultation ............................................................................... 24

References ............................................................................................................................................. 25

Section 3: Manuscript ......................................................................................................................... 39

Abstract ................................................................................................................................................ 41

Highlights ............................................................................................................................................. 42

List of abbreviations ........................................................................................................................... 43

Introduction ........................................................................................................................................... 44

Methods ................................................................................................................................................ 46

viii

Identification of the research question .......................................................................................... 46

Identification of the relevant studies ............................................................................................. 46

Study selection .............................................................................................................................. 47

Screening and Agreement ............................................................................................................ 48

Data charting process ..................................................................................................................... 48

Collating and summarising the findings of included studies ....................................................... 49

Analysing the data ........................................................................................................................ 49

Data validation ............................................................................................................................. 49

Reporting ...................................................................................................................................... 49

Results ................................................................................................................................................... 50

Overview of study characteristics .................................................................................................. 52

Characteristics of studies classified as biomechanical ............................................................. 55

Characteristics of studies classified as surgical ........................................................................ 58

Characteristics of studies classified as pathophysiological ...................................................... 60

Characteristics of studies classified as segmental assessment ................................................. 63

Discussion ......................................................................................................................................... 69

Study limitations ......................................................................................................................... 76

Conclusion ............................................................................................................................................ 77

References ......................................................................................................................................... 79

Section 4: Appendices ....................................................................................................................... 116

Appendix A; Ethics notification ..................................................................................................... 117

Appendix B: Search strategy ........................................................................................................... 118

Appendix C: Screening template .................................................................................................... 121

Appendix D: Interrater agreement .................................................................................................. 122

Appendix E: Data Items .................................................................................................................. 123

Appendix F: Data abstraction tables ............................................................................................... 124

Appendix G: Alternative descriptors .............................................................................................. 197

Appendix H: Surrogate measures ................................................................................................... 199

Refersences ......................................................................................................................................... 200

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List of figures

FIGURE 1. PRISMA-SCR (PREFERRED REPORTING ITEMS FOR SYSTEMATIC REVIEWS AND META-

ANALYSES EXTENSION FOR SCOPING REVIEWS) FLOW DIAGRAM OF THE SEARCH STRATEGY AND

STUDY SELECTION.15 ..................................................................................................................................................................................... 50

List of tables

TABLE 1. OVERVIEW OF INCLUDED STUDIES (N=333) ......................................................................... 51

TABLE 2. OVERVIEW OF THE INCLUSION OF DEFINITIONS, MEASURES, OR INDICATORS OF SPINAL

STIFFNESS AS PART OF THE STUDIES INCLUDED IN THE SCOPING REVIEW ............................................ 52

TABLE 3. BREAKDOWN OF STUDIES INCLUDED IN THE SCOPING REVIEW BY STUDY CATEGORY AND

THE INCLUSION OR OMISSION OF A DEFINITION OF STIFFNESS .................................................................. 53

TABLE 4. BREAKDOWN OF STUDIES INCLUDED IN THE SCOPING REVIEW BY STUDY CATEGORY AND

THE INCLUSION OR OMISSION OF OBJECTIVE OR SUBJECTIVE MEASURES OF STIFFNESS .................. 54

TABLE 5. OVERVIEW OF THE METHODS OF QUANTIFYING SPINAL STIFFNESS AS UTILISED BY STUDIES

INCLUDED IN THE BIOMECHANICAL THEME .................................................................................................... 55

TABLE 6. OVERVIEW OF THE METHODS OF QUANTIFYING SPINAL STIFFNESS AS UTILISED BY STUDIES

IN THE SURGICAL THEME ...................................................................................................................................... 58

TABLE 7. SUMMARY OF STIFFNESS INDICATORS REPORTED IN THE PATHOPHYSIOLOGICAL THEME ... 61

TABLE 8. KEY FEATURES OF QUALITATIVE DEFINITIONS REPORTED IN MANUAL SEGMENTAL

ASSESSMENT CATEGORY ....................................................................................................................................... 65

TABLE 9. OVERVIEW OF VARIOUS DESCRIPTORS USED TO DESCRIBE MANUAL SEGMENTAL

ASSESSMENT ............................................................................................................................................................. 65

TABLE 10. OVERVIEW OF HOW OBJECTIVE MEASURES WERE QUANTIFIED FOR MECHANICAL

STIFFNESS ASSESSMENT ........................................................................................................................................ 67

TABLE 11. KEY FEATURES OF QUANTITATIVE DEFINITIONS REPORTED IN MECHANICAL SEGMENTAL

ASSESSMENT CATEGORY ....................................................................................................................................... 68

1

Section 1: Literature review

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Definition of pain

Pain is one of the most common reasons why patients consult a primary health care

professional (Tompkins et al., 2017). Therefore, the assessment of pain is an essential aspect

of clinical practice informing effective management options. The ability to effectively diagnose

and treat pain first requires an understanding of what constitutes pain. The International

Association for the Study of Pain (IASP), defines pain as “an unpleasant sensory and emotional

experience associated with actual or potential tissue damage, or described in terms of such

damage” (Merskey & Bogduk, 1994). This definition reflects the multidimensional nature of

pain by including both sensory and emotional features and avoids tying pain to the stimulus

(Merskey & Bogduk, 1994; Williams & Craig, 2016). Since the inception of the IASP

definition, there have been various criticisms of the definition in the literature. For example,

the use of certain terms such as ‘unpleasant’ has been argued to ‘trivialise’ severe chronic pain

(Aydede, 2019). Another example is the omission of cognitive and social dimensions of the

pain experience (Williams & Craig, 2016). Despite these criticisms, the IASP definition has

provided a common understanding and characterisation of the pain experience, that is both

relevant to clinicians and patient’s alike.

Spinal pain, and in particular low-back pain (LBP), are common musculoskeletal

problems that pose a significant social, psychologic, and economic burden (Rubin, 2007). It has

been estimated that approximately 15% to 20% of adults may be affected by LBP within a single

year, and approximately 50% to 80% of adults may experience one episode of LBP during their

lifetime (Rubin, 2007). LBP has been defined as “pain, muscular tension, or ‘stiffness’ that is

localized between the costal margins and the inferior gluteal folds, with or without radiating leg

pain” (Koes et al., 2006). It is apparent from the definition provided above, that the use of the

term ‘stiffness’ suggests that pain may co-exist with stiffness.

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Further evidence towards this claim can be found in a contemporary theory that explains

the adaptation to pain, which was conceptualised by Hodges and Tucker (2011). The theory

for the ‘motor adaptation to pain’ hypothesises that the basis of adaptation to pain is to protect

the painful body part and to reduce pain (Hodges & Tucker, 2011). This is claimed to be, in

part, achieved through “changes in mechanical behaviour such as modified movement and

stiffness,” which is suggested to lead to protection from further pain or injury (Hodges &

Tucker, 2011). One limitation of the ‘motor adaptation to pain’ theory is that it emphasises the

role of ‘mechanical changes’ in augmenting ‘modified’ movement and ‘stiffness’. This is in

contrast to the growing body of literature suggesting that a disconnect may exist between the

mechanical (physiological) properties of joints and tissues, and subjective reports of stiffness

(Haigh et al., 2003; Helliwell et al., 1988; Karayannis et al., 2013; Stanton et al., 2017). For

example, Haigh et al. (2003) reported that patients with bilateral rheumatoid arthritis who have

had one limb amputated could still feel stiffness in the missing joint. This suggests that stiffness

may be neurally-driven, rather than being solely caused by ‘true’ physiological changes in the

joint itself.

Moreover, a recent study by Stanton et al. (2017) identified that pairing sound (e.g.

‘whooshing’ noise) with mobilisations applied to the back, modulated the participants’

perception of force. Interestingly, a ‘creaking’ sound heightened reports of back stiffness when

compared to mobilisations without noise. This emphasises the potential role of peripheral and

central neural mechanisms in protecting and guarding the spine from perceived harmful

movement (Moriarty et al., 2011; Wallwork et al., 2017). This is also in line with the current

understanding of how contextual variables may influence an individual’s pain experience

(Moseley & Arntz, 2007). According to Moseley and Butler (2015) pain represents a protective

mechanism rather than an indicator of tissue damage. It follows then, that stiffness,

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just like pain is an unpredictable sensation that may cause an individual to protect and guard

the spine from further injury (Stanton et al., 2017).

Historical evolution of stiffness

Early work represented stiffness from a classical mechanics perspective in the field of

physics, where Robert Hooke, an English physicist, made a significant contribution to the

understanding of springing bodies. Hooke described that the force or power of an elastic body

“to restore itself to its natural position is always proportionate to the distance …” (Hooke, 1678,

p. 4). Subsequently, this came to be known as ‘Hooke’s law’ of elasticity and can be expressed

by; 𝐹𝑠 = −𝑘𝑥. Here, (𝐹𝑠) is the force applied to the spring, (𝑥) is the displacement of the spring,

and (𝑘) is the spring constant. This mathematical expression has been used to describe the

relationship between the force and displacement.

In engineering, stiffness is often used to characterise structural materials. Here, stiffness

has been defined as “a measure of a material’s resistance to elastic deformation” (Askeland &

Wright, 2015, p. 219). Because structural materials consist of an ‘area’ that must be accounted

for, the concepts of stress and strain were introduced. However, stress cannot be measured

directly, thus can only be inferred from the measure of strain and a constant known as Young’s

modulus (Askeland & Wright, 2015). The relationship between stress and strain has been

expressed by Heindl and Mong, (1936) as 𝑆𝑡𝑟𝑒𝑠𝑠 = 𝑙𝑜𝑎𝑑

. Here,

𝑆𝑡𝑟𝑎𝑖𝑛 𝑑𝑒𝑓𝑜𝑟𝑚𝑎𝑡𝑖𝑜𝑛 𝑝𝑒𝑟 𝑢𝑛𝑖𝑡 𝑜𝑓 𝑙𝑒𝑛𝑔𝑡ℎ 𝑋 𝑎𝑟𝑒𝑎

the deformation is a measure of the strain and relates to a change in the configuration of an

elastic structure, which is different from that of the original ‘unloaded’ configuration

(Baumgart & Cordey, 2000).

Although the concepts of stiffness related to structural material initially emerged in

physics and engineering, it has been extensively characterised in the field of biomechanics.

Here, stiffness has been used to describe the response of biological systems to mechanical

5

loading (Latash & Zatsiorsky, 2016). Stiffness appears to be synonymous with the relationship

between load and displacement and is expressed as 𝑆𝑡𝑖𝑓𝑓𝑛𝑒𝑠𝑠 = 𝐿𝑜𝑎𝑑

. Here, spinal 𝐷𝑖𝑠𝑝𝑙𝑎𝑐𝑒𝑚𝑒𝑛𝑡

stiffness can be calculated by dividing the load by the displacement.

Load is a vector quantity that is specified in terms of ‘magnitude’ and ‘direction,’ for

which Newton (N) is the unit of measurement. The load is described in terms of an applied

‘force’ or ‘moment’ (Ashton-Miller & Schultz, 1991). There are six possible orthogonal ‘load’

configurations related to the applied forces (i.e., anterior/posterior shear, left/right shear, and

axial compression/tension), moments, or torsions (i.e., flexion/extension, right/left lateral

bending, and clockwise/counter-clockwise axial torsion) (Ashton-Miller & Schultz, 1991;

Panjabi et al., 1986).

Displacement is a vector quantity specified in terms of the distance between the initial

position and the final position. The unit of measurement for displacement is millimetres (mm).

The displacement is described in terms of a ‘translation’ or ‘rotation’ (Ashton-Miller & Schultz,

1991; Panjabi et al., 1986). There are three possible points in the spinal motion segment, where

the displacement can be measured in terms of ‘translations’ (i.e., anterior, lateral, cranial) and

rotations (flexion, lateral bending and axial torsion) (Ashton-Miller & Schultz, 1991).

The term ‘stiffness’ and its related constructs are broadly recognised across the

biomechanical literature. Subsequently, the concept of stiffness has come into common usage

within the clinical context. In particular, it is evident that clinicians have adopted the term

‘stiffness’ to describe palpatory findings (e.g., the resistance of joints to movement) during the

physical examination (Latash & Zatsiorsky, 2016; Maher & Adams, 1995). In clinical practice,

stiffness is often used interchangeably with other alternative descriptors (i.e., synonyms and

antonyms) such as ‘resistance’ and ‘hypomobility’ during manual segmental assessment (see

Appendix G: Alternative descriptors). However, the adoption of biomechanical terminology to

6

describe findings during manual spinal assessment, appear to be ambiguous, inconsistent and

poorly defined, bringing their clinical utility into question (Lee et al., 2005; Maher, Latimer, et

al., 1998). This raises several issues. First, it is difficult for researchers to obtain valid and

reliable data when investigating manual spinal assessment. Second, the way stiffness is defined

has implications for how it is assessed in clinical practice. For example, it may make it difficult

to assess the impact of clinical interventions adequately. Third, it may impede clear

communication with the patient. For example, what clinicians describe as stiffness during

manual spinal assessment, may not reflect how stiffness is described or experienced by patients.

Finally, and most importantly, it may have therapeutic consequences and lead to ineffective

management of patients that present with stiffness in the clinic.

Considerations for primary care

Although a majority of patients present to primary care settings because of pain, some

patients may also consult their general practitioner because of pain and accompanying stiffness

(Almoallim et al., 2017). Spinal stiffness may be a symptom and potentially important clinical

indicator of disease (Amine et al., 2010; de Schepper et al., 2012). For example, morning

stiffness is characteristic of inflammatory conditions affecting the spine such as Ankylosing

Spondylitis and osteoarthritis (de Schepper et al., 2012; Sengupta & Stone, 2007), whereas a

stiff neck may be associated with Meningitis (Bachan et al., 2018). Although patients often

consult their general practitioner for spinal stiffness or pain, they may also seek the advice of

rehabilitative healthcare professionals, such as physiotherapists, osteopaths, and chiropractors

as they believe that clinical interventions may help alleviate stiffness or pain (Bishop et al.,

2013; Goodsell et al., 2000).

Considerations for rehabilitation

Stiffness is a common clinical feature associated with musculoskeletal conditions

affecting the spine, such as the neck, and lower back (Tomczyszyn et al., 2018; Yadla et al.,

7

2008). A key component of the consultation should be to precisely understand what patients

are referring to when describing stiffness in their presentation. Most importantly, clinicians

need to identify which aspects of the description and what features of the presentation are

relevant, when considering what stiffness means in the context of each individual patient.

Therefore, it is critical that clinical stiffness is clearly defined to assist clinical decision-making

processes. Failure to do so may lead to inappropriate interventions that do not alleviate

symptoms or improve functional impairment, negatively affecting patient outcomes.

Another important component of the consultation is the physical examination of the

spine. This may include both active and passive range of motion assessments (Maitland et al.,

2005; Wong & Kawchuk, 2017). Clinicians may use (static) manual assessment of the spine as

a part of the clinical examination to make a judgement about the patient’s stiffness (Maher et

al., 1999). This involves a clinician-applied force to a spinal landmark (i.e., spinous process or

articular pillar) at the spinal region(s) (e.g., lumbar or thoracic) of interest (Viner & Lee, 1995;

Wong & Kawchuk, 2017). The manual diagnosis of spinal stiffness may constitute the basis

for clinical decision making on where to apply manual therapy interventions (Koppenhaver et

al., 2014).

Manual therapy is a non-pharmacological management option for the treatment of

spinal related stiffness and is used by a wide range of rehabilitative healthcare professions

including, but not limited to physiotherapy, osteopathy, and chiropractic. Manual therapy has

been defined as “the use of hands in a curative and healing manner or a hands-on technique

with therapeutic intent” (Lederman, 2005). Manual therapy has also been defined as “the

application of therapist-applied manual forces in procedures intended to modify the quality

and range of motion of the target joint and soft tissue structures” (Abbott et al., 2009, p. 6).

Throughout this review, the term ‘clinician’ is used to describe any rehabilitation healthcare

professional who may or may not utilise manual therapy as a part of clinical interventions and

8

management of patients with spinal stiffness.

Manual therapy generally involves the application of passive movement/force to

joints (i.e., mobilisation and manipulation), muscles (i.e., soft tissue inhibition/sustained

stretching, muscle energy techniques), and neural tissues (i.e., neurodynamic interventions)

(Clar et al., 2014). Many different theories have been proposed to explain the physiological

and psychological mechanisms and clinical effects associated with manual therapy

interventions (Bialosky et al., 2011; Cook, 2011; Stamos-Papastamos et al., 2011). In a

recent study by Bialosky et al. (2018), the multifactorial mechanisms through which manual

therapy interventions exert their effectiveness are emphasised. This study highlighted the

importance of biomechanical and neurophysiological mechanisms that underpin the mode

of action of manual therapy techniques that are utilised in the clinical context.

There is a large volume of published studies describing the role of Spinal Manipulative

Therapy (SMT) and mobilisations in the management of patients with spinal stiffness

(Campbell & Snodgrass, 2010; Lascurain-Aguirrebena et al., 2016; Lee et al., 1993; Shum et

al., 2013; Stamos-Papastamos et al., 2011). It has been suggested that a relationship exists

between pain, reduced movement and abnormal spinal joint stiffness (Maher & Latimer, 1992).

Clinically, facet joints that are identified as stiff may be considered candidates for High-

Velocity Low Amplitude (HVLA) techniques (Fernández-de-las-Peñas et al., 2005). HVLA is

one type of SMT where a clinician-applied high-velocity low-magnitude force is exerted on a

spinal motion segment at the end of the joint range. The application of HVLA often creates

increased joint surface separation resulting in a fluid cavitation (audible ‘crack’) (Campbell &

Snodgrass, 2010). Therapeutic rationales that underpin the application of SMT relate to a

reduction in spinal stiffness, increase in segmental motion, and reduction in pain (hypoalgesia)

(Colloca & Keller, 2001; Fritz et al., 2011).

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The importance of measuring stiffness

Objective and subjective measures comprise a diverse range of tools, instruments or

scales utilised in the assessment of clinical phenomena (variables) that are meaningful to

patients, assist clinical decision-making processes, and assist in the development of measures

for research purposes (Rothstein, 1989; Soobiah et al., 2019). To determine whether a measure

is objective, reliability may be assessed to see if a repeated measure provides consistent results

(Elasy & Gaddy, 1998). Reliability estimates may be used to indicate the degree of error

associated with a measure (Rothstein, 1989). To determine if an objective measure is useful for

making inferences about a specific variable, it is important to assess the extent to which an

instrument measures what it claims to measure; its validity (Elasy & Gaddy, 1998).

For this review, the term ‘objective’ will describe the data-driven (quantitative)

approaches used to quantify the biometric characteristics of spinal stiffness. The adjectives

objective and subjective have also been used to describe the quality of a measure rather than

the phenomena being measured (Rothstein, 1989). For example, stiffness is a subjective

phenomenon that could, in theory, be objectively measured if it has been demonstrated to be

reliable and valid. However, for this review, the term ‘subjective’ is used to indicate measures

based on an individual’s perception or experience of spinal stiffness.

Objective measures of spinal stiffness

Stiffness is a fundamental concept in biomechanics used to evaluate structural and

functional characteristics of the spine (Oxland, 2016). In general terms, stiffness is tested by

the application of a load and observing the displacement response (behaviour, relationships or

characteristics). Objective spinal stiffness measures may provide important biometrics relating

to stiffness of the spine and surrounding structures. Spinal stiffness has been extensively

characterised in the field of biomechanics. Biomechanical studies utilise mechanical

instruments to assess the in-vitro stiffness properties of cadaveric Functional Spinal Unit (FSU)

10

specimens. The motion segment or FSU is defined as two adjacent vertebrae, the intervertebral

disc, the facet joints, and the spinal ligaments (Oxland, 2016). The FSU has been defined as

“the smallest motion segment of the spine and exhibits biomechanical characteristics similar to

that of the entire spine” (Benzel, 2012, p. 45). The FSU exhibits 6 degrees of freedom; three

linear directions and three rotations (Panjabi et al., 1986). During biomechanical testing, a load

or force vector is applied, and the relative displacement between the vertebrae of the FSU is

measured. Various quantitative approaches can be used to generate load-displacement graphs

which represent visual interpretations of the load-displacement responses, where the Y-axis

represents the load application, and the X-axis represents the displacement response.

A wide range of mechanical instruments have been developed to assess spinal stiffness

in human subjects. Instrumented measurements were operationalised in an attempt to offer

better consistency and reliability of spinal measures of stiffness (Stanton & Kawchuk, 2009),

as opposed to manual measures of spinal stiffness which have been shown to be affected by

relatively poor reliability (Snodgrass et al., 2006; Stanton & Kawchuk, 2009; Wong &

Kawchuk, 2017). The two main types of instruments are mechanical and mechanically assisted

methods of indentation; which employ similar basic operations and mechanisms of assessment.

Objective measurements of stiffness are obtained by the application of an instrumented

posterior to anterior (P-A) load at the target motion segment resulting in a force and

displacement response data generated by various customised computer software programs. A

standard mechanical spinal stiffness- testing device generally consists of an indentor, which is

a cylindrical instrument that contacts the target spinous process. The indentor is driven by a

motor or a pulley system that controls the upward and downward movement of the indentor.

(Wong & Kawchuk, 2017). The load cell generally, consists of a strain gauge and transducer,

which converts compression and tension forces into electrical signals that can be measured and

standardised. Load cells quantify the indentation forces (N) that are pre-determined, and the

displacement sensor quantifies the indentor displacement (mm) (Wong & Kawchuk, 2017).

11

The test-retest reliability of mechanical spinal stiffness measurements in humans has been

reported to be high (Wong & Kawchuk, 2017), yet their invasiveness, size, complex operation,

and low ecological validity limits their clinical utility.

Subjective measures of spinal stiffness

Subjective measures of stiffness can be obtained from the clinician’s perspective during

the physical examination (e.g. palpation), often referred to as the objective examination with

reference to the acronym: SOAP – Subjective, Objective, Assessment, and Plan (Fruth, 2017).

For the purpose of this review, clinician-reported measures are referred to as ‘subjective

measure of spinal stiffness’. One of the most common forms of manual spinal assessment

reported in the literature is the P-A central pressure test. This involves the application of a P-A

oscillatory force to the spine of a prone patient to assess the perceived vertebral movement and

its resistance, (i.e., spinal stiffness) (Maitland et al., 2005). P-As are intended to localise and

assess the dysfunctional intervertebral movement, whereby the clinician forms a subjective

impression of the P-A movement response to load (Kiviniemi et al., 2001). The information

gained from the clinical examination may be used to determine the spinal levels that may benefit

from treatment and facilitate decisions of where to apply manual techniques.

An important consideration when assessing PA movement is the contribution of

stiffness from adjacent vertebral segments. The PA test is not a direct test of the stiffness of a

motion segment and has been interpreted as a passive test of the stiffness of the entire lumbar

spine in three-point bending (Lee & Evans, 1997). During the application of the PA force at

12

the target spinous process, (i) the pelvic reaction force can be assumed to be acting through the

anterior superior iliac spines, (ii) the vertebral segment above is subjected to an extension

moment, and posterior shear force, and (iii) the vertebral segment below is subjected to

extension moment and anterior shear force. Thus, the application of the PA force can be

considered as a three-point bending relationship between the target motion segment and

adjacent motion segments during PA segmental assessment (Lee & Evans, 1997).

The patient’s perspective may be obtained during the case history and by the use of

various self-report and Patient-Reported Outcome Measures (PROMS). The most common

self-reported outcome measure identified in the literature appears to be the adaption of pain

rating scales, such as the Visual Analogue Scale (VAS) and Numerical Rating Scale (NRS) for

the assessment of spinal stiffness intensity (severity) and duration. The VAS may be

represented as a 6, 11 or 101-point scale, which is generally anchored by a verbal description.

For example, The VAS has been used to obtain participants’ subjective symptoms of neck

stiffness on a 6-point scale (0–5), where 0 indicated that patients did not feel any neck stiffness

and 5 indicated that patients were acutely aware of neck stiffness (Akagi & Kusama, 2015).

The NRS has also been adapted by studies for the assessment of stiffness and required the

respondent to rate their stiffness on a scale accompanied by a verbal description. For example,

participants’ subjective measure of stiffness was established by asking participants to report

how they ‘felt’ ranging from “not stiff at all” to “most stiff imaginable’’, scored from 0 – 100

(Stanton et al., 2017).

In summary, self-report measures have been used to assess stiffness from the patient’s

perspective. The most common approach is the adaption of simple pain rating scales such as

the NRS and VAS, which allow for a self-assessment of stiffness intensity and duration.

However, these self-report measures may be argued to represent a unifocal understanding of

the patient’s experience of stiffness. There is evidence to suggest that the clinical concept of

13

spinal stiffness is multifactorial and is unlikely to be satisfactorily rated on a single scale

(Maher & Adams, 1995). A similar view is supported by Williamson and Hoggart, (2005) in

the context of pain rather than stiffness, but nonetheless points out the limitations of only

including unidimensional aspects of pain (e.g., intensity).

Patient-reported outcome measures (PROM) are tools or instruments that can be used

to measure the patients’ health outcomes. PROMs can be used to gather information about the

patients’ symptoms, function or overall wellbeing (Nelson et al., 2015). Disease-specific

PROMs are designed to identify specific symptoms, disease activity and assess their impact on

function (Weldring & Smith, 2013). For example, the Bath Ankylosing Spondylitis Disease

Activity Index (BASDAI) is a six-item self-administered questionnaire that includes a subset

of questions relating to symptoms of morning stiffness. Questions about the severity and

duration of stiffness are presented on a VAS accompanied by verbal descriptor “How would

you describe the overall level of […]” (Cardiel et al., 2003). Specific questions that relate to

stiffness are included in two items within the BASDAI which ask the patient about their

morning stiffness duration and severity (Sengupta & Stone, 2007).

Another PROM specific for assessing postoperative complications following lumbar

spinal fusion is the Lumbar Stiffness Disability Index (Hart, Gundle, et al., 2013). This tool

consists of 10 questions specifically designed to assess the impact of functional limitations

following surgery. This PROM adapted items from the Activities of Daily Living scale, which

is used to assess routine aspects of self-care tasks necessary for managing basic physical needs

such as getting out of bed, bathing and showering, personal hygiene and grooming, dressing,

and toilet hygiene (Hart, Pro, et al., 2013; Mlinac & Feng, 2016). One reason for including an

assessment of Activities of Daily Living, is because functional limitations and a loss of mobility,

independent of pain, can cause difficulties for patients to perform certain Activities of Daily

Living (Hart et al., 2014).

14

Conclusion

Primary healthcare professionals have an essential role to play in assessing and

managing patients presenting with spinal stiffness in the clinic. Despite this, it appears that the

term ‘stiffness’ is often used implicitly and without clear explication of its meaning (Latash &

Zatsiorsky, 2016; Maher, Latimer, et al., 1998). As a consequence, there may be considerable

confusion regarding the applicability of the term stiffness in the clinical context. Self-reported

subjective stiffness measures have often been used in conjunction with objective measures of

stiffness in clinical research. However, a growing body of literature suggests that subjective

measures may not correlate well with objective measures of stiffness (Haigh et al., 2003;

Karayannis et al., 2013; Stanton et al., 2017). This indicates a need for more clarity regarding

the use of definitions and what types of objective and subjective measures are being used in

research. Most importantly, an emphasis should be placed on how these definitions and

measures may inform clinical decision-making processes. At present, there appears to be no

clear definition, nor is there a “gold standard” measure of spinal stiffness that is representative

of the clinical context. Therefore, more research in this area is needed.

15

Section 2: Methodology

16

Philosophical perspective

The two main philosophical approaches employed in scientific research are

constructivism and positivism. Positivism emphasises objectivity, experimentation, and

generalisability, in contrast to constructivism, which emphasises constructed realities,

interaction with participants, and rich description (Mertens, 2019). Contained within these two

paradigms are theoretical and philosophical assumptions about the way knowledge is

constructed and understood. The constructivist paradigm proposes that reality is socially

constructed from subjective accounts and perceptions that explain how the world is experienced

by individuals (Mertens, 2019). By contrast, positivism is grounded in a rationalistic, empiricist

philosophy, which proposes that absolute truth can be uncovered and known with certainty by

scientists (Gordon, 2016; Mertens, 2019).

The underlying philosophy guiding this review is positivism; which calls for a scientific

approach to research based on verifiable data that can be observed and accounted for by

empirical evidence. Positivism is grounded in empiricism, and from an epistemological

perspective is one of several sources of knowledge that claims all knowledge is derived from

the senses (Gordon, 2016). Empirical research is determined through observation or

experimentation, whereby conclusions are logically drawn from empirical data rather than from

theoretical construction or belief (Allen, 2017; Gordon, 2016). The positivist paradigm aligns

with the empirical approach to research and is a suitable way to frame the theoretical-

methodological framework for the design of the present project.

The scoping review methodology is particularly appropriate to meet the purpose and

address the objective(s) of this study. In particular, this review seeks to understand

generalisable knowledge about spinal stiffness based on the objective data identified in

empirical literature, providing a comprehensive account of what forms the basis of clinical

knowledge regarding spinal stiffness. This is a critical first step in understanding what is

17

actually known, what is generally accepted, and the current state of thinking around defining

and measuring spinal stiffness in the literature. The following section will establish how the

chosen methodology – scoping review, is situated within the evidence hierarchy.

One major challenge that researchers are presented with when undertaking a review of

the literature is the difficulty in adopting a suitable study design and framework in which to

structure their review (Noble & Smith, 2018). An extensive range of different types of literature

reviews can be used to summarise the current state of the existing literature. Scoping reviews,

in particular, are a useful methodology for mapping the literature and clarifying key concepts

and definitions, as well as identifying outcome measures used in the broader context. For this

scoping review, providing clarity regarding how the term stiffness is defined and measured is

an important gap in the literature. This can be demonstrated by the fact that a search for a

definition of pain reveals important guiding documents, including consensus statements and

standardised definitions. However, a search for a definition of stiffness reveals neither a

consensus statement nor a standardised definition. Therefore, the question of ‘what’ needs to

be asked, before the questions of ‘how’ and ‘why’ can be addressed. To illustrate this,

Randomised Controlled Trials are generally conducted to evaluate the cause-effect relationship

that exists between a specified treatment and outcome (Spieth et al., 2016). However, in cases

whereby, the outcome variable (e.g., stiffness) has not having been clearly defined, it would be

difficult to meaningfully investigate the cause-effect relationship within this specific

population group.

Conducting a systematic review of the literature around a topic with no clear definition

is similarly less feasible. This is because systematic reviews require a highly focused clinical

question (Noble & Smith, 2018). Systematic reviews are often used to evaluate interventions

and combine the results of several empirical studies to give a more reliable estimation of an

intervention’s effectiveness (Centre for Reviews and Dissemination., 2009). The problem with

18

undertaking a systematic review at present is the lack of a clear definition of stiffness. Therefore,

leading to difficulties in combining results and interpreting findings in a meaningful way.

Comparison of key characteristics of scoping reviews and systematic reviews

According to Mays et al (2001, p. 194) “scoping reviews aim to map rapidly the key

concepts underpinning a research area and the main sources and types of evidence available”.

Arksey and O’Malley (2005) expanded on this definition, describing four reasons a scoping

review may be undertaken: (1) to examine the extent, range, and nature of research evidence;

(2) to determine the value of undertaking a full systematic review; (3) to summarise and

disseminate research findings, and (4) to identify research gaps in the existing literature.

Colquhoun et al. (2014, p. 1292) has recommended the following definition: “a scoping

review is a form of knowledge synthesis that addresses an exploratory research question aimed

at mapping key concepts, types of evidence, and gaps in research related to a defined area or

field by systematically searching, selecting, and synthesising existing knowledge”. This builds

on Mays et al., (2001) definition and the descriptions provided by Arksey and O’Malley (2005)

providing a more succinct definition that relates to the methodology, but also describes key

differences that make scoping reviews distinct from other forms of knowledge syntheses

(Colquhoun et al., 2014). Scoping reviews follow similar processes as systematic reviews, both

employing transparent and rigorous methods to identify and analyse the literature relating to a

research question (DiCenso et al., 2010).

Systematic and scoping reviews both aim to provide a summary of the existing literature

on a specific topic and share some methodological features such as they employ a systematic

approach to reviewing the literature. However, the nature and purpose of the research question

is distinctively different. Crucially, systematic reviews aim to provide an in-depth summary

and synthesis of high-quality evidence concerning a specific topic against a predefined research

19

question and selection criteria (Munn et al., 2018). By contrast, scoping reviews allow for more

general questions and exploration, aiming instead for breadth rather than depth of a topic

(Peterson et al., 2017; Pham et al., 2014). Scoping reviews allow for more flexibility and

encourage the researcher to be more reactive to what presents itself in the literature.

Additionally, the scoping review method involves the identification of all relevant literature by

enabling ongoing modifications to search terms or methods throughout the review process

(Arksey & O’Malley., 2005).

Scoping reviews may be used for ‘reconnaissance’ to clarify key concepts or definitions,

identify key characteristics or factors relating to a concept, identify trends or gaps, and inform

future research (Levac et al., 2010; Munn et al., 2018; Peters et al., 2015). Scoping reviews may

be used to address broad topics which include a variety of study designs and methodologies and

to explore a field of research that has not been comprehensively reviewed (Pham et al., 2014).

Arksey and O’Malley (2005) have proposed a methodological framework for the

conduct of scoping reviews. This has been further refined by the Joanna Briggs Institute (2015),

with the addition of more recent innovations and enhancements to the scoping review

methodology. Although no definitive method of scoping reviews exists, there have been

recommendations by several authors to develop a standard methodology for scoping reviews

(Colquhoun et al., 2014; Dwan et al., 2008; Tricco et al., 2016). In response to this, Tricco et

al (2018) developed a reporting checklist to assist researchers in conducting scoping reviews.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for

Scoping Reviews (PRISMA-ScR) was developed by an expert panel of authors to guide the

reporting of scoping reviews. This checklist provides guidelines using explicit methods to

guide the reporting of scoping reviews.

20

Specifically, the original PRISMA statement was adapted with the following revisions:

five items from the original PRISMA were removed because they were deemed not relevant for

scoping reviews. For example, risk of bias across studies is not included as the scoping review

method is not intended to be used to critically appraise (or appraise the risk of bias of) a

cumulative body of evidence. Two items were deemed optional, (i.e., critical appraisal of

individual sources of evidence and critical appraisal within sources of evidence) and the

wording was modified for all items (Tricco et al., 2018). This reporting guideline is consistent

with the Joanna Briggs Institute (2015) Guidance for Scoping Reviews, which highlights the

importance of methodological rigour in the conduct of scoping reviews. Despite advances in the

scoping review methodology and the addition of frameworks, reporting guidelines and

checklists, several limitations still exist.

The lack of methodological quality appraisal of the evidence typical of scoping reviews

has been reported as a potential limitation (Peters et al., 2015). However, it has been suggested

by Arksey and O’Malley (2005) that critical appraisal is not an essential aspect of scoping

reviews. Additionally, current reporting guidelines include critical appraisal within sources of

evidence as an ‘optional’ component for the conduct of scoping reviews (Tricco et al., 2018).

This scoping review did not include a quality appraisal as it was intended to provide an

overview of the existing evidence regardless of the methodological quality or risk of bias

(Peters et al., 2015).

Methodological approach

Arksey and O’Malley (2005) have described a five-stage descriptive, analytical

framework which was followed in this scoping review. Specifically, framework stages one

(identifying the research question) through to framework stage five (charting the data) with the

option to include a sixth consultation stage. The five stages, as proposed by Arksey and

O’Malley, are as follows: (1) Identifying the research question, (2) Identifying the relevant

21

studies, (3) Study selection (4) Charting the data Stage, (5) Collating, summarising and

reporting the results, and (6) (optional): Consultation. The six stages, as recommended by

Arksey and O’Malley, are explained below in the context of this thesis.

Framework Stage 1: Identifying the research question

The first stage involves the identification of a research question. Arksey and O’Malley

(2005) acknowledge the need to maintain a broad scope, as the primary focus is to summarise

the breadth of evidence available on the selected topic (Levac et al., 2010). The present scoping

review broadly examined the extent, nature and range of ‘definitions and measures of objective

and subjective spinal stiffness reported in the literature’. This question facilitated the mapping

of ‘definitions’ and ‘measures’ of ‘subjective’ and ‘objective’ spinal stiffness in the literature.

Framework Stage 2: Identifying the relevant studies

The second stage involved the identification of all relevant studies that addressed the

research question. During this stage, decisions were made regarding the most appropriate

databases to use and consideration of the search terms used for the development of the search

strategy. Due to the need to execute a broad search strategy, consideration was given to the

limitations and resource constraints, such as, availability of supervisory team, resources

available to the researcher and the time frame available to complete this research. In line with

recommendations by Levac et al (2010), the supervisory research team of the present project

consisted of members with topic-specific, clinical and methodological knowledge.

Grey literature

It is often appropriate to include both published and unpublished grey literature in a

scoping review (Joanna Briggs Institute, 2015). However, this is irrelevant for the present

review due to only including peer-reviewed empirical literature. Furthermore, the lack of peer-

review typical of grey literature may have adversely affected the uptake and relevance of the

findings presented in this review (Levac et al., 2010).

22

Clarification of terminology

Arksey and O’Malley (2005) indicate the importance of defining terminology from the

outset of the scoping review due to the possibility that the search strategy may return a large

number of irrelevant studies that do not address the guiding research question. Despite this

recommendation, the current review did not include an operational definition of stiffness as the

review sought to identify what definitions are available. Additionally, it was determined that

the spine would not be operationally defined at the outset of the study. This was due to wanting

to begin with a broad search and encourage the researcher to be reactive to what presents itself

in the literature. As the researcher became more familiar with the available data, it became

apparent that it would be beneficial to define the spine in order to avoid including irrelevant

literature that did not contribute to the representativeness of the overall spine in the clinical

context.

After screening through the biomechanical literature, it was evident that most studies

agreed the FSU constituted the smallest motion segment unit of spine that exhibits similar

biomechanical characteristics to that of the overall spine (Panjabi et al., 1986). Therefore, an

informed decision was made to operationally define the spine in order to limit search results to

studies that described spinal stiffness in the context of the characteristics of the overall spine.

The spine was operationally defined as the vertebrae of the cervical, thoracic, lumbar, sacral

and the coccygeal regions along with the intervertebral discs, ligaments, rib cage, and spinal

musculature (Oxland, 2016). For the purpose of this review, The FSU was operationally

defined as “two adjacent vertebrae, the intervertebral disc, the facet joints, and the spinal

ligaments” (Oxland, 2016).

23

Framework Stage 3: Study selection

The third stage involved the selection of studies relevant to the research question.

According to Arksey and O’Malley (2005) arriving at search criteria is considered to be an

iterative process which enables a comprehensive coverage of the literature. For this review,

priori eligibility criteria were established before the commencement of the study selection

process. During the study selection, modifications were made to the eligibility criteria and are

explained in the methods section. A potential limitation during the screening of studies was the

inherent subjectivity associated with interpreting the eligibility criteria. A strategy employed

to minimise inconsistencies in the selection of studies in this review was the use of two

independent reviewers. Additionally, pilot-testing was conducted by two reviewers, and the

selection consistency and agreement score were calculated to assess the inter-rater reliability

between the two reviewers (see Appendix D: Interrater agreement).

Framework Stage 4: Charting the data

The abstraction of data for a scoping review is often referred to as ‘charting the results’.

Generally, the data charting includes a mixture of general information about the study and

specific information relating to, for instance, citation details, key definitions, and outcome

measures employed (Arksey & O’Malley, 2005). For this review, key data items were extracted

and documented according to their relevance to the guiding question and objectives of the

review (Levac et al., 2010; Peters et al., 2015) (see Appendix E: Data Items). A data table was

developed to chart the relevant data and was summarised according to the themes that were

identified (see Appendix F: Data abstraction tables). This enabled the identification of key

definitions and subjective and objective measures of spinal stiffness to be identified in the

literature. The data was abstracted based on the relevant study characteristics that related to

definitions and measures of spinal stiffness.

24

Framework Stage 5: Collating, summarising and reporting the results

Due to the potentially large volume, breadth, clinical and methodological diversity of

studies that may be included in a scoping review, Arksey and O’Malley (2005) recommend a

variety of numerical and narrative methods that can be employed during this stage. For this

review, the studies identified were analysed according to themes utilising an informative

summary approach (see Appendix F: Data abstraction tables). This aligned with the purpose

and objectives of this present review and allowed the reporting of informational contents of

definitions and measures of subjective and objective spinal stiffness for the data items included.

This method was further refined towards the end of this review when there was better awareness

of and familiarity with the contents of included studies, in line with recommendations from the

Joanna Briggs Institute (2015).

Framework Stage 6: (optional) Consultation

According to Arksey and O’Malley (2005) stage six is considered an optional

component of scoping reviews. In contrast, the Joanna Briggs Institute (2015) recommends

adopting consultation as a required component of the scoping review methodology. However,

there appears to be agreement that there should be a clearly established purpose for consultation

(Arksey and O’Malley, 2005; Levac et al., 2010).

This preceding section described the methodological approach, outlining the basic

tenets of the positivist perspective, describing how this scoping review is situated within the

evidence hierarchy, and providing a comprehensive outline of the framework proposed by

Arksey and O’Malley (2005) as it applies to the scoping review presented as part of this Masters

thesis.

25

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Section 3: Manuscript

Note to the reader: This manuscript has been prepared according to the guidelines for

Archives of Physical Medicine and Rehabilitation, available here:

https://doi.org/10.1016/S0003-9993(09)00368-2

https://doi.org/10.1016/S0003-9993(09)00368-2

40

Defining and measuring objective and subjective spinal stiffness: A

scoping review

Joel R. Moses1, Sylvia Hach1, Jesse Mason1

1School of Community Studies, Unitec Institute of Technology, Auckland, New Zealand

Running Head: Defining and measuring objective and subjective spinal stiffness

Acknowledgements

We would like to thank Dipti Vora, Library Knowledge Specialist, for her guidance in the

development of the search strategy. “The authors declare no conflicts of interest”.

Corresponding Author:

Joel Moses, School of Community Studies,

Unitec Institute of Technology,

Auckland, New Zealand

[T] +64-274395635

[E] [email protected]

mailto:[email protected]

41

Abstract

Objective: To examine and identify the breadth of definitions and measures of objective and

subjective spinal stiffness in the literature, with a focus on clinical implications and research

opportunities.

Data Sources: Eligible peer-reviewed studies were identified using PubMed, Ebsco health,

and Scopus electronic databases.

Study Selection: Inclusion criteria included human subjects, English language, no date

restrictions, studies that reported (a) definition(s) or included subjective or objective outcome

or experience measures or indicators of spinal stiffness (no date restrictions). Exclusion criteria

included grey literature, non-spinal stiffness and animal studies.

Data Extraction: Following the 6-step framework by Arksey and O’Malley1 and based on the

eligibility criteria, studies that reported definitions and measures of spinal stiffness were

collected using a data abstraction form and classified into four themes; biomechanical, surgical,

pathophysiological and segmental spinal assessment. Fifteen categories to identify similarities

and differences between studies were generated.

Data Synthesis: Among 2121 records that were identified, 333 met the eligibility criteria.

There were 299 subjective and objective measures (124 subjective;175 objective measures) and

60 indicators of spinal stiffness. The majority of studies (n = 72%) did not define stiffness and

there is no consensus regarding a standardised definition of stiffness in the reviewed literature.

Conclusion: This review highlights the breadth of objective and subjective measures that are

both clinically and methodologically diverse. There was marked variation in the definitions

reported in studies. There were no definitions of stiffness provided alongside self-reported or

patient-reported outcome measures. Stiffness is a clinically important symptom that may

42

indicate the presence of underlying pathophysiology/disease which has implications for

patients’ health outcomes. An important distinction should be made between the patient’s

subjective reports of stiffness and this may differ from objective clinical assessments.

Keywords: Spinal; Stiffness; Musculoskeletal; Rehabilitation; Biomechanics.

Highlights

► Only 36% of the studies reported a more or less explicit definition of stiffness.

► There is no consensus regarding a standardised definition of stiffness in the reviewed

literature.

► There are no definitions of stiffness provided alongside self-reported or patient-reported

outcome measures.

► The relationship between subjective and objective measures of stiffness is not well

established.

► Stiffness is a symptom that may indicate the presence of underlying pathophysiology.

43

List of abbreviations

FSU – Functional Spinal Unit

L-D – Load-displacement

F-D – Force-displacement

PROM – Patient-reported outcome measure

BASDAI – Bath Ankylosing Spondylitis Disease Activity Index

LSDI – Lumbar Spinal Disability Index

VAS – Visual Analogue Scale

P-A – Posterior to anterior

44

Introduction

Spinal stiffness has been extensively characterised in the biomechanical literature,

where it is most often synonymous with the relationship between load and displacement. This

broad description of stiffness has been applied to a wide range of different research contexts;

however, its clinical relevance remains unclear. Stiffness is a common clinical feature

encountered in rehabilitative settings and may indicate the presence of underlying

pathophysiology/disease.2–4 In routine clinical practice, stiffness may be assessed by clinicians

using a range of manual segmental assessment techniques.5 This generally involves a clinician-

applied posterior to anterior (P-A) force directed at the spine of a prone patient to assess the

perceived intervertebral movement.6

The clinical assessment of patients that report stiffness is an important aspect of the

consultation. However, communicating with patients about the stiffness they experience may

present a challenge to clinicians, given that the term is often used in a colloquial manner. This

is further complicated by the diverse range of biomechanical terminology used by clinicians

and researchers to describe stiffness, which may not correspond to how stiffness is described

by patients. The lack of conceptual clarity surrounding the use of the term stiffness not only

impedes communication between researchers, clinicians and patients, but has important

implications for clinical assessment and evaluation of patient outcomes.

A wide range of mechanical instruments have been employed for the assessment of

stiffness.7–9 These instruments appear to be highly dependent on experimental approaches,

methods, and operationalisations of stiffness used in these studies. A significant challenge has

been the inability to measure stiffness directly in patients.10–12 Although some attempts have

been made to compare (objective) instrumented measures with patient-reported subjective

measures (subjective), instrumented measures did not correlate well with patient-reported

45

measures of spinal stiffness.10,13 This may be further compounded by inconsistent definitions

provided alongside rating scales used to assess the patient's self-reported stiffness.5

At present, there is no clear definition of spinal stiffness, nor is there a definitive method

of assessment. Given the broad applications of definitions and measures of stiffness, this

scoping review sought to examine and identify what definitions and measures of objective and

subjective spinal stiffness have been reported in the existing literature.

46

Methods

A scoping review methodology according to the framework recommended by Arksey

and O’Malley1 and The Joanna Briggs Institute,14 in conjunction with the reporting checklist

developed by Tricco et al.,15 was used to gather and organise the relevant information that

addressed the broad research question and provided a comprehensive examination of existing

peer-reviewed literature. The objectives of the subsequent review were: (1) to examine the

nature, range and extent of peer-reviewed empirical research to identify definitions and

measures of subjective and objective spinal stiffness, (2) to clarify key concepts and definitions

of spinal stiffness, (3) to describe subjective and objective measures of spinal stiffness, and (4)

to provide an overview of the current literature and practical considerations for clinicians and

researchers. The local ethics committee (Unitec Research Ethics Committee) determined that

a specific ethics application was not required to undertake the present study (see Appendix A;

Ethics notification).

Identification of the research question

This scoping review was guided by the following broad research question: What

definitions and measures of objective and subjective spinal stiffness have been reported in the

literature?

Identification of the relevant studies

The search strategy (developed by the first author with input from a knowledge

specialist and revised by the remaining authors) was applied to PubMed, Scopus, and Ebsco

health database (final search: 20/12/2018). The search terms used were: “stiffness”, “spinal”,

“defin*”, and “measur*”. Two search syntaxes were constructed: [stiffness AND spinal AND

defin*] for definitions, and [stiffness AND spinal AND measur*] for measures of spinal

stiffness (Appendix B: Search strategy).

47

Study selection

Eligibility criteria were established before executing the search, and according to

instructions by Arksey and O’Malley,1 any necessary modifications were implemented as the

review progressed. The inclusion criteria were the following: (1) published peer-reviewed

empirical studies with no date restrictions, (2) studies included combinations of the initial

search terms within the title or abstract, (3) full-text studies available electronically, (4)

published in English, (5) studies that reported (a) definition(s) of spinal stiffness or included

subjective or objective measures or indicators of spinal stiffness, (6) studies that reported

patient/clinician/research outcome or experience measures. Exclusion criteria were as follows:

(1) published or unpublished grey literature, (2) studies investigating non-spinal (e.g., arterial,

hepatic or dermatological) stiffness, and (3) animal studies.

The review process consisted of two levels of screening: (1) a title/abstract/keyword

review and (2) full-text review. For the first level of screening, a title/abstract/keyword

screening template was developed by two of the authors (Appendix C: Screening template).

The first author independently screened titles and abstracts of all articles. All citations from

electronic bibliographic databases were imported into a Microsoft ® Excel (version 1907)

spreadsheet, reviewed against the eligibility criteria and either included, fenced or excluded.

During first level screening, it was noted that studies reported descriptive alternatives or

included surrogate measures that described the properties of stiffness. Thus, eligibility criteria

were modified to: (1) studies that used any term that (in)directly described stiffness, including

surrogate measures of stiffness identified in the initial search syntax. No additional

modifications were made to the initial search syntax as it was determined that the term ‘stiffness’

was sufficient to capture any associated terms or surrogate measures. The identification of these

terms was used to determine whether other terms were semantically linked or were being

conflated with other terminology which (in)directly described stiffness.

48

For the second level of screening, the full texts of studies were independently screened

by the first author to determine their eligibility. Reference lists of studies were manually

searched for other relevant studies. All studies identified during the full-text screen, which met

the inclusion criteria were uploaded to Mendeley Desktop (version 1.19). Two additional

exclusion criteria were implemented at this screening step due to the identification of studies

that were not relevant to the scope of this review: (1) studies that measured stiffness of

exogenous materials (e.g., rod, construct, screw), (2) studies that measured a component of

spinal stiffness, but not the stiffness of components that contributed to overall spinal stiffness.

Components of the spine included local anatomical structures of the Functional Spinal Unit

(FSU) (e.g., intervertebral disc, ligaments, facet joints) and other global contributions to spinal

stiffness (e.g., spinal musculature, intra-abdominal/thoracic pressure, rib cage support). The

reason for excluding components of the spine that do not contribute to overall spinal stiffness

was to improve the representativeness of the biomechanical characteristics of spinal stiffness

as it relates to the clinical utility of measures identified in the literature.

Screening and Agreement

During the first level of screening, studies screened by the first author were tested for

selection consistency. Eligibility criteria were reapplied to 150 studies from both search

strategies and across databases by the second author and demonstrated ‘substantial’ agreement,

according to Vera and Grant16 (Kappa = 0.77, see Appendix D: Interrater agreement).

Remaining discrepancies were resolved by the third author to arrive at a consensus.

Data charting process

Data was abstracted from the relevant studies using a standardised data charting form

(where applicable) on the following characteristics: (1) Citation details, (2) definitions of spinal

49

stiffness, (3) subjective measures of spinal stiffness, (4) objective measures of spinal stiffness,

and (5) indicators of spinal stiffness (Appendix E: Data Items).

Collating and summarising the findings of included studies

Analysing the data

The final 333 studies were assessed for commonalities and differences after gaining

familiarity with the data and were classified into the four themes as follows: (1) biomechanical,

(2) surgical, (3) pathophysiological, and (4) segmental assessment. Studies within each

respective theme were subsequently grouped into fifteen categories (for a summary of data

extracted for each theme and their respective categories, (Appendix F: Data abstraction tables)

Data validation

Validation of study selection into one of the four themes completed by the first author

was achieved through verification of 5% of the total number of articles (17 of total of 333) by

the remaining authors. Subsamples of each theme were selected according to proportional

sampling, whereby the proportion that each theme represented of the total sample were selected

at random for validation. Any discrepancies identified during the audit were discussed by

reviewers until a consensus was reached.

Reporting

Data were analysed by examining and summarising the informational contents of the

abstracted data in relation to the guiding research question and objectives of this review. The

results are presented according to the four themes and their respective categories, using a

descriptive summary of the main findings, condensed and presented in table format.

50

Results

Overall, the search yielded 2,121 studies, of which 1,096 were screened after the

removal of duplicates (see Figure 1). First level (title and abstract) screening excluded 649

studies, and a further 139 studies were excluded following second level (full text) screening. A

further 25 studies were identified during manual searching, which resulted in a total number of

333 studies included for review. Included studies were classified into four themes,

biomechanical, surgical, pathophysiological and segmental assessment, and within each theme,

studies were allocated to a particular category (see Table 1).

Figure 1. PRISMA-scR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses

extension for Scoping Reviews) flow diagram of the search strategy and study selection.15

51

Table 1. Overview of included studies (n=333)

Theme Category Studies included

(n= 333) n (%)

Biomechanical

Functional Spinal Unit 25 (8) Stability 16 (5) Instability 7 (2) Finite element model 22 (7)

Total 70 (22)

Surgical

Clinical biomechanics 20 (6) Intraoperative 14 (4) Postoperative 31 (9) Scoliosis 11 (3)

Total 76 (22)

Pathophysiological Ankylosing Spondylitis 34 (10) Meningitis 10 (3) Systemic causes 7 (2) Spinal pain 16 (5) Other 14 (4)

Total 81 (24)

Segmental Assessment*

Manual segmental assessment† Mechanical segmental assessment‡

106 (32)

Total 106 (32)

*In this case, Segmental assessment refers to both manual and mechanical methods used to assess

spinal stiffness.

†Manual segmental assessment is often referred to as posterior to anterior accessory mobility/motion

testing,6,17 and passive physiological intervertebral motion testing.18

‡Mechanical segmental assessment involves the use of mechanical instruments for the assessment of

spinal stiffness.

52

Overview of study characteristics

In total, 122 (37%) of studies reported (a) definition(s), whereas, 240 (72%) did not

report (a) definition(s) of spinal stiffness. A total of 175 (52.5%) objective and 124 (37%)

subjective measures of spinal stiffness were included in this review. A subset of 60 (18%)

studies included indicators of spinal stiffness. The highest number of indicators (70%) were

included in the pathophysiological theme (see Table 2).

Table 2. Overview of the inclusion of definitions, measures, or indicators of spinal

stiffness as part of the studies included in the scoping review

Theme Defined Not

Defined

Objective

Measures

Subjective

Measures

Indicators

Biomechanical 24 46 63 0 4

Surgical 23 53 39 23 14†

Pathophysiological* 0 81 0 39 42

Segmental Assessment 75 60 73 62 0

Total 122 240 175 124 60

*In the case of the pathophysiological theme, 52% of the studies reported stiffness indicators

primarily related to clinically relevant symptoms.

†Fourteen studies reported symptom (indicators) of stiffness related to postoperative complications.

53

Examining definitions included per categories showed that no definitions were reported

in the ‘pathophysiological’ theme and the post-operative category (see Table 3). The majority

of studies (61%) in the ‘segmental assessment’ theme reported definitions, and some studies

included two distinct definitions related to objective and subjective measures. There was

general variability of studies that defined stiffness between the ‘biomechanical’ and ‘surgical’

categories, although the majority did not define stiffness.

Table 3. Breakdown of studies included in the scoping review by study category and the

inclusion or omission of a definition of stiffness

Theme Category Defined

(n=122)

n = (%)

Not Defined

(n=240) n (%)

Biomechanical

Functional spinal unit 12 (10) 13 (5) Stability 5 (4) 11 (5) Instability 4 (3) 3 (1) Finite element model 3 (2) 19 (8) Total 24 (20) 46 (19)

Surgical

Clinical biomechanics 10 (8) 10 (4) Intraoperative 10 (8) 4 (2) Postoperative 1 (1) 30 (13) Scoliosis 2 (2) 9 (4) Total 23 (19) 53 (22)

Pathophysiological Ankylosing spondylitis 0 (0) 34 (14) Meningitis 0 (0) 10 (4) Systemic causes 0 (0) 7 (3) Spinal pain 0 (0) 16 (7) Other 0 (0) 14 (6) Total 0 (0) 81 (34)


Manual stiffness assessment

Mechanical stiffness assessment

75 (61) 60 (25)

Total 75 (61) 60 (25)

*In the case of segmental assessment, a subset of studies reported both quantitative and qualitative

definitions when comparing subjective and objective measures of spinal stiffness

54

Examining stiffness measures included per categories showed that only objective

measures were included in the ‘biomechanical’ theme categories. However, the ‘segmental

assessment’ has the highest number of objective measures when compared to other categories.

Only subjective measures were included in the ‘pathophysiological’ theme categories and the

postoperative category. However, the ‘segmental assessment’ theme included the highest

number of subjective measures overall (see Table 4).

Table 4. Breakdown of studies included in the scoping review by study category and the

inclusion or omission of objective or subjective measures of stiffness

Theme Category Objective

Measures

(n=175) n (%)

Subjective

Measures

(n=124) n (%)

Biomechanical

Functional spinal unit 25 (14) 0 (0) Stability 12 (7) 0 (0) Instability 4 (2) 0 (0) Finite element model 22 (13) 0 (0) Total 63 (36) 0 (0)

Surgical

Clinical biomechanics 20 (11) 0 (0) Intraoperative 14 (8) 0 (0) Postoperative 0 (0) 23 (19) Scoliosis 5 (3) 0 (0) Total 39 (22) 23 (19)

Pathophysiological* Ankylosing spondylitis 0 (0) 25 (20) Meningitis 0 (0) 0 (0) Systemic causes 0 (0) 0 (0) Spinal pain 0 (0) 10 (8) Other 0 (0) 4 (3) Total 0 (0) 39 (31)


Manual stiffness assessment

Mechanical stiffness assessment

73 (42) 62 (50)

Total 73 (42) 62 (50)

*In the case of segmental assessment, a subset of studies included multiple measures; in total, 135

measures from 106 individual studies were included.

55

Characteristics of studies classified as biomechanical

The ‘biomechanical’ theme included studies that reported definitions and measures

related to structural and functional biometric properties of the spine. The load-displacement

(L-D) behaviour was generally used to quantify the stiffness of Functional Spinal Units (FSU)

in biomechanical studies (see Table 5).

Table 5. Overview of the methods of quantifying spinal stiffness as utilised by studies

included in the biomechanical theme

Quantification Frequency Relative frequency Reference

Load – displacement 16 39% 19,20,29–34,21–28

Force – displacement 8 20% 35–42

Torque – displacement 4 10% 43–46

Moment-displacement 4 10% 47–50

Load – deflection 3 7% 51–53

Force – torque 2 5% 54,55

Load – deformation 2 5% 56,57

The ‘FSU’ category comprised of studies that utilised a wide range of mechanical

instruments, experimental protocols, and set criteria to evaluate (in-vitro) biomechanics of

cervical, thoracic and lumbar spine stiffness. The majority of studies utilised FSUs,19,20,52,55,58–

61,22,23,25,35,37,44,45,49 whereas less studies utilised multi-segmental specimens during

experimental testing.36,47,54,62 Definitions in this category were described in terms of

mathematical laws, by the L-D relationship. (e.g., “applied load divided by the

displacement”23), and various characteristics on L-D graphs such as the ‘inverse slope’,22,47,61

and ‘linear’ region of the L-D curve”.35,36 Some studies reported less precise definitions, such

as “… hardening response”51 and the “… ability to withstand external force”.58 Twenty-five

studies included objective measures that utilised a diverse range of mechanical instruments for

the assessment of in-vitro spinal motion segment stiffness. Various types of mechanical

instruments were employed such as adapted or novel robotic machines,25 various custom

56

adaptations and jigs,19,54 Hexapod (Stewart platforms),41 and 3D coordinate systems.20 The

mechanical instruments were most commonly quantified by using data-driven approaches to

derive the L-D characteristics of FSUs.

The ‘stability’ category encompassed studies that investigated the passive, active and

neural components of stiffness that contributed to overall stability and stiffness of the spine.

Formal descriptions of concepts related to stiffness were often included in definitions of

stability.27,63 For example, segmental stability was defined as “the correlation of an applied

moment to the resultant deformation as shown in the L-D curves”,56 and the “force constant of

a spring calculated as change in force divided by displacement”.64 Spinal stability was generally

assessed by applying a perturbation to a system (i.e., a human subject) and observing the ability

of the body to resist displacement. Perturbation was the most commonly reported objective

measure of spinal stiffness identified in the stability category.42,64–68 Mechanical perturbations

were evaluated in terms of trunk muscle activity,42,65 kinetic and kinematic trunk responses,67,69

estimated mechanical properties of the trunk,70 and the contribution of trunk muscle activity to

overall spinal loading.

The ‘instability’ category was comprised of studies that investigated instability in terms

of its association with low back pain.50,71 The first attempts to define stiffness in the literature

as a whole were found in early studies investigating spinal instability, e.g.26,53. Here, spinal

instability was defined “as a loss of stiffness in the spine”,53 where ‘stiffness’ referred to “the

amount of motion within a system relative to a load applied to the structure”.53 A definition that

was suggested to be more workable was instability being “synonymous with a loss of motion

segment stiffness”, such that force applied to the motion segment produces greater

displacement than would be seen in a normal structure”.71 The term ‘stiffness’ has been used

to describe “the ratio of the applied load divided by displacement”.26 Here, ‘load’ and

‘displacement’ are described in four overlapping senses. Firstly, ‘loads’ and ‘motions’ are used

57

to define stiffness. Secondly, ‘load’ is defined as an applied ‘force’ or ‘moment’ that is

specified in terms of magnitude and direction. Thirdly, ‘motion’ is dependent on the applied

‘loads’ (forces and moments). Lastly, ‘displacement’ is defined as a ‘translation’ or ‘rotation’.

Flexibility was used to describe the inverse relationship to stiffness and has been defined as

“the ratio of displacement divided by the applied load”.26

The ‘finite element model’ category comprised of studies that utilised various

numerical simulation techniques in conjunction with experimental studies and provided insight

into the in-vivo loading conditions of the FSU.30,72 Finite element models were developed to

predict spinal motion or displacement responses to loading, where the vertebrae are described

as simple rigid bodies and other connective tissues representing beam or spring elements of an

FSU.73,74 The 6x6 stiffness matrices were used to define the L-D relationships,34 whereby, the

forces at the vertebral body centres are assumed to be related to the displacements by a 6x6

stiffness matrix with 36 terms (21 independent stiffness matrix terms due to the consideration

of matrix symmetry).30 However, Gardner-Morse and Stokes30 noted that a limitation of the 6x6

stiffness matrix approach was that the motion segment stiffness matrix required the assumption

of linear L-D behaviour. These authors proposed that in order to account for a motion segment

consisting of two vertebrae, each having six degrees of freedom would require a 12x12 stiffness

matrix.

58

Characteristics of studies classified as surgical

The ‘surgical’ theme encompassed studies that reported definitions and included

measures of spinal stiffness that related primarily to intraoperative measurement, pre- and

postoperative surgical interventions. The L-D behaviour was most commonly used to quantify

stiffness (see Table 6) and employed similar stiffness assessment protocols and methods to the

biomechanical theme.

Table 6. Overview of the methods of quantifying spinal stiffness as utilised by studies in

the surgical theme


Load – displacement 20 67% 75,76,85–94,77–84

Force – displacement 6 20% 95–100

Load – deformation 4 13% 83,101–103

The ‘clinical biomechanics’ category comprised of studies that utilised a wide range of

instruments to assess the structural and functional biomechanics of the spine, in the context of

surgical experimental interventions and procedures. One of the mechanical properties,

commonly used to characterise the stiffness of the spine, was the L-D relationship of the

FSU.100 Studies included in this category most commonly described stiffness in terms of the

slope of the L-D curve.76,77,79 The term ‘stiffness’ appeared to be used interchangeably with the

term ‘resistance’. For example, Dickman77 described the slope of the loading curve as “the

measurement of the relative resistance to the motion (stiffness)”. Twenty studies included

objective measures that utilised various mechanical instruments, e.g.,22,36,37 to investigate the

effects of surgical procedures and interventions of stiffness, e.g.81,83,95

59

The ‘intraoperative’ category encompassed studies that investigated spinal instability

by conducting in-vivo quantitative measurement of spinal stiffness.85 Data obtained from these

methods were primarily used to assess the operative level and provided a basis for treatment

recommendations and decisions regarding surgical intervention. In the year 1996, Frank85 was

the first to define the term stiffness as “the force needed to distract adjacent vertebrae within a

motion segment”. A mathematical definition is given by Krenn et al.104 who describes the

stiffness formula, “(S) of a body that deflects a distance (d) under an applied force (F); S=F/d”.

Other quantitative descriptions of stiffness include calculations used to quantify segmental

stiffness. For example, “the peak applied distraction force divided by the displacement between

the screws,”86 and the slope of the L-D curve.90,92,94 Several mechanical instruments have been

developed for the intraoperative (in-vivo) measurement of spinal motion segment stiffness. The

first documented use of intraoperative stiffness assessment was by Frank,85 who used a

vertebral retractor system to measure cervical spine stiffness. The vertebral retractor system

consisted of a spinal spreader equipped with force and distance sensors which measured the

distraction stiffness between two adjacent vertebrae. This provided surgeons with the ability to

quantify the intraoperative L-D responses exhibited by patients.85 Similar intra-operative in

vivo stiffness quantitative assessment techniques have been described by Hashimoto et al.86 and

Krenn et al.89 The ‘distraction’ stiffness was most commonly quantified by the slope of the L-

D response.84,85,94,86–93

The ‘scoliosis’ category encompassed studies that assessed the flexibility of the scoliotic

spine. Flexibility and stiffness were common biomechanical parameters for the planning of

surgical correction in subjects with scoliosis.105 F-D and L-D characteristics were often used to

describe the vertebral displacement observed in bending X-rays.98,99,105 The terms ‘stiffness’ and

‘flexibility’ appear to be used interchangeably to describe experimental measurements and

parameters in the characterisation of the scoliotic spine.98,105,106 For example,thoracic curves

were described as being stiffer than lumbar curve”.107 Inversely, “the flexibility of the spine was

60

decreased in the thoracic regions while the stiffness of the lumbar spine is increased”.98

Radiography was used to identify the degree of scoliosis curvature (5 studies). Plain film X-ray

was used to measure the spinal flexibility of subjects with scoliosis. During the preoperative

assessment of flexibility, radiographs were evaluated to assess the cobb angle measurements

and reducibility of the spinal curves. There were several methods employed to assess curve

flexibility, including fulcrum bending,107 anteroposterior and lateral standing, traction and

bending radiographs in the supine position,108 and the spinal suspension test.99

The ‘postoperative’ category encompassed studies that utilised patient-reported

outcome measures (PROMs). One study described spinal stiffness to contextualise how

stiffness applied to the Lumbar Spinal Disability Index (LSDI). In this study, ‘potential

stiffness’ was expressed in terms of “a loss of flexibility”.109 The LSDI109,110,119,111–118 was the

most commonly included PROM, followed by the Visual Analogue Scale (VAS).120–128 Several

postoperative stiffness indicators were included in studies investigating outcome measures and

complications after surgical intervention (see Table 2). For example, stiffness was reported as

a symptom of myelopathy,129,130 prolotherapy,131 cervical dorsal rhizotomy,132 and

postoperative complication of disc arthroplasty.133

Characteristics of studies classified as pathophysiological

The ‘pathophysiological’ theme included studies that reported stiffness as being

characteristic or indicative of pathophysiological processes. The majority of studies (42)

included stiffness indicators (seeTable 7.). The most common indicators were the presence of

symptom-reported stiffness related to various clinically relevant pathophysiological processes.

61

Table 1. Summary of stiffness indicators reported in the pathophysiological theme

Disease/condition Stiffness

indicator

Description of indicator Reference

Ankylosing Spondylitis Symptom Morning stiffness 134–139

Pain and stiffness

Inflammatory Low Back Pain Symptom Stiffness after resting 140–142

Meningitis Symptom

(triad)

Neck stiffness, fever, and altered

mental status

3,143–150

Spinal Tumour Symptom Spinal stiffness 151,152

Diffuse Idiopathic Skeletal

Hyperostosis

Symptom Stiffness and non-radicular pain 153,154

Whiplash associated disorders Symptom Pain and stiffness

4,155

Traumatic Atlanto-axial

subluxation

Symptom Spontaneous neck stiffness 156

Congenital osseous anomalies

of the upper cervical spine

Symptom Neck pain and stiffness 157

Fibromyalgia Symptom Early morning stiffness 158

Japanese Viral Encephalitis Symptom Neck stiffness 159

Lyme Neuroborreliosis Symptom Neck stiffness 160

Non-paralytic Poliomyelitis Symptom Painful stiffness of the neck and back

with an objective finding of limited

neck flexion

161

Subarachnoid Haemorrhage Clinical

prediction

rule

Neck pain or stiffness 162

The ‘ankylosing spondylitis’ category encompassed studies that investigated the

clinical assessment, diagnostic criteria, and PROMs related to ankylosing spondylitis. The Bath

Ankylosing Spondylitis Disease Activity Index (BASDAI) was the most utilised PROM (10

studies) among available studies. The BASDAI was comprised of a six-item self-administered

questionnaire that measured symptoms such as fatigue, spinal pain, localised tenderness, and

morning stiffness.163 The BASDAI uses the VAS, which included specific items for assessing

stiffness include morning stiffness severity and duration.163–168Although no definitions of

stiffness were reported alongside the BASDAI, Mengshoel and Robinson169 attempted to

modify original stiffness items on the BASDAI and asked patients to indicate how they

62

perceived stiffness in the spine. This qualitative work provided insight into the patient

experience of ankylosing spondylitis and three new themes were developed: ‘stiffness’ and

‘well-being,’ ‘stiffness and bodily awareness,’ and ‘stiffness and hope’.

The ‘meningitis’ category encompassed studies that included neck stiffness as a

symptom indicator of meningitis. Stiffness was identified in this category as a characteristic

symptom included in the triad hallmark features of fever, neck stiffness and altered mental

status3,146 Neck stiffness was considered to be an important clinical feature of meningitis3,143,145

and postoperative complications following surgical procedures.146,150

The ‘systemic causes’ category consisted of studies that reported spinal stiffness arising

from systemic diseases. Seven indicators were reported in 7 studies related to symptoms of

neck stiffness: Retropharyngeal Ganglioneuroma,170 Lyme neuroborreliosis,160 Subarachnoid

Haemorrhage,162 and Retroclival Haematoma due to odontoid fracture,171 Neck and back

stiffness was also reported as a symptom of non-paralytic poliomyelitis,161 Vertebral

abnormalities associated with synthetic retinoid use,172 and Fibromyalgia.158

The ‘spinal pain’ category encompassed studies investigating pain in the lumbar region

(lower back), thoracic (mid-back), and cervical region (neck) which was associated with

stiffness. This category consisted of studies that included PROMs, symptoms, and clinical signs

that may be indicative of mechanical or inflammatory spinal pain and whiplash-associated

disorders. The VAS was the most utilised PROMs (4 studies) which assessed neck and back

stiffness. For example, three studies utilised various PROMs in an attempt to discriminate

between inflammatory and mechanical low back pain.140–142 One single discriminating factor

to emerge from these studies is that morning stiffness appears to be an important indicator of

inflammatory low back pain.140–142 Two studies that investigated clinical signs, symptoms, and

prognostic factors related to whiplash associated disorders,4,155 and reported that neck

symptoms (i.e., pain and stiffness) with or without objective clinical findings are common in

63

whiplash injuries.4

The ‘other’ category encompassed investigating clinical features, symptoms, adverse

events and rare occurrences due to various pathophysiological processes. Ten studies included

indicators of neck and back stiffness. Symptoms of stiffness were identified in the following:

Diffuse Idiopathic Skeletal Hyperostosis,154 Congenital Osseous Anomalies of the upper

cervical spine,157 Osteoarthritis of the cervical and lumbar spine,173 Lumbar Degenerative Disc

Disease,174,175 Post Lumbar Puncture Headache,150 and Primary Diffuse Leptomeningeal

Gliomatosis.176

Characteristics of studies classified as segmental assessment

The ‘segmental assessment’ theme encompassed studies that investigated manual

(qualitative) or mechanical (quantitative) segmental assessment of spinal stiffness in human

subjects. It was observed that a vast majority of studies used mechanical instrumentation to

assess the reliability and validity of manual segmental assessment (see Table 2). Of these, 75

definitions were reported, whereas 60 of the 135 measures included did not report a definition

of stiffness.

Manual segmental assessment was the most commonly employed measure in reliability

and validity studies assessing spinal stiffness. Typically, manual assessment involved a

clinician-applied manual force to a spinal landmark (i.e., spinous process or articular pillar) in

evaluating stiffness as well as other aspects of motion segment characteristics such as range of

motion, mobility and pain provocation.177–179 The P-A intervertebral motion test was the most

commonly employed subjective measure (30 studies) for the (static) assessment of manual

segmental stiffness, and is described elsewhere.180 A similar variation to the P-A intervertebral

motion test was the ‘Passive Physiological Intervertebral Motion’ test, which was a dynamic

assessment of stiffness, cf.181 Similar manual segmental assessment techniques have been

described with the subject sitting or in the side-lying position.182 Other types of manual

64

segmental assessment methods included: the lateral gliding test,183 joint end-play

Assessment,184 springing, and overpressure testing.185

In an attempt to investigate the reliability and validity of PA stiffness, a stiffness

reference-based protocol was used by Maher and Adams186 to compare a mechanical reference

stimulus with a mechanical instrumented device.180 Clinician-applied PA pressures were rated

on an 11-point scale assisted by a stiffness reference device anchored to discrete stiffness

stimuli. The -5 point on the scale was described as corresponding to “markedly reduced

stiffness”, and the +5 point on the scale was described as “markedly increased stiffness”.180,186

Raters were often advised to concentrate on the loading portion of the F-D curve when trying

to match the stiffness. 187,188

Stiffness has been most commonly defined from the clinician’s perspective. For

example, ‘quality’ of,18,189 ‘impression’ of,190,191 and ‘perceived’ by.192,193 The most common

feature included in definitions was ‘resistance’ (see Table 8). It appears that stiffness is used

synonymously with the term ‘resistance’ in the manual segmental assessment category. For

example, stiffness is described as the “perceived resistance through intervertebral joint range

of movement”.194 Other examples include; the “quality of resistance,”18 “range and resistance

to movement,”195 “increased tissue resistance to the displacement,”196 and “the resistance to

motion on force application”.197 The second most common feature included in definitions was

the F-D relationship, For example, stiffness is expressed in terms of ‘the ratio of change in

applied force to change in displacement,”8 the “amount of force applied to the displacement

produced,”187 and the “slope of the F-D curve”.196 Another feature of definitions was the

classification of spinal segment stiffness in terms of ‘increased’ or ‘decreased’ ‘mobility,’ for

example, ‘hypomobile,’ ‘normal,’ or ‘hypermobile’.17,191,198

65

Table 8. Key features of qualitative definitions reported in manual segmental assessment

category

Features of definition used Frequency Relative frequency Reference

Resistance 14 40% 190,192,204–207,194,195,197,199–203

Force-displacement 13 37% 8,18,209–

211,180,181,187,193,196,204,205,208

Mobility 5 14% 17,183,198,200,212

Force-deformation 3 9% 204,213,214

Although stiffness is commonly used to describe segmental motion characteristics,

numerous other descriptors (i.e., qualities and characteristics) have been identified that

described subjective findings associated with manual assessment of the spine. Descriptors were

both reported as features included in definitions or as standalone descriptors of segmental

assessment. The use of the terms ‘motion’ or ‘movement’ were commonly used in the literature

to describe segmental assessment. The term ‘motion’ appeared to be used synonymously with

the term ‘stiffness’ to describe the combined measure of both displacement, and the ‘nature’

and ‘quality’ of the resistance to that displacement.202 Results of segmental assessment have

been described in terms of, ‘hypomobility,’ ‘resistance,’ ‘restriction,’ ‘fixation,’ ‘hardness,’

‘end-feel,’ and ‘pain provocation’. (see Table 9. Overview of various descriptors used to

describe manual segmental assessment).

Table 9. Overview of various descriptors used to describe manual segmental assessment

Descriptor Frequency Relative frequency Reference

Hypomobility 15 31% 5,17,200,202,215–217,177,181,188,191,193–195,198

Resistance 14 29% 8,183,219–222,190,193,194,196,201,205,206,218

Restriction 7 14% 18,182,183,197,221,223,224

End feel 5 10% 17,177,178,183,198

Fixation 4 8% 17,182,193,223

Hardness 2 4% 181,210

Pain provocation 2 4% 177,203

66

Hypomobility appears to be the most commonly reported descriptor in the literature

reviewed (see Table 9) This finding was consistent with Maher and Simmonds215 findings in

relation to how therapists conceptualised and characterised the clinical concept of spinal

stiffness. These authors performed a cluster analysis on 31 published descriptors in the literature

and identified three superclusters, (i) limited mobility, (ii) increased mobility and (iii)

viscoelasticity. Hypomobility has been conceptualised as a reduction in accessory motion and

has been used to evaluate relative segmental stiffness.17 The segment of interest has been

classified using the quantitative scale: ‘hypomobile,’ ‘normal,’ or ‘hypermobile,’ which was

based on the clinician’s subjective judgement of stiffness.191 A subjective perception of high

‘resistance’ to spinal movement has been semantically linked with increased spinal ‘stiffness,’

whereas a perceived low ‘resistance’ to spinal motion has been semantically linked with

‘hypermobility’.180

The term ‘restriction’ appeared to be used both implicitly and inconsistently in most

studies.225 Although one study semantically linked the term ‘restriction’ with ‘end-feel,’

whereby the abnormal end-feel was defined as “the sensation that one would expect when the

range of motion of a zygapophyseal joint is restricted”.183 The term ‘end-feel’ appeared to be

semantically linked with other descriptors such as ‘hard’ or ‘not hard,’ whereby a ‘hard’ end-

feel was described as the “increased firmness at the end of the available range of motion at a

joint”.177 Other such terms that were identified to describe ‘end-feel’ included: ‘empty’,

‘springy’, and ‘stiff’.178Additionally, ‘end-feel’ has been expressed in terms of the presence of

a joint fixation has been proposed to be determined when “no motion is felt, and a hard ‘end-

feel’ is noted on “stressing the segment passively”.17

Several mechanical indentation instruments were identified which were designed to

replicate clinician-applied PA forces and provide an objective quantification of PA stiffness.

67

The most commonly reported objective quantification of mechanical instrumented stiffness

was the F-D characteristics (see Table 10). These characteristics have been routinely used to

characterise the response of the spine to mechanically applied P-A forces. Three broad

categories of instruments have been described; (i) mechanical, (ii) mechanically assisted, and

(iii) dynamic.


Load-displacement 3 5% 197,253,254

Force-deformation 3 5% 9,255,256

Force-time 2 3% 257,258

Torque-angular

displacement

2 3% 259,260

Force-acceleration 1 2% 261

Force-velocity 1 2% 223

Load-deformation 1 2% 262

A wide range of mechanical instruments have been employed by researchers for the

assessment of spinal stiffness in human subjects. However, the basic construction and

mechanism of assessment was similar across all instruments. The experimental set-up involves

the subject lying in the prone position on a plinth with the indentor probe positioned over the

target spinous process. A vertical penetration load is delivered by the indentor extending along

a linear path, and the resultant displacement responses were recorded using various computer

software programs.5,188,191 For example, the Stiffness Assessment machine was one type of

mechanical instrument used to quantify stiffness, described elsewhere.180 Mechanically

assisted indentation methods utilised smaller, less automated techniques to measure

stiffness.191 Assisted indentation utilised a manual load application with the addition of

instrumentation, which was designed to give the operator improved reliability and accuracy.191

Table 10. Overview of how objective measures were quantified for mechanical stiffness

assessment

5,7,194,195,199,200,204,207,209,217,220,222,8,2

25–234,13,235–244,180,245–

252,182,184,188,191,192

79% 48 Force-displacement

68

Assisted indentation methods differ from previously used mechanical instruments, as the spinal

indentation force was produced by a human operator rather than a motor-driven device.242 More

recently, a dynamic continuous stiffness testing system has been designed to measure the

lumbar P-A stiffness and is described elsewhere.7,250

The most characteristic feature of the definitions reported in this category was the F-D

characteristics obtained from data-driven approaches that utilised various customised software

programs (see Table 11). Different features of definitions included descriptions of the slope of

the F-D curve such as the ‘linear portion’ (region) of the F-D curve,194,199,237,238,244 ‘slope’ or

‘first derivative’ of the F-D curve,191,225,249 ‘slope’ of the linear region of the F-D

curve,’187,199,233,241 and ‘gradient’ of the regression line’.8,192,231,263 Other features included in

definitions were the relationship between force and displacement (e.g., “the change in force per

unit change in displacement”).225 Stiffness has also been defined in terms of resistance to

movement or motion; for example, Xia et al222 operationally defined stiffness as the quantitative

measure of the resistance to motion.

Table 11. Key features of quantitative definitions reported in mechanical segmental

assessment category

Definition used Frequency Relative frequency Reference

Force – displacement 14 64% 187,191,241,249,250,264,194,199,200,209,225,233,237,238

Resistance 4 18% 13,203,222,245,256

Load – deformation 2 9% 9,255

Load – displacement 1 5% 265

Torque – angle 1 5% 260

69

Discussion

The overall aim of the present review was to identify what definitions and measures of

objective and subjective spinal stiffness have been reported in the existent literature, with a

focus on research implications and how this may inform clinical practice. These results show

that approximately one-third of the studies reported definitions of stiffness. For studies that did

include definitions, many different features were included. Most commonly, studies reported

definitions from a research perspective using quantitative descriptions to describe objective

measures used to quantify the biometric properties of spinal stiffness. Quantitative definitions

primarily related to mathematical laws, which referred to more or less explicitly stated

relationships between load and displacement,26,31 descriptions of L-D curve data,22,36 and

descriptions of formula.46,104 There was marked diversity in definitions that reported

quantitative descriptions of stiffness. This diversity could be attributed to the instruments

(techniques) used, the methods of measurement used, and the numerous operationalisations of

stiffness. Despite the use of data-driven approaches for measuring and defining stiffness, the

marked variation of definitions presented makes it difficult to compare findings between

studies.

Other quantitative descriptions (i.e., synonyms and antonyms) were also used to

describe different features of stiffness. For example, the term ‘resistance’ was typically used

synonymously with stiffness to describe load and displacement in terms of the resistance of

spinal movement. Another less frequently used term was ‘flexibility’, which represented the

inverse relationship to stiffness,26 although the term ‘flexibility’ was frequently used

implicitly.98,105 The use of alternative descriptors has the capacity to provide clarification of

concepts related to stiffness. However, these terms need to be described appropriately, and

sufficient context should be provided so that it is not possible for the reader to refer to any other

entity other than the alternative descriptive term being used. Moreover, formal descriptions

70

representing semantic links to stiffness related concepts were often included in definitions of

stability and instability. Stiffness was semantically linked with concepts related to stability (e.g.,

“… stiffening of the motion segment which results in greater stability” 64), and instability (e.g.,

“… loss of stiffness”71). Although the conflation of stability and instability with concepts of

stiffness may be facilitative in applied biomechanics, it may also lead to a certain degree of

ambiguity in the analysis of relationships and distinguishing features between these terms in the

clinical setting. The concepts of stability and instability would benefit from better clarification

for clinical purposes.

Stiffness has been commonly defined from a clinician perspective (how a clinician

perceives spinal stiffness) in studies that investigated manual segmental assessment. Most

definitions described characteristics of stiffness (e.g., “impression of …”190,191 or “quality of

…”18,189) from the clinicians’ perspective. Furthermore, clinician-based descriptions were often

accompanied by quantitative descriptions (e.g., “… force and displacement”205). The

integration of quantitative descriptions into manual segmental assessment of spinal stiffness

could be problematic for several reasons. First, qualitative and quantitative descriptions confer

fundamentally different approaches. Second, quantitative descriptions may not reflect

clinicians’ subjective judgements based on the realities of assessment in clinical practice. For

example, the clinician may concentrate on the “resistance through intervertebral joint range of

movement”,194 the “‘hard’ end-feel quality”,177 or some other entity not otherwise defined.

Third, the inherent subjectivity of manual palpation, means that the incorporation of

quantitative descriptions into stiffness judgements will inevitably result in variability in how

stiffness is perceived and interpreted in studies. Finally, and most importantly, this may

adversely affect the validity and reliability of future studies that assess stiffness in relation to

manual segmental assessment from the clinician’s perspective.

71

Another important finding was the marked variation of research-reported qualitative

descriptors used by clinicians to describe findings during manual segmental assessment. For

example, qualitative descriptors such as ‘hypomobility,’5,17,200,202,215–217,177,181,188,191,193–195,198

‘resistance,’8,183,219–222,190,193,194,196,201,205,206,218 ‘restriction,’ 18,182,183,197,221,223,224 and ‘end-

feel’17,177,178,183,198 may be integrated into clinician-judgements about stiffness. At first sight,

the diversity of descriptors appears to facilitate the paradigmatic perspective of clinicians who

use manual segmental assessment. However, the lack of explicit operational definitions of

descriptors, and the inconsistencies in the use of terminology, means that the exact meaning of

descriptors and their relationship with stiffness is not well delineated. In order to improve

reporting of qualitative descriptors of stiffness, operational definitions should be provided.

Further, consideration should be given to how these descriptors might influence the variability

of results. Most importantly, the variability of descriptors identified means that it would be

difficult to compare findings in a meaningful way in studies.

Self-report measures such as the VAS and PROMs such as the BASDAI and the LSDI,

did not provide explicit definitions of stiffness. However, in the case of the LSDI, the authors

provided a narrative explication of potential stiffness (i.e., loss of flexibility) which was

considered from the patient’s perspective, cf.109 In the case of the BASDAI, one study made

modifications to the original stiffness items, making them more specific to a patient’s

experience of Ankylosing Spondylitis, cf.169 In sum, the absence of explicit definitions of

stiffness concerning self-report measures and PROMs identified in this study has important

implications for future research. Most importantly, without operational (i.e., respondent)

definitions of stiffness on self-report scales, interpretations of stiffness may differ between

respondents (or patients), clinicians and authors of the scale. Furthermore, the lack of verbal

descriptors and the implicit use of the term ‘stiffness’ means that their clinical utility remains

unclear. A critical first step for the development of self-report measures and PROMs is to

72

ensure authors provide a respondent definition of stiffness at the outset of the study. This would

facilitate improved reporting and allow for more meaningful interpretations of stiffness-items

in future studies

The majority of studies used the term stiffness implicitly, without clear explication of

its meaning, which could be argued to raise several issues. First, there is no consensus statement

or standardised definition of stiffness. Second, it leaves the term stiffness open to interpretation

by the reader. Third, it hinders the reproducibility of results in subsequent studies. Fourth, it

could affect transparency across different research contexts. Finally, and most importantly, it

could represent a barrier for adopting evidence-based practice in clinical decision-making

processes. Unfortunately, this could represent a loss of clarity and impact clinical outcomes.

The current review identified over three hundred measures of spinal stiffness and found

that most studies used objective measure and methods for the assessment of stiffness, whereas

subjective measurements were less frequent. In relation to objective measures, the most

prevalent methods of quantifying stiffness were by studies that utilised various mechanical

instruments to quantify the load (or force)-displacement characteristics, using data-driven

approaches. The utilisation of mechanical instruments differed in whether they assessed

stiffness in human subjects (in-vivo and ex-vivo), or cadaveric specimens, (in-vitro).

Studies classified into the ‘biomechanical’ theme were particularly distinct, in that they

did not include any subjective measures of spinal stiffness. The absence of subjective measures

may be explained by the emphasis on the application of mechanical instruments to quantify the

behaviour of stiffness experimentally, and for this reason, could not assess subjective elements

of stiffness. Studies classified into the ‘surgical’ theme also employed similar mechanical

instruments to quantify stiffness, but in the context of surgical intervention. However, the

‘intraoperative’ category was unique, in that a subset of studies utilised intraoperative

73

techniques (e.g., spinal stiffness gauge), for the assessment of the stability of motion segments

at the operative level. Intraoperative techniques were used to quantify the behaviour of motion

segments and added to the objectivity of treatment recommendations and decisions regarding

surgical procedures.

Studies classified into the ‘segmental assessment’ theme emerged as particularly

distinct, as studies often compared clinician-perceived manual segmental assessment to

mechanical instruments or stiffness reference-based devices to investigate the reliability and

validity of manual segmental assessment. The differentiation of stiffness into subjective and

objective measures allowed for the application of methodological triangulation (i.e., using

quantitative and qualitative methods to investigate the stiffness phenomenon) to identify

similarities and differences across methods.266 In the case of spinal stiffness, triangulation

appears to be impractical for assessing segmental stiffness from a subjective (sensory) and

objective (biomechanical) perspective. In general, it appears that judgements of spinal stiffness

obtained from manual segmental assessment do not appear to correlate well with instrumented

measurement.198,200

In relation to subjective measures, the most prevalent were self-reported measures,

followed by PROMs. The VAS represented a simple self-reported measure that reflected

unidimensional characteristics (i.e., severity and duration) of stiffness. PROMs represented a

wide range of measurable outcomes related to stiffness, which included disease activity, quality

of life and functional status. At present, the LSDI was the only PROM that addressed the impact

of stiffness on Activities of Daily Living, cf.109 In contrast, other PROMs were generally

restricted to severity (sensory) and duration (time-dependent) characteristics, cf.2,267

The reliance on sensory and time-dependent characteristics for the assessment of self-

reported and PROMs meant that the patients (respondents) own self-conceptualisation of

74

stiffness was not considered. Although these measures may be practical from a research

perspective, failure to consider stiffness from a multidimensional perspective means that their

clinical utility as a measure remains unclear. More work is needed to develop self-reported

measures and PROMs that assess responses (behavioural and psychological) and impacts

across different life domains relevant to patients. Furthermore, PROMs should reflect the

multidimensional factors associated with the patient’s perceptions of stiffness, providing

clinicians with a more comprehensive understanding of the issues faced by patients with spinal

stiffness. This would improve clinical decision-making processes by facilitating the

implementation of outcome measures that matter to patients and thereby enhancing treatment

efficacy.

Studies classified into the ‘pathophysiological’ theme had two distinguishable features.

First, none of the studies included objective measures of spinal stiffness. The absence of

objective measures may be explained by the fact that studies were mainly interested in self-

reported, PROs and other indicators relevant to the clinical presentation of spinal stiffness.

Second, approximately half of the studies included stiffness as an indicator; often included as

part of a set of indicators, symptom triad, or clinical prediction rule. The most prevalent

indicators were symptoms and characteristics, describing patient-specific features of various

clinically relevant pathophysiological processes. Patient-reported symptoms appeared

particularly relevant to patients and may provide clinicians with an indication of the patient’s

current health status, thereby informing clinical decision-making processes.

Important clinical implications of findings

Stiffness is a clinically relevant symptom reported by patients and has implications for

patient-relevant health outcomes in the rehabilitation setting. In the initial evaluation of patients

presenting with spinal stiffness, consideration should be given to the possibility of serious

75

causes such as inflammatory disease,2,141 degenerative conditions,173,175 infection (bacterial or

viral),160,268 cancer,152 trauma,4,155,156 intracranial pathology,162,171 and postoperative

complications.129–133 The symptom of stiffness and its relationship to other clinical

manifestations is essential to differentiate between a benign condition and pathophysiology.

For instance, neck stiffness accompanied by fever and altered mental status may suggest

meningitis,3 while morning stiffness and back pain may suggest Ankylosing Spondylitis2 or

Osteoarthritis.175 The recognition of these symptoms is critical to prompt further clinical

investigations to confirm or deny pathophysiological aetiology of the patient presenting with

spinal stiffness.

The clinical assessment may rely on the presence of subjective stiffness in the absence

of objective clinical findings. It appears that disparities exist between objective measures and

subjective reports of spinal stiffness in the literature,4,13,118 This highlights several clinical

implications. First, an important distinction should be made between the patient’s subjective

reports of stiffness, which may be different from objective clinical assessments.13,118 Second,

the mismatch between subjective and objective measures of stiffness may be further

compounded by the absence of definitions from patients’ perspectives. Third, clinical outcomes

may be better assessed by improving patients’ self-reported assessments. Finally, the

relationship between subjective and objective measurements of spinal stiffness does not appear

to be well established in the literature. An emergent theory that has been identified in the

literature is the notion that stiffness may serve a ‘protective’ or ‘guarding’ function.13,269,270

This is thought to be related to the patient’s state of consciousness and various psychological

factors, such as fear, anxiety and pain.13,161

Protective stiffness may be neurally-driven in an attempt to protect the spine for

different reasons.13 This is in line with recent research suggesting the experience of feeling stiff

may not reflect biomechanical stiffness.13,271 Similar research also suggests an association

76

between spinal stiffness and the muscle guarding phenomenon as well as possible

proprioceptive deficits.270 Pain and anxiety may increase spinal stiffness due to co-contraction

of spinal muscles,272,273 emphasising the role of psychological processes influencing stiffness

on a physiological level. Stiffness is also reported as a postoperative complication and may

serve a protective function during recovery following surgical procedures.269 There is clinical

diversity in studies that report stiffness as serving a ‘protective’ or ‘guarding’ function in both

acute and chronic patient populations. Therefore, more work is required to characterise further

the relationship between the ‘protective’ and ‘guarding’ phenomenon concerning spinal

stiffness. This may have important implications for assessment and treatment of patients with

spinal stiffness. It further emphasises the need to understand how patients explain and

understand their symptoms in relation to spinal stiffness.

Study limitations

Only peer-reviewed literature was included in this scoping review, which represents the

evidence base of what informs clinical knowledge. Therefore, secondary sources of evidence

such as grey literature, books and manuals were not included. The purpose of this scoping

review was to be exploratory in addressing the question of ‘what’ rather than ‘how’; therefore,

the methodological quality of the included studies was not assessed. The ‘optional’ consultation

exercise was not conducted as a part of the present review, although future studies may use this

study as a basis in which to engage with key stakeholders in a more meaningful and informed

consultation process. Although the scoping review framework14 recommends the involvement

of multiple reviewers for the second level of screening, following pilot-testing, agreement

scores suggested that the screening template was sufficient for determining the eligibility of

studies. Therefore, it was determined that the first author would conduct the second level

screening independently.15

77

Conclusion

The findings of this scoping review highlight the marked diversity in the reporting of

definitions both within and across different research contexts. At present, there are several

limitations of using the term stiffness in clinical practice. Stiffness has evolved semantically

following the development of concepts originating in physics and engineering, as well as

following the extensive characterisation of stiffness in biomechanical literature. Given the

historical evolution of the term ‘stiffness’ and its various conceptualisations, new ad hoc

(operational) definitions, and other descriptors of stiffness frequently appear in the literature.

Unfortunately, this may lead to a variety of issues; most importantly, it impedes clear

communication between clinicians and patients. At this point, it is important to stress that the

literature appears not to address definitions of stiffness from the patient’s perspective, which

includes the absence of definitions alongside self-reported, PRO measures. Further,

symptomatic stiffness is still less well characterised and understood in the current literature.

Adopting a patient-centred approach to defining stiffness and evaluating the strengths and

weaknesses of current definitions/descriptors and measures of spinal stiffness may provide the

clinician with better insight into how to effectively assess and manage stiffness in rehabilitative

settings.

The breadth of outcomes measures reflects the multifactorial nature of spinal stiffness.

Subjective and objective measures of stiffness are widely used in research and clinical settings,

to evaluate motion segment behaviour, to evaluate the effect of an intervention, for clinical

assessment and evaluate patient outcomes. Objective measures of stiffness have been

extensively characterised utilising mechanical instruments to quantify the behaviour of spinal

stiffness experimentally across different methodological and clinical contexts. Attempts to

employ methodological triangulation to investigate subjective and objective spinal stiffness to

assess the reliability and validity of manual segmental assessment appear impractical. Thus,

78

the relationship between objective and subjective measures of stiffness remains elusive.

Moreover, the tendency to rely on sensory and time-dependent characteristics in both self-

report and PRO measures fails to capture the multifactorial nature of spinal stiffness. Therefore,

the development of multidimensional indices and scales is necessary to reflect outcomes that

matter to patients.

79

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116

Section 4: Appendices

The scoping review protocol was registered prospectively with the open science framework

on 7 of March 2019. Reference: Moses, J. (2019, March 7). Scoping review protocol:

Defining and measuring objective and subjective spinal stiffness. Available here;

https://doi.org/10.17605/OSF.IO/SWKU6

https://doi.org/10.17605/OSF.IO/SWKU6

117

Appendix A; Ethics notification

118

Appendix B: Search strategy

Keyword search

• Stiffness

• Definition

• Measure

• Objective

• Subjective

• Spinal

Initial search terms and key phrases

Initial searches were undertaken in order to survey the available literature and to arrive at a

search syntax for the present project that would maximally capture the available literature and

be feasible for a research project of 90 credits. The following search terms were gathered

from the listed key words of relevant journal articles and relevant terms in the MeSH

database.

Title and/or abstract must include any combination of:

stiffness, stiffness AND pain

AND

definition, meaning, concept, construct,

AND

measure, outcome, assessment, utility.

AND

objective, static OR passive, active, dynamic, perturbation.

AND

subjective, symptom, experience, perception, sensation, psychosomatic.

AND

spinal, back, low back pain, lumbar spine, thoracic spine, cervical spine.

119

Table showing the initial electronic search strategy executed in PubMed (04/09/2018)

for preliminary syntax check

Sample search syntax Database Yield

Stiffness AND defin* PubMed 4003

Stiffness AND Body AND measur* PubMed 3077

Stiffness AND musculoskeletal AND measur*

(note includes arterial and visceral stiffness)

PubMed 1431

Stiffness AND back AND measur* PubMed 531

Stiffness AND musculoskeletal AND measur* AND defin* PubMed 512

Stiffness AND perception AND measur* PubMed 42

Stiffness AND subjective AND measur*: PubMed 66

Stiffness AND Body AND measur* AND defin* PubMed 271

Stiffness AND pain AND spinal PubMed 749

Stiffness AND pain AND back AND subjective PubMed 28

Stiffness AND spinal AND measur* PubMed 891

Stiffness AND spinal AND defin* PubMed 175

Rationale for search strategy selection

The initial search strategy was broad and included any type of musculoskeletal OR body

stiffness. However, for reasons of clinical relevance regarding the manual therapy profession,

the preliminary searches were constrained to focus on the spinal region. The final search

syntax that was used for the present study included: “stiffness AND spinal AND defin*” and

“stiffness AND spinal AND measur*”.

120

Final search strategy

Database: PUBMED

Date: 01/11/2018

#Search (stiffness AND spinal AND defin*).

#Search (stiffness AND spinal AND measur*)

Sort by: Relevance Filters: Humans; English

The search strategy was adapted to Scopus and Ebsco health database (Academic Search

Complete, The Allied and Complementary Medicine Database, CINAHL with Full Text,

Health Business Elite, Health Source: Nursing/Academic Edition, LGBT Life with Full Text,

MasterFILE Premier, MEDLINE with Full Text, Psychology and Behavioural Sciences

Collection, SocINDEX with Full Text, SPORTDiscus with Full Text).

Table showing an overview of the final search strategy

Date of retrieval Search syntax Database Yield

01/11/2018 stiffness AND spinal

AND defin*

PubMed 119


AND measur*

PubMed 652


AND defin*

Ebsco 94


AND measur*

Ebsco 417


AND defin*

Scopus 157


AND measur*

Scopus 682

TOTAL: 2121

121

Appendix C: Screening template

Screening Questions and Inclusion Criteria were the following:

Does the title/abstract/keywords include any combination of search terms?

AND

Does the study report (a) definition(s) of spinal stiffness or include subjective or objective

measures or indicators of spinal stiffness?

AND

Does the study investigate patient/clinician/research-reported outcome or experience

measures of spinal stiffness?

Exclusion criteria were as follows:

Studies published in the grey literature

Studies investigating animal stiffness

Studies investigating non-spinal stiffness

Studies not published in English

122

Appendix D: Interrater agreement

Definitions for level of agreement

Kappa

Range Definition

< 0 Less than chance

0.01-0.20 Slight

0.21-0.40 Moderate 0.61-0.80 Substantial

0.81-0.99 Near perfect

Example data of 2x2 table format showing data distribution with balanced marginal

distribution

Rater 2 Total Yes No

Rater 1 Yes 83 4 87 0.87% No 12 51 63 0.63% Total 95 55 150

0.95% 0.55%

𝑃𝑜 = 51 + 83

= 0.89 150

87 𝑃𝑒 =

150 ×

95 +

150

55 ×

150

63 = 0.52

150

𝐾𝑎𝑝𝑝𝑎, 𝐾 = 0.89 − 0.52

1 − 0.52

= 0.77

123

Appendix E: Data Items

These data items were used to gather the relevant full-text data:

1. Citation details

2. Objective measures of spinal stiffness

- Measure/indicator

- Definition/description

3. Subjective measures of spinal stiffness

- Measure/indicator

- Definition/description

4. Surrogate definitions or measures of spinal stiffness

- Alternative descriptor

▪ Synonym

▪ Antonym

- Characteristic

124

Appendix F: Data abstraction tables

Data abstraction: Biomechanical theme

Functional spinal unit Cervical spine (n=4)

Reference Objective measure Measure/Indicator Definition/Description

(Panjabi et al., Two customised spine testing jigs Load – displacement No definition of stiffness reported

1986)

(McElhaney et Minneapolis Test Systems – servo-controlled Load – deflection Increasing stiffness explained in terms of

al., 1988) hydraulic testing machine (Hardening response)

(Wen et al., 3D coordinate systems Load – displacement The secant stiffness is the slope of the

1993) straight line calculated by a simple linear

regression of the loading part of a load-

displacement curve in the elastic zone

between the first point after the greatest

variation in the curve gradient and the

point with maximum loading.

(Dugailly et al.,

2017) A customized spine testing device Torque – angular displacement. 𝑆𝑡𝑖𝑓𝑓𝑛𝑒𝑠𝑠 (𝑁𝑚⁄⸰) =

∆ 𝑇𝑜𝑟𝑞𝑢𝑒𝐸𝑍

∆𝑅𝑂𝑀𝐸𝑍

125

Functional spinal unit: Thoracic spine (n=7)


(Tawackoli et

al., 2004) Custom designed spine testing machine Force – torque No definition of stiffness reported

(Myklebust et

al., 2004)

Axial compressive load experiments were Force – deflection Stiffness is defined as a measure of the

ability to withstand an external force

(Kayanja et al.,

2006)

Material Testing System Load – displacement No definition of stiffness reported

(Busscher et al.,

2009)

Custom designed four-point bending device Load – displacement The stiffness of a spinal segment is

generally calculated as the inverse slope

of a part of the load-displacement curve.

(Wolfla et al.,

2010)

Custom designed electro-hydraulic testing

device

Force – displacement Stiffness was defined as the slope in the

linear region of the force-displacement

response.

(Verkerke et al.,

2011)

Custom designed four-point bending device Moment – angular displacement Stiffness in the Neutral Zone was

calculated as the inverse of the slope in

the complete range of the Neutral Zone,

since this part of the curve showed linear

characteristics (Fig.

(Wagnac et al.,

2017)

Material Testing System Force – displacement Stiffness was defined as the slope of the

most linear portion of the curve, prior to

failure. Failure energy was defined as the

area under the force-displacement curve,

up to failure.

126

Functional spinal unit: Lumbar spine (n=14)


(Neumann et al.,

1993) Force and moment transducer Load – displacement Stiffness (K) was defined as the applied

load divided by the displacement

(T. A. Schmidt

et al., 1998) VICON cameras Torque – rotational displacement No definition of stiffness reported

(Dolan and

Adams, 2000)

Electromagnetic tracking device Bending – stiffness curves No definition of stiffness reported

(Parkinson et

al., 2004)

Custom designed spine testing jig Moment – angle relationship No definition of stiffness reported

(Caride et al.,

2005)

Custom designed spine testing apparatus

(unconstrained) Force – torque No definition of stiffness reported

Material Testing System (constrained)

(Gay et al.,

2007)

Custom designed spine testing apparatus Force – displacement No definition of stiffness reported

(Edwards et al.,

2009)

Custom designed spine testing apparatus Load – displacement No definition of stiffness reported

(Wachowski et

al., 2011)

Coordinate system Rotational angle – axial torque

characteristics

Hook’s law: law of physics that states

that the force (F) needed to extend or

compress a spring by some distance x

scales linearly with respect to that distance.

127

(van Engelen et

al., 2012)

Custom designed device – hydraulic material

testing system

Load – deflection No definition of stiffness reported

(Bisschop, Custom designed four-point bending device Load – displacement No definition of stiffness reported

Kingma, et al.,

2013)

(Stolworthy et Custom designed spine simulator Torque – rotational displacement (Nm/1⸰) Operational definition of Neutral zone

al., 2014) stiffness (Nm/1⸰) as the amount of torque required to cause 1⸰ of rotation within the

near constant-slope neutral- zone region.

(Borkowski et The restoring force method Moment – displacement No definition of stiffness reported

al., 2014)

(Amin et al., Six degree of freedom hexapod robotic Load – displacement No definition of stiffness reported

2016) testing system.

(Zirbel et al., DIP-Boltzmann presents several potential Torque – rotational displacement (Nm/1⸰) This stiffness represents the inverse of

2013) advantages in terms of standardizing the the slope of the line in the Neutral Zone. calculation of flexibility parameters (i.e.,

ROM, stiffness, and hysteresis).

128


(Quint and

Wilke, 1998) Custom designed spine testing device Load – angular deformation

Reduced mobility is considered to be a

stiffening of the motion segment, which

results in greater stability.

The segmental stability was defined by

the correlation of an applied moment to

the resultant deformation, as shown in

the load-displacement curves.

(Essendrop et

al., 2002)

Sudden Mechanical Perturbation

Co-measure-Electromyography

The stiffness of the spine was calculated

from the equation of motion of the system

after the release.

No definition of stiffness reported

(Petra et al.,

2003) Electromyography The summed muscle force relative to the

resultant net moment was calculated at the

instant of peak resultant net moment to

obtain an indication of the stiffness of the

spine.


(Bull Andersen

et al., 2004)

Sudden Mechanical Perturbation Stiffness is described as the force that

tends to restore the static equilibrium

(e.g. force constant of a spring calculated

as change in force divided by

displacement)

(Vera-Garcia et

al., 2006)

Sudden posterior loading

Co-measure-Electromyography

Force – displacement No definition of stiffness reported

Stability (active, passive, neural contribution to spinal stiffness) (n=16)

𝑑𝑇/𝑑𝑎 = 𝑠𝑡𝑖𝑓𝑓𝑛𝑒𝑠𝑠 (𝑁𝑚/𝑑𝑒𝑔𝑟𝑒𝑒) Torque – rotational displacement 3-SPACE isotrak system (McGill et al.,

1994)

129

(Moorhouse and

Granata, 2007)

Pseudorandom binary sequence of position

perturbations

Force – time No definition of stiffness reported

(Lee et al., Pseudorandom force perturbations The parameters were described as effective No definition of stiffness reported

2007) stiffness, effective damping, and effective

mass because the stiffness represented

combined behaviours from intrinsic and

reflexive stiffness, and the damping

represented combined behaviours from

intrinsic and reflexive damping.

(Bazrgari and A three-camera Optotrak system Loads on the human spine are influenced No definition of stiffness reported

Shirazi-Adl, not only by the gravity, inertia and external

2007) loads but also by the stiffness of the

ligamentous spine and forces in trunk

muscles.

(Cheng et al., Co-contraction of antagonistic muscles is Insufficient co-contraction and No definition of stiffness reported

2008) important to augment the stiffness of the neuromuscular control could decrease

spine. stiffness in the cervical spine.

(Chad et al., Spine Load and Stiffness Estimation: Force – time Stiffness is the closest quantifiable

2009) Electromyography surrogate of spine stability. With reference to the spine, stability can be thought of as ensuring sufficient stiffness by optimally coordinated muscle contraction and therefore stiffness around

the spine

(Howarth et al., Trunk muscle activity during wheelchair Trunk muscles are important for generating No definition of stiffness reported

2010) ramp accent active stiffness surrounding the spinal

column.

(Cheng et al., Co-contraction of antagonistic muscles is This indicated that the spinal stiffness of the No definition of stiffness reported

2014) important to augment the stiffness of the patients is predominantly taken up from the

spine.

130

(Lamberg and

Hagins, 2014)

(Shojaei et al.,

2018)

Intra-abdominal pressure increases the ability

for the lumbar and thoracic segmental control

by facilitating spinal stiffness.

Six trunk stiffness tests in upright posture

under (to estimate contribution to spine

stability)

Breath control is linked in predictable ways

to potentially improve lumbar spine

stiffness when presented with mechanical

challenges during functional tasks and

should be incorporated into physical

therapy interventions.

Changes in the moment and the lumbar

flexion angle


Spinal stability, in a biomechanical

sense, is defined as the capacity of the

system that provides spinal equilibrium

to sustain the equilibrium in the presence

of mechanical perturbations. Therefore,

spinal stability can partially be assessed

through measures of trunk bending

stiffness.

(Talebian et al.,

2018) Sudden perturbation Neck Stiffness calculated based on the

kinematic responses to the sudden

perturbation. The head and neck were

modelled as a linear second-order system,

with scalar coefficients of stiffness,

damping, and inertia.


muscle guarding phenomenon as well as

possible proprioceptive deficits.

131

Instability (n=7)


(Pope and

Panjabi, 1985) No objective measure of stiffness reported Load – deflection Stiffness was defined as the amount of motion

within a system relative to a load applied to the

structure.

Instability is defined from a biomechanical

perspective, as a loss of stiffness in the spine.

(Ashton-Miller

and Schultz,

1991)

No objective measure of stiffness reported Load – displacement Stiffness is generally defined as the ratio of the

applied load divided by displacement.

(Dolan et al.,

2005)

Mechanical Testing Apparatus Moment – angular rotation Bending Stiffness was defined as the gradient of the

tangent to the linear region of the graph at 20 Nm.

Biomechanical reviews agree that segmental

instability is best defined in terms of reduced

stiffness (reduced resistance to movement)

(Szust, 2006) Material Testing System – Bionix testing

machine

Load – displacement No definition of stiffness reported

(Pope et al.,

2006)

No objective measure of stiffness reported No objective measure of stiffness

reported

Instability is synonymous with a loss of motion

segment stiffness, such that force applied to that

motion segment produces greater displacement than

would be seen in a normal structure.

(Fry et al.,

2014)

Opto-electronic motion measurement

system.


(Sayson and

Lotz, 2015)

Spinal Kinematics with the KineGraph

Vertebral Motion Analyzer Measure in vivo spinal kinematics

to assess segmental stiffness and

biomechanical instability


132

Finite element model (n=22)


(Roberts et al.,

1969) Stiffness matrix Motion and deformation in the head-neck region. No definition of stiffness reported

(Yang and King, Materials testing machine Force – deformation No definition of stiffness reported

1984) Force – deflection

(Gardner-Morse

et al., 1990)

6 X 6 stiffness matrix The reported linear stiffnesses is either from 1) the

stiffness at a point on the curve (tangent stiffness),

or 2) a line between two points on the curve

(secant stiffness), or 3) the stiffness from a

relatively linear portion of the curve.


(Pitzen et al.,

2000)

Finite element model Values are given in N/mm for testing in axial

compression. Range of motion was used to

calculate the stiffness of the model.


(Panjabi et al.,

2000)

Center of rotation apparatus Load – displacement The stiffness test protocol, by

definition, requires the application

of one motion component and

measurement of the loads

generated.

The flexibility protocol is the

reverse, i.e., apply one

displacement component and

measure the resulting motions.

133

(van Deursen et

al., 2000)

Biomechanical computer model Vertical displacement and axial torsion. No definition of stiffness reported

(Ng and Teo,

2001)

Nonlinear Finite-Element Analysis Force – displacement No definition of stiffness reported

(Buford et al.,

2002)

Model Study (Spinal kinematics) Torsional stiffness No definition of stiffness reported

(Ng et al., 2003) Model study – 3D cervical spine finite

element model


(Gardner-Morse

and Stokes,

2004)

12 X 12 stiffness matrix. Load – displacement No definition of stiffness reported

(Hans et al.,

2009)

Custom-made 6D apparatus Force – displacement No definition of stiffness reported

(Iyer et al.,

2010)

Quasi-static stiffness-based biomechanical

model Force and moments No definition of stiffness reported

(Lafon et al.,

2010)

Virtual model (spine and pelvis) – 3D

stiffness distribution along scoliotic spine.

Vertebral displacements between standing and

bending positions were computed No definition of stiffness reported

(Kleinberger,

2010)

3D finite element model. Load – displacement The large strain axial stiffness of

the column was defined by the

peak load divided by the maximum displacement.

134

(Meijer et al.,

2011)

Finite element model Force and moments No definition of stiffness reported

(Graham and

Brown, 2012) EMG-driven biomechanical model Rotational stiffness was also calculated about

lateral bend (x-axis) and axial twist (y-axis) axes

by appropriate substituting of coordinates. To get

an estimate of overall stiffness, the Euclidean

norm of the stiffness about all three axes was

calculated.


(Karadogan and

Williams, 2012)

Three-dimensional static modelling Force and Moments No definition of stiffness reported

(H. Schmidt et

al., 2013) Poroelastic Finite Element model Shear stiffness and Load – displacement No definition of stiffness reported

(Ellingson et al.,

2016)

Three- dimensional non-linear Finite element

model

Load and moment data Stiffness explained in terms of

(Newton meters/Degree)

(Stokes and

Gardner-Morse,

2016)

Hexapod’ (Stewart platform) apparatus Force – displacement and Rotation – moment

data.


(Holewijn et al.,

2017)

Custom build spinal motion simulator Load – displacement No definition of stiffness reported

(Malakoutian et

al., 2018)

ArtiSynth biomechanical modelling toolkit. 6 × 6 stiffness matrix - Load – displacement No definition of stiffness reported

135

Total

biomechanical

studies (n = 70)

Total objective measures = 63

No objective measures = 3

Total subjective measure = 0

Total indicators = 4 Yes definition =24/70

No definition = 46/70

136

Data abstraction: Surgical theme

Biomechanics (n=20)

Reference Objective stiffness measure Measure/Indicator Definition/Description

(Ferguson et Minneapolis Test Systems Load – displacement Stiffness values are described in terms of

al., 1988) the moment (N-m) required to produce a unit shear (mm) or angular (degree)

displacement.

(Patwardhan Three-dimensional Finite element model of the Moment – angular displacement No definition of stiffness reported

et al., 1990) spine

(Stokes and Model study - Finite element model Hook distraction from the changes in the No definition of stiffness reported

Gardner- distance between the hook sites

Morse, 1993)

(Dahl et al., Material testing system Force – displacement Dynamic stiffness described in terms of

2006) force load per unit of displacement under

dynamic or high rate loading.

(X.-Y. Wang Shenzhen SANS Testing Machine Load – displacement The stiffness was defined as the linear

et al., 2008) slope of the curve. (load-displacement)

(Dickman et Minneapolis test systems – Bionix frame Load – displacement Dynamic stiffness described in terms of

al., 2009) force load per unit of displacement under dynamic or high rate loading

137

The slope of the loading curve provided

the measurement of the relative resistance

to motion (stiffness)

(Buttermann VICON motion measurement system Axis of applied motion derived from the Stiffness expressed in terms of (Nm/deg)

et al., 2009) flexibility curves of each specimen.

(Luo et al., Computer-controlled, hydraulic materials testing Load – deformation No definition of stiffness reported

2010) machine.

(Perrin et al., 3D measurement system Load – deformation The stiffness was defined as the quotient of

2011) the loading to the deformation and was

calculated for the elastic zone.

(Clin et al., Radiographic self-calibration technique Force – displacement No definition of stiffness reported

2011)

(Bisschop et Hydraulic materials testing machine Load – displacement Shear yield force (SYF) was defined as the

al., 2012) point at which shear load caused a decrease in stiffness, i.e. a decrease in the

slope of the load-displacement curve.

(Bisschop, Hydraulic materials testing machine Load – displacement No definition of stiffness reported

Van Dieën,

et al., 2013)

138

(Kingma et

al., 2013)

Hydraulic materials testing machine Load – displacement No definition of stiffness reported

(Daniels et

al., 2013)

Pendulum testing system Load and moment No definition of stiffness reported

(van Royen

et al., 2013)

Material testing system (optical system) Load – displacement Segmental stiffness is then inferred from

the relation between applied force and the

resulting displacement

(Tallarico et

al., 2014) Minneapolis test systems – Bionix frame Torque: range of motion No definition of stiffness reported

(van Royen

et al., 2014) Hydraulic materials testing machine Load – deformation stiffness expressed in terms of

(Nm/degree)

(Kingma et

al., 2014)

Hydraulic materials testing machine Load – displacement No definition of stiffness reported

(Drazin et al.,

2015)

MTS Bionix frame. Load – deformation. No definition of stiffness reported

Load – displacement

(Esmende et

al., 2015)

Pendulum testing system Newton-meter – degree No definition of stiffness reported

139

Intraoperative (n=14)

Reference Objective Stiffness measure Measure/Indicator Definition/Description

(Frank et al., Vertebral retractor Load – displacement Stiffness defined as the force needed to

1996a) distract adjacent vertebrae within a motion

segment.

(Frank et al., Sensor-equipped vertebral retractor system Load – displacement The stiffness (S) of a body that deflects a

1996b) distance (d) under an applied force (F) is

given by S=F/d

(M. Brown, Spinal Stiffness Gauge No quantification of objective measure No definition of stiffness reported

Wehman, et

al., 2002)

(M. Brown, Spinal Stiffness Gauge Force – displacement No definition of stiffness reported

Holmes, et

al., 2002)

(Hashimoto Spinal Distractor Load – displacement Distraction stiffness of the operative

et al., 2003) segment (N/mm) was calculated as the peak applied distraction force (N) divided by the displacement between the screws

(mm).

(Karami et Spinal Stiffness Gauge Load – displacement No definition of stiffness reported al., 2005)

140

(Tanaka et

al., 2006)

Spinal Distractor Load – displacement Stiffness was defined as the curve

produced during cyclic loading from 0-100

(N). More precisely, stiffness was defined

as the tangent stiffness at the middle range

of loading.

(Krenn et al.,

2008) Spinal Spreader Force – deflection The stiffness (S) of a body that deflects a

distance (d) under an applied force (F) is

given by S=F/d

(Ambrosetti-

Giudici et al.,

2009)

Computer-assisted spinal distractor includes Load – displacement No definition of stiffness reported

(Kitahara et

al., 2009)

Intraoperative measurement system Load – displacement Stiffness described as the relationship

between the load and displacement of the

spinal segment while rotation is applied.

The stiffness is operationally defined as the

slope of the line fitting the load-

displacement curve from 1 to 2mm on right

rotation and from 1 to 2 mm on left

rotation

(Hasegewa et

al., 2009)

Intraoperative measurement system Load – displacement Stiffness (N/mm) was defined as the slope

of the line fitting the load-displacement

curve from -15 mm to -10 mm on flexion

motion.

141

(Hasegawa et

al., 2010)

Intraoperative measurement system Load – displacement Stiffness was defined as the slope of the

line fitting the load-displacement curve

from –15 mm to –10 mm on flexion.

(Li et al.,

2013) Spinal Stiffness Gauge Load – displacement No definition of stiffness reported

(Hasegawa et

al., 2014)

Intraoperative measurement system Load – displacement load-displacement data stiffness (N/mm)

was defined as the slope of the line fitting

the load-displacement curve from - 15 mm

to -10mm on flexion.

142

Postoperative (n=31)

Lumbar Spinal Disability Index

Reference Subjective stiffness measure Measure/Indicator Definition/Description

(Hart, Gundle, et al., 2013) Lumbar spinal disability index

(LSDI)

Activities of daily living (ADLs) No definition of stiffness reported on LSDI

(Hart, Pro, et al., 2013) LSDI ADLs Stiffness operationally defined: Potential stiffness

expressed in terms of (loss of flexibility)

(Hart et al., 2014) LSDI ADLs No definition of stiffness reported on LSDI

(Kim et al., 2015) LSDI ADLs No definition of stiffness reported on LSDI

(Kimura et al., 2016a) LSDI ADLs No definition of stiffness reported on LSDI

(Zhang et al., 2017) LSDI ADLs No definition of stiffness reported on LSDI

(Choi et al., 2018) Korean (modified) – LSDI ADLs No definition of stiffness reported on LSDI

(Daniels et al., 2015) LSDI ADLs No definition of stiffness reported on LSDI

(Daniels et al., 2017) LSDI ADLs No definition of stiffness reported on LSDI

(Hart et al., 2017) LSDI ADLs No definition of stiffness reported on LSDI

(Ailon et al., 2018) LSDI ADLs No definition of stiffness reported on LSDI

143

Postoperative

Additional outcome measures

Reference Subjective Stiffness measure Measure/Indicator Definition/Description

(Million et VAS(VAS) – Back stiffness Verbal descriptor: Do you have any stiffness No definition of stiffness reported on

al., 1981) in the back? (No stiffness- intolerable VAS scale

stiffness)

(T.-C. Lee, Low back pain The authors found that a variable degree of No definition of stiffness reported

1996) stiffness of the low back was a very common,

although acceptable, complaint in the follow-

up interviews.

(Kaminsky et Neck stiffness was subjectively graded on a 1. No or occasional neck stiffness. No definition of stiffness reported for this

al., 2004) three-point scale 2. Intermittent or frequent neck scale. stiffness, but no difficulties with

activities of daily living.

3. Neck stiffness causing difficulty or

interfering with activities of daily

living (ADL’s).

(Dagenais et Prolotherapy Symptom Stiffness reported as a symptom of No definition of stiffness reported

al., 2005) prolotherapy injection

(Ohnari et Myelopathy Symptom Stiffness reported axial symptom of cervical No definition of stiffness reported

al., 2006) myelopathy

144

(O’Shaughne

ssy et al.,

2010)

Post-disc arthroplasty Soreness and stiffness of the lumbopelvic

region are frequently reported by patients

after this surgery

The second most frequently reported side-

effect was light to moderate stiffness of short

duration (12 to 24 hours).

The most frequent side-effects reported were

a slight increase in pain as well as minor to

moderate lower back stiffness.


(Lykomitros

et al., 2010)

Removal of cervical collar Resolution of stiffness after cervical collars

were removed


(Mori et al.,

2012)

VAS – Back stiffness low back discomfort as surrogate for heavy

feeling or stiffness

No definition of stiffness reported on

VAS scale

(Larson et

al., 2012)

VAS – Back stiffness No verbal descriptors No definition of stiffness reported on

VAS scale

(Rizvi et al., 2012)

VAS – Neck stiffness verbal descriptors: None/mild/severe No definition of stiffness reported on VAS scale

145

(Kawaguchi

et al., 2013)

The axial symptoms, such as the feeling of

limited neck motion and neck stiffness, were

assessed by a questionnaire.

Verbal description ‘‘Do you have any

problems with neck rotation when driving or

when someone calls out to you from behind

you?’’ When the symptoms were positive for

more than several months, and the patients

answered that the symptoms disturbed their

activities of daily living, the axial symptoms

were judged to be ‘‘present’’.


(Sherief et

al., 2013)

Myelopathy Symptom Stiffness reported symptom of cervical

myelopathy


(Mori et al.,

2015)

Stiffness classified as a type of pain Surrogate measure: Axial neck pain was

classified as 1 of 5 types as follows: pain,

stiffness, tension, tightness,


(Chivukula

et al., 2015)

Cervical dorsal rhizotomy Neck stiffness and a complication of

intradural cervical dorsal root rhizotomy


(L. Wang et

al., 2016)

VAS – Neck stiffness verbal descriptors: None/mild/severe No definition of stiffness reported on

VAS scale

(Guo, Chen,

et al., 2016)


VAS scale

146

(Guo, Zhang,

et al., 2016)


VAS scale

(Kimura et

al., 2016b)

SF-36 questionnaire

functional limitations on ADL caused by

lumbar stiffness resulting from lumbar surgery

21 items relating to basic ADL. Responses

were classified into 5 categories: A, “no

effect at all”; B, “a little effect”; C, “a

considerable effect”; D, “I cannot do this at

all”; and E, “no answer”.

No definition of stiffness reported on SF-

36 scale

(Zhu et al.,

2017)


VAS scale

(Iizuka et al.,

2017) VAS – Neck stiffness No verbal descriptors No definition of stiffness reported on

VAS scale

147

Scoliosis (n=11)

Reference Objective Stiffness measure Measure/Indicator Definition/Description

(Stokes and

Laible, 1990)

12 X 12 Stiffness Matrix (Finite element

model)

The stiffness matrices representing the

intervertebral motion segments were taken

from published data for the thoracic spine


(Duke et al., Finite element model Force – displacement No definition of stiffness reported

2005) Supine bending test

(Radiograph) Flexibility of the spine was decreased in the

upper thoracic and thoracic regions while the

stiffness of the lumbar spine was increased.

(Clamp et al., Fulcrum bending test The bending Cobb angle was measured from No definition of stiffness reported

2008) (Radiograph)

the fulcrum bending radiographs. Statistical analysis was used to relate the parameters to

the flexibility index.

(de Oliveria

et al., 2014)

Spinal suspension test (SST)

(Radiograph)

Force – displacement

The flexibility of the spine was calculated

based on the change of curvature induced by

the loading force.


148

The stiffness matrices have been mainly

defined according to Hooke’s law, which

is a linear approximation to the responses

of motion segments to loads. One of the

Force – displacement 6 × 6 stiffness matrix

(finite element model)

(Jalalian et

al., 2017)

149

mechanical properties, crucial for

characterizing the spine stiffness, is the

load-displacement relationships of the

spinal motion segments.

(Mahaudens

et al., 2010)

Antero-posterior (AP) and lateral standing

spinal digital radiographs.

After surgery, the spine becomes stiffer with

the decrease of the spinal range of motion


Traction and bending radiographs in supine

position

(Janssen et

al., 2013)

Radiographic analysis of the sagittal profile of

the spine and spinopelvic alignment

The human spine shows less rotatory

stiffness compared with other spines in

nature due to the occurrence of posteriorly

directed shear loads that act uniquely on

certain areas of the human spine


(Salmingo et

al., 2013)

Assessed the impact of implant rods on

scoliotic correction

Parameters such as flexibility or stiffness of

the scoliotic spine need to be considered. As

it is one of the major factors that influence

the outcome of the clinical operation.


(Rousseau et

al., 2014) Implications of hip surgery of spine stiffness Hip surgery must be carefully planned in the

case of stiff lumbar spine. No definition of stiffness reported

(H. Chen et Investigated body morphology (slender and Posterior shear loads were shown to play a No definition of stiffness reported

al., 2017) tall) adolescents on mechanical stiffness role in the rotational stiffness of the human

spine due to its unique biomechanical

loading.

Implicit use of mechanical stiffness

150

(Agarwal et

al., 2018)

Investigated the relationship between patient's

curve flexibility (determined using curve

correction under gravity) in juvenile idiopathic

scoliosis

The stresses on the rod were found to

increase with increased axial stiffness of the

spine

Spines longitudinal stiffness in tension

expressed in terms of Young’s modulus

(N/mm2)

Total

surgical

studies (n =

76)

Total objective outcome measures = 39

Total subjective outcome measures = 23

Total indicators =14

Yes definition = 23

No definition = 53

151

Data abstraction: Pathophysiological theme

Ankylosing Spondylitis (n=34)

Reference Subjective measure Measure/Indicator Definition/Description

(Kinsella et Subjective response of morning stiffness, The subjective evaluation was based on No definition of stiffness reported

al., 1967) duration and severity of morning stiffness patients' opinions, which were graded as

following showed “no change”, were

“worse” or “improved”.

(Hill et al., Clinical diagnosis of ankylosing spondylitis The term immobility stiffness or pain has No definition of stiffness reported

1976) been used to cover discomfort which starts

while the patient is at rest

(Hanly et al., Psoriatic spondyloarthropathy Presence of spinal pain and stiffness No definition of stiffness reported

1988)

(Hidding and VAS – stiffness Pain and stiffness were each assessed by No definition of stiffness reported on VAS

Van der asking the patient to describe his or her scale

Linden, perceived pain or stiffness on a 0 –10 cm

1995) horizontal VAS(0 = no pain or stiffness, 10

= worst pain or stiffness imaginable)

(Averns et VAS – stiffness No verbal descriptors No definition of stiffness reported on VAS

al., 1996) scale

(Ozgocmen Duration of morning stiffness (min) Duration of morning stiffness was No definition of stiffness reported

et al., 2000) indicated as time, in minutes, elapsed

between arising in the morning and the

development of noticeable improvement.

152

(Yaron et al.,

2002)

Clinical characteristics of patients with

psoriasis arthritis

Morning stiffness No definition of stiffness reported

(Gorman et

al., 2002)

Questionnaire Duration of morning stiffness (in minutes) No definition of stiffness reported

(Cardiel et

al., 2003)

Bath Ankylosing Spondylitis Functional

Index – VAS

Severity and duration of stiffness (0 hours

to 2 or more hours). 0 –100 mm with

“none” anchored at one extreme and “very

severe” at the other.


(Brandt et

al., 2004)

Bath Ankylosing Spondylitis Disease

Activity Index – VAS

The severity and duration of morning

stiffness.


(Dagfinrud et

al., 2004)

Ankylosing Spondylitis (AS) is a chronic inflammatory disease

characterised clinically by pain and

stiffness of the back


(Riyazi et al.,

2005)

WOMAC (Osteoarthritis index) Stiffness (2 items): after first waking and

later in the day

No definition of stiffness reported o

(J. Chen et

al., 2006) What is Ankylosing Spondylitis Pain and stiffness occur and limits

movement in the back and in other joints

that are affected


153

(Kaya et al.,

2007)

VAS – stiffness Morning stiffness No definition of stiffness reported on VAS

scale

(Sengupta

and Stone,

2007)


Activity Index – VAS Severity and duration of morning stiffness

Morning-related stiffness (0 – 100), where

0 = no stiffness and 100 = very severe

stiffness).

No definition of stiffness reported on VAS

scale

(Mengshoel

and

Robinson,

2008)


Activity Index – VAS Severity and duration of morning stiffness

The two extremes of the 0 – 100 mm line

were ‘no pain/ stiffness’ and ‘most severe

pain/stiffness’.

No definition of stiffness reported on scale

The stiffness items were modified to make

them more specific. Instead of asking about

general stiffness, we asked the patients to

indicate how they perceived stiffness in the

lumbar, thoracic and cervical spine.

The meaningful statements were coded, for

example under ‘stiffness’, and new

categories were developed, for example

‘stiffness and well-being’, ‘stiffness and

bodily awareness’, and ‘stiffness and hope’.

(Khoo et al.,

2008)


Activity Index – VAS

Stiffness and duration of morning stiffness

0 – 10 cm, for overall level of morning


scale

154

(Fendler and

Braun, 2009)

Prediction model from 2002 consisting of 7

variables for RA patients’ clinical symptoms

and examination played a major role:

Morning stiffness > 1hr No definition of stiffness reported

(Madsen et Bath Ankylosing Spondylitis Metrology Measures morning stiffness ranging from No definition of stiffness reported

al., 2009) Index (BASMI) – VAS (0 – 10cm)

(Jenks et al., Bath Ankylosing Spondylitis Disease Morning stiffness (range 0 – 10cm) No definition of stiffness reported

2010) Activity Index – VAS

(El Miedany The Multidimensional Patient-Reported Assessment of the duration of morning No definition of stiffness reported

et al., 2010) Outcome Measures (PROMs) Questionnaire; stiffness using “0 – 10cm” horizontal

visual analogue scale, as well as duration

of morning stiffness in minutes.

(Amine et Bath Ankylosing Spondylitis Functional Severity and duration of stiffness (0 to 2 h No definition of stiffness reported on VAS

al., 2010) Index – VAS or more). 0 – 100-mm with “none” scale anchored at one extreme and “very severe”

at the other

(Bal et al., Clinical characteristics of the patients with Duration of morning stiffness No definition of stiffness reported

2011) ankylosing spondylitis

(Ying-Yan et Bath Ankylosing Spondylitis Disease Intensity and duration of morning stiffness No definition of stiffness reported al., 2012) Activity Index – VAS

155

(Ibn Yacoub Gender and disease features in Moroccan Morning stiffness duration (minutes) No definition of stiffness reported

et al., 2012) patients with ankylosing spondylitis measured on a 0 – 100 VAS

(Hegde et al.,

2014) Ankylosing spondylitis The main clinical symptom is

inflammatory back pain typically occurring

at night and morning stiffness improving

after exercise. The pain, stiffness, and

limited mobility of the spine can cause

severe limitations in daily life activities.


(Addimanda Bath Ankylosing Spondylitis Disease 0 – 100 mm – stiffness intensity No definition of stiffness reported

et al., 2014) Activity Index – VAS Duration of morning stiffness

(Eroğlu et

al., 2014)

Demographic and clinical data in patients

with ankylosing spondylitis

Morning stiffness as an indicator of

ankylosing spondylitis


Duration of morning stiffness (minutes)

(Der Heijde

et al., 2014)

VAS 0–10- cm VAS – Morning stiffness No definition of stiffness reported on VAS

scale

Inflammation (morning stiffness)

(Boonen et

al., 2015)

Primary and secondary outcome measures

will be based on the DC-ART Ankylosing

Spondylitis Working Group Core Set.

Spinal stiffness (duration of morning

stiffness)


156

(Rodriguez

and Poddubnyy,

Signs and symptoms of Ankylosing

Spondylitis

Symptoms such as pain and stiffness No definition of stiffness reported

2015)

(Kalim et al.,

2017)

Radiographic and clinical disease activity

parameters in ankylosing spondylitis

Early morning stiffness duration (hours) No definition of stiffness reported

(Song et al.,

2017)

VAS VAS, 0–10 – The degree of fatigue and

morning stiffness was measured by a VAS,

with a higher score indicating severer

fatigue and morning stiffness.


Morning stiffness duration (min)

(Wadeley et al., 2018)

Bath Ankylosing Spondylitis Disease Activity Index – VAS

stiffness on waking and duration of stiffness (0 – 10cm)


157

Meningitis (n=10


(Anga et al., Febrile encephalopathy clinical signs of meningeal irritation No definition of stiffness reported

2010) (headache, stiff neck and kernig's sign)

(Baborie et Primary diffuse leptomeningeal gliomatosis Patient with a 2-month history of No definition of stiffness reported

al., 2001) intermittent abdominal pain, back

stiffness, and weight loss

(Bachan et Meningitis It is characterised by fever, severe No definition of stiffness reported

al., 2018) headache, nausea, vomiting, stiff neck,

photophobia, altered consciousness,

convulsion/seizures and coma.

(Bang et al., Tuberculous meningitis One or more of fever, headache, neck No definition of stiffness reported

2016) stiffness, vomiting, confusion, coma,

convulsions, cranial nerve palsies,

hemiplegia or paraplegia)

(Brouwer et Community-Acquired Listeria Triad of neck stiffness, fever and altered No definition of stiffness reported

al., 2006) monocytogenes Meningitis in Adults mental status.

(Lin et al., Postoperative meningitis after spinal surgery clinical triad of fever, neck stiffness and No definition of stiffness reported

2014) consciousness disturbance during the

postoperative period.

(Menaker et The diagnosis of bacterial meningitis Neck stiffness No definition of stiffness reported

al., 2005)

(A. G. Carcinomatous meningitis from primary On neurological examination, he had mild No definition of stiffness reported

Nicholson signet ring cell carcinoma of bladder neck stiffness, photophobia and was

et al., 2004) Kernig’s positive.

(Pagliano et Bacterial meningitis in childhood Fever and neck stiffness were the main No definition of stiffness reported

al., 2007) symptoms.

158

(Shin et al.,

2017)

Post lumbar puncture headache Intracranial bleed - subarachnoid

Throbbing = Occipital headache with

sudden onset, severe, constant. Prodromal

pain in one eye, ptosis, blunting of

consciousness, vomiting, stiff neck.

Meningitis = Acute occipital headache,

neck stiffness, fever, photophobia.


159

Spinal pathophysiology (n= 14)


(Alaya and Lumbosciatica revealing intramedullary lumbar spine stiffness No definition of stiffness reported

Osman, 2017) ependymoma

(Al-Herz et al., VAS- DISH How would you describe the overall level No definition of stiffness reported on VAS

2008) of morning stiffness you have had from scale the time you wake up? And, how long

does your morning stiffness last from the

time you wake up?). They were all scaled

from 0 to 100 mm, 0 being none and 100

being extreme, except for the duration of

stiffness VAS which was scaled from 0 to

120 min.

(An and Intervertebral disc degeneration (IDD) With disc degeneration, biomechanical No definition of stiffness reported

Masuda, 2006) changes in the intervertebral disc and the

motion segment follow. In the early stages

of disc degeneration, the involved motion

segment is less stiff than in the advanced

stages, particularly in flexion-extension

(Datar et al., Retroclival Hematoma due to Odontoid He presented to the hospital 6 weeks after No definition of stiffness reported

2013) Fracture falling from standing height, with

(case report) headache, neck pain, and stiffness.

Following that episode, he started

experiencing headache, neck pain, and

stiffness.

No definition of stiffness reported The interviewer also asked about the

presence, duration and location of

morning stiffness. If morning stiffness

was present, the interviewer asked what

its duration was (possible answers were:

Interview questions about pain and morning

stiffness

(de Schepper

et al., 2012)

160

less than half an hour, half an hour to 1 h

or more than 1 h), and where it was

located. The location of the stiffness was

divided in (1) legs, (2) arms, (3) back

and/or neck, and (4) legs and arms and

back. Spinal morning stiffness was

present if the participant answered that the

morning stiffness was located at ‘3’ or

‘4’. Morning stiffness in the legs was

defined as stiffness in location ‘1’ or ‘4’.

Back pain is often defined as pain

possibly with muscle tension or stiffness,

localized below the costal margin and

above the inferior gluteal folds, with or

without radiating leg pain

(Gilbert et al.,

2011)

M. D. Anderson Symptom Inventory–Spine

Tumor Module [MDASI-SP]

Items originally included in MDASI-SP

1. Neck stiffness

2. spine pain (dull, sharp, or

burning)

3. spine pain radiating or spreading

to neck, trunk, arms, or legs

4. numbness or tingling in neck,

trunk, arms, legs, or crotch 5. weakness in arms

6. weakness in hands

7. difficulty using arms or legs

8. weakness in legs

9. difficulty walking

10. loss of control of urination

(incontinence) 11. difficulty urinating on one’s own 12. loss of control of bowels


161

13. change in bowel pattern

(diarrhoea or constipation) 14. sexual function

15. trouble caring for oneself (eating,

grooming, toileting, or dressing)

16. difficulty completing tasks

(Hosalkar et

al., 2008)

Congenital Osseous Anomalies of the Upper

Cervical Spine

Neck pain and stiffness have been

reported to be a presenting complaint in

patients with upper cervical anomalies


(Kuperus et

al., 2018)

Diffuse idiopathic skeletal hyperostosis

(DISH)

Increased spinal stiffness may play a more

important role in the increased fracture

risk of and the typical fracture patterns

observed in individuals with DISH.

The ankylotic effect of the bridging

ossifications in DISH is often not

significant enough to be perceived by a

patient (e.g., he/she experiences stiffness

in a portion of the spine), the

biomechanical effects should be large

enough to measure.


(Lemus et al.,

2015)

Traumatic Atlanto-axial subluxation Spontaneous stiffness of the patient’s

neck


162

(Mata et al.,

1997)

Diffuse idiopathic skeletal hyperostosis

(DISH)

The principal symptoms are stiffness and

non-radicular pain about the spine and the

enthesis


(Nibu et al., Neck dissection questionnaire (NDQ) NDQ developed by Nibu et al., was used No definition of stiffness reported

2010) to assess quality of life after neck

dissection. These items were: (1) neck

stiffness, (2) neck constriction, (3) neck

pain, (4) neck numbness, (5) shoulder

drop, (6) reach above, and (7) neck

appearance

(Wassenaar et The diagnosis of osteoarthritis Osteoarthritis of the cervical and lumbar No definition of stiffness reported

al., 2009) spine was present when there was pain

and/or stiffness in the cervical or lumbar

spine region on most days

(Y. W. Wong Spinal epidural hematoma Possible risk factors for spinal epidural No definition of stiffness reported

and Luk, hematoma include stiffness along the

2008) fusion block

Systemic cause (n=7)


(Huston et al.,

1956)

Non-paralytic poliomyelitis Painful stiffness of the neck and Back were

common physical signs. An objective

observation of limited flexion was much

more common than a subjective complaint

of pain. Stiffness of the neck was as

common as spinal stiffness in patients

exhibiting paralysis or poliomyelitis virus

excretion. However, it was also found in

many patients in whom the clinical

diagnosis of poliomyelitis was not made.

The state of anxious alertness characteristic


163

(Gerber et al.,

1984)

Vertebral abnormalities associated with

synthetic retinoid use

Symptoms of stiffness and tenderness upon

compression of the long bones were noted

In addition, a pattern of axial stiffness and

arthralgias has been noted.


(Solomon et

al., 2008)

Japanese encephalitis virus Neck stiffness No definition of stiffness reported

of poliomyelitis was seen more often,

usually associated with stiffness of the

neck and spine.

Prolonged early morning stiffness, which is

considered an indicator of inflammatory

musculoskeletal disease,

No definition of stiffness reported Early morning stiffness, defined as

stiffness in the morning on rising, lasting

for at least 1 hr.

The diagnosis of fibromyalgia syndrome.

Clinical characteristics were reported as

symptom description and physical

examination findings

(Fitzcharles

and Boulos,

2003)

164

No definition of stiffness reported Presenting with an unusual symptom

complex that consisted primarily of neck

stiffness, neck pain, and dysphagia.

Retropharyngeal Ganglioneuroma

Presenting with Neck Stiffness

(Gary et al.,

2010)

165

(Djukic et al.,

2012)

Lyme neuroborreliosis Patients with headache and fever displayed

more often neck stiffness.


(Perry et al.,

2013)

Decision Rules to Rule Out Subarachnoid

Hemorrhage

Patients with subarachnoid haemorrhage

were older and had more rapid peaking

headaches, onset during exertion, loss of

consciousness, neck pain or stiffness, and

vomiting.


166

Spinal pain (n=16)


(Jacobson et al., VAS[VAS] – Back stiffness (selected Verbal descriptor: “no stiffness” on the No definition of stiffness reported on VAS

2002) bedding system) far-left side of the line and “extreme

stiffness” on the far-right side of the

line.

scale

(Richter et al., VAS– Neck stiffness Symptoms. Presence, location, time of No definition of stiffness reported on VAS

2004) (WAD)

onset after collision, and severity (by a

VAS, where 1 is, for example, ‘‘no

pain/stiffness’’ and 10 is ‘‘maximum

imaginable pain/stiffness’’.

scale

(Farasyn and

Meeusen, 2006) The Backache Index 4-point score per outcome. The observer

noted down the scoring outcomes, and

the sum of the five outcomes yields the

‘‘Backache Index’’ or BAI with a

maximum of 15 points.

No definition of stiffness reported on BAI

(Dagenais et al., Side effects related to prolotherapy for back Post injection stiffness No definition of stiffness reported

2006) and neck pain.

(Kimhi et al., 2007) The duration of morning stiffness was

recorded.

Duration of morning stiffness (in

minutes) No definition of stiffness reported on scale

(Ylinen et al.,

2007)

VAS– neck stiffness VAS, range from 0 (no symptoms) to

100 (severe symptoms and unbearable

pain),


scale

(Yip et al., 2007) VAS– neck or back The low back or neck stiffness (0 = no

stiffness and 10 = stiffness ‘as bad as it

could be’)


scale

167

(Rydevik et al.,

2008)

Whiplash injuries and associated disorders Neck symptoms in terms of pain and

stiffness with or without objective

clinical findings are the most important

and common symptoms associated with

whiplash injuries. Neck motion may be

considerably restricted because of pain

but also due to stiffness. Neck pain often

occurs soon after a whiplash trauma,

while stiffness can occur later.


(Grenier and

McGill, 2008)

Low back pain and spine stability The passive stiffness was combined with

active stiffness generated by the muscles

and calculated using the moment

distribution.


They appeared to stiffen the torso

muscles which stabilize the spine

partially via additional compression to

the column.

(Luca Vismara,

Francesco

Menegoni, Fabio

Zaina, Manuela

Galli, Stefano

Negrini, 2010)

Obesity-related thoracic stiffness Thoracic stiffness with normal lumbar

ROM appears to be a feature of obesity No definition of stiffness reported

(Keeling et al.,

2012)

The 6-item questionnaire to assess

Inflammatory low back pain.

Has the back been stiff, especially in the

morning [morning stiffness]?


Do you experience stiffness in your back

and/or hips [YES]/[NO]?

168

A: When you get out of bed

B: Afternoon

C: Evening

D: No consistent time

(Walker and

Williamson, 2009)

Potential signs and symptoms of ILBP or

MLBP

Stiffness after resting (includes sitting) No definition of stiffness reported

(Farasyn et al.,

2013)

The Backache Disability Index. Morning back stiffness score (MBS)

with a maximum of 5 points.


(Ferreira and de

Luca, 2017)

Low back pain The pathoanatomical changes at the

spinal segment result in stiffness


(Tomczyszyn et al.,

2018)

Interview question Have you experienced low back pain,

i.e., long-lasting pain or stiffness within

the last 12 months? Yes/No


(Arnbak et al.,

2018) The Calin Criteria At least 4 of 5 of Back pain >3 months

Age at onset <40 years Insidious onset

Morning stiffness Improvement with

exercise


Mandatory: Back pain >3 months

At least 2 of 4 of:

Morning stiffness >30 minutes

Improvement with exercise but not with

rest. Waking in the second half of the

night because of back pain Alternating

buttock pain


“ “ The Berlin criteria

169

Total studies in

Pathophysiological

theme (n = 81)

Total subjective outcome measures =

39

Total indicators = 42 Yes definition = 0

No definition = 81

170

Data abstraction: Segmental assessment

Segmental Stiffness Assessment (n=106)

Reference Manual and/or Mechanical stiffness

measure

Measure/Indicator Definition/Description

(Howe et al., 1983)

Mechanical

Goniometer The angle between the two positions of the

pointer was measured and divided by 2 to

give the average.


(Maitland,

1986)

Manual

Posterior to anterior spinal mobilisation

(P/A) force, or ‘springing’, applied to the

spinous process.

Evaluation of segmental hypomobility

based in part on tests of passive

intervertebral movement


(Jull and

Bullock, 1987)

Manual

P/A spinal stiffness assessment Thoracic and lumbar: palpation of

intersegmental motion and manual PA

pressures L1–L5, rated on a 5-point scale.

The stiffness properties of the materials

comprising the joint are perceived manually

as a consistently increasing resistance which

then limits movement. Any change in the

stiffness properties of the joint are perceived

as changes in the nature and quality of

resistance.

Manual

171

(Michael Lee

and Svensson,

1990)

P/A spinal stiffness assessment The stiffness is perceived by feeling the

resistance to translation which is offered by

the spinous process of the vertebra during

PA mobilisation movements.

The stiffness is the ratio of change in

applied force to change in displacement

Mechanical

The Spinal Physiotherapy Simulator (SPS) Force – displacement The gradient of the regression line was

designated as the stiffness coefficient.

(Maher and

Latimer, 1992)

Manual

Segmental mobility tests Perceived range of movement and

resistance be used to make a judgement

about spinal compliance or stiffness.


(M Lee and

Svensson,

1993)

Manual

P/A spinal stiffness assessment Clinicians often apply posteroanterior

forces over a spinous process of a vertebra

to assess the resistance to movement.

Information about the degree and nature of

perceived resistance to posteroanterior

movement is used to help make a diagnosis

and select treatment techniques.


Mechanical

The Spinal Physiotherapy Simulator (SPS) Force – displacement The gradient represents the stiffness of the

movement, designated K (N mm), and the

X-intercept, designated C (mm), indicates

the amount of low stiffness displacement.

172

(Michael Lee et al., 1993)

Manual

P/A spinal stiffness assessment Clinician judged: P/A stiffness testing at the

T4 and T5 spinal levels.

‘Spinal’ stiffness is perceived by feeling the

resistance provided by the patient

Mechanical

The Spinal Physiotherapy Simulator (SPS) Force – displacement The stiffness coefficient ‘K’, the gradient of

the regression line.

(Maher and

Adams, 1994)

Manual

P/A spinal stiffness assessment Clinician judged: P/A pressures to L1-L5

rated on an 11-point scale

The scale ranged from - 5 (markedly

decreased stiffness) to 5 (markedly

increased stiffness), with 0 representing normal stiffness.


(Jull et al.,

1994)

Manual

Passive accessory and physiological

intersegmental movements from CO-l to

C6-7

Cervical; Manual PAIVM assessment of

segmental tissue stiffness and the presence

or absence of symptomatic joint dysfunction.

The relationship between displacement and

the nature of tissue resistance to

displacement

(Binkley et al.,

1995)

Manual

P/A spinal stiffness assessment Clinician judged P/A accessory mobility at

L1 – L5-S1

Stiffness was recorded on an 11-point scale,

from -5 (markedly reduced stiffness) to 5

(markedly increased stiffness), with 0 being

normal stiffness.

Segmental stiffness described in terms of

increased or decreased mobility (i.e.,

(hypermobility and hypomobility).

173

(Viner and

Lee, 1995)

Manual

P/A spinal stiffness assessment Clinician judged stiffness assessment at L1

– S1 To make an assessment of the stiffness, the

therapist takes note of the displacement of

the tissues under his or her hands and the

amount of force needed to produce that

displacement.

Mechanical

Force plate Vertical and horizontal ground reaction

force to the manually applied oscillating

force to each spinal level


(Maher and

Adams, 1995b)

Manual

P/A spinal stiffness assessment

Stiffness reference device

Clinician judged: P/A stiffness of human

spines compared to a series of metal springs

was recorded on an 11-point scale, from -5

(markedly reduced stiffness) to 5 (markedly

increased stiffness), with 0 being normal

stiffness.

Stiffness is expressed in terms of how much

force is required to produce a given

deformation.

(Jull, 1995) Manual

P/A spinal stiffness assessment (Surrogate measure) Jull and bullocks use

of the term ‘motion’ to describe the

combined measure of both displacement

and resistance to that displacement.

One common method of describing the

movement is in terms of its stiffness or the

slope of the force-displacement curve.

174

(Simmonds et

al., 1995)

Manual

Passive motion testing The degree to which the spinal model

simulated normal motion was assessed

using two 11-point numerical rating scales.

(least stiff, medium stiff, most stiff) For

each level of stiffness, the therapists were

asked to grade the spinal model according

to how well it simulated normal physiologic

motion.

Intervertebral ''fixations'' (i.e., a stiff or

locked motion segement.

(Maher and

Adams, 1995a)

Manual

Mechanical device incorporating metal

springs was used to generate the stiffness

stimuli.

Clinician judged: whether the second

stimulus was "greater" or "less" in stiffness

than the first stimulus


(Maher and

Adams, 1996)

Manual

Mechanical device that generates purely

elastic stiffness stimuli similar to the PA

stiffness of the human spine was used to

provide the stiffness stimuli.

Clinician judged: by pushing on the

stimulus once or twice with either vision

occluded or not occluded and to rate the

stiffness on a 1 to 5 scale.

There are a number of terms used to

describe the quality of the movement. The

most common describes the movement in

terms of its stiffness, i.e. the load/

displacement relationship.

(Latimer et al.,

1996)

Manual

P/A spinal stiffness assessment Clinician applied P/A force to the Lumbar

spine.

Stiffness is perceived by estimating the

amount of force applied and the amount of

displacement that results.

Mechanical

The Portable Stiffness Device Force – displacement Stiffness is equal to the slope of the linear

portion of the force-displacement curve.

Mechanical

175

(Raymond and

Evans, 1997)

P/A mobilisation Specifically, designed loading frame

applied P/A mobilisation to L4 spinous

process


(Michael Lee

et al., 1997)

Mechanical

Portable Stiffness Measuring Device. Force – displacement In the region from 30 to 100 N, the response

has been characterized by describing the

gradient of this linear region (that is, the

stiffness coefficient, K)

(L. L.

Nicholson et

al., 1998)

Manual



stimuli.

Clinician judged: both samples of the

stimuli and then to judge whether the

second stimulus was 'stiffer' or 'less stiff'

than the first.


(Michael Lee

et al., 1998)

Mechanical

The Spinal Physiotherapy Simulator (SPS) Force – displacement No definition of stiffness reported

(Edmondston

et al., 1998)

Mechanical

Spinal Posteroanterior Mobilization

Apparatus (SPAM)


Manual

176

(Maher,

Latimer, et al.,

1998)

P/A spinal stiffness assessment Lumbar: manual PA pressures to L3 rated

on an 11-point scale assisted by a stiffness

reference device and compared to

instrumented oscillating PA pressures

One common method of describing the

movement is in terms of its stiffness or the

slope of the force-displacement curve. These

authors cited (Jull, 1995, p. 522)

Mechanical

The Stiffness Assessment Machine Force – displacement Stiffness is obtained by calculating the slope

of the linear portion of the force-

displacement curve above 30 N. The second

measure (D30) characterizes the toe, region

of the force-displacement curve and is

obtained by measuring the displacement to

30 N.

(Maher,

Simmonds, et

al., 1998)

Manual

P/A spinal stiffness assessment The relationship among P/A pressure

descriptors were examined using cluster

analysis.

Stiffness descriptors described in terms of

three superclusters (limited mobility,

increased mobility, and viscoelasticity)

(Latimer et al.,

1998)

Manual

P/A spinal stiffness assessment The P/A pressure test is used to provoke the

patient's pain and to identify areas of

increased stiffness, manual therapists

perform the central posteroanterior (PA)

pressure test, which involves the therapist

applying an anteriorly directed force over

the spinous process of the prone patient.

Increased tissue resistance to displacement

(i.e., increased stiffness) Stiffness being the

relationship between load and deformation

Mechanical

Mechanical spinal indentation Force – displacement The slope of the regression line is defined as

the stiffness coefficient

Mechanical

177

(Maher et al.,

1999)

The Stiffness Assessment Machine (SAM) Force – displacement No definition of stiffness reported

(Edmondston

et al., 1999)

Manual

P/A spinal stiffness assessment The diagnosis of symptomatic segmental

hypomobility is based in part on tests of

passive intervertebral movement, which

include testing the response to

posteroanterior (PA) pressure applied to the

spinous process.

Stiffness expressed in terms of the

therapist's perception of the range and

resistance to movement (stiffness), and the

associated symptom response.

Mechanical

Spinal Posteroanterior Mobilisation

Apparatus

Force – displacement Stiffness coefficient (in N/mm) was

calculated from the slope of the line of best

fit using linear regression analysis.

(Brodeur and

DelRe, 1999)

Mechanical

The Portable Stiffness Device Force – displacement No definition of stiffness reported

(Keller et al.,

2000)

Manual

P/A spinal manipulation The clinician takes note of the stiffness felt

during mobilization palpation procedures.

The displacement of the vertebra and the

resistance to the displacement.

Spinal stiffness or the load/displacement

response

Stiffness is expressed in terms of (mobility)

Manual (objective)

178

(L. L.

Nicholson et

al., 2000)



stimuli.

Clinician judged spring stiffness comparing

sample baseline stiffness stimuli to a

second stiffness stimuli

The relationship between the force applied

to the spine by the hand of the therapist and

the displacement that occurs at the point of

force application determines "spinal elastic

stiffness" and is described by the equation

𝑆𝑡𝑖𝑓𝑓𝑛𝑒𝑠𝑠 = 𝐹𝑜𝑟𝑐𝑒 𝑎𝑝𝑝𝑙𝑖𝑒𝑑/ 𝑑𝑖𝑠𝑝𝑙𝑎𝑐𝑒𝑚𝑒𝑛𝑡

(Goodsell et

al., 2000)

Mechanical

A stiffness measurement device was

custom-made to quantify central P/A force

Force – displacement The stiffness coefficient (K) is the gradient

of the regression line fitted to the data between 30 and 90 N

(Keller and

Colloca, 2000)

Mechanical

Activator Methods Chiropractic Technique

(AMCT) assessment protocol; Dynamic

stiffness assessment protocol


(Colloca and

Keller, 2001)

Mechanical

Activator Methods Chiropractic Technique

(AMCT) assessment protocol; Dynamic

stiffness assessment protocol


(L. L.

Nicholson et

al., 2001)

Mechanical

The stiffness Assessment Machine (SAM) Force – displacement The stiffness coefficient K is the slope of the

regression line between 30 and 90 N of

applied force.

(Kiviniemi et

al., 2001)

Manual

Posteroanterior (PA) force, or ‘springing’,

applied to the spinous process.

Clinician applied P/A mobilisation at L1-3

and L5

Through this technique, the physiotherapist

gains an impression of the movement

response to load, or stiffness.

Mechanical

The Spinal Posteroanterior Mobilization Force – displacement No definition of stiffness reported

Mechanical

179

(Gregory N.

Kawchuk and

Fauvel, 2001)

Spinal indentation equipment with subject

restraint system.

Force – displacement The most accurate method of stiffness

determination of curvilinear data is to

determine the slope of tangent lines fit to

small sections of the curve.

(Squires et al.,

2001)

Mechanical

Stiffness Assessment Machine (SAM) Force – displacement The stiffness coefficient (K) is the gradient

of the regression line between 30–90N of

the stiffness curve, with units of Newtons

per millimetre

(Gregory N.

Kawchuk and

Fauvel, 2001)

Mechanical

Spinal indentation equipment with subject

restraint system.

Force – displacement The most accurate method of stiffness

determination of curvilinear data is to

determine the slope of tangent lines fit to

small sections of the curve.

tissue stiffness or the slope of the Force –

displacement curve

(Petty et al.,

2002)

Mechanical


(Keller and

Colloca, 2002)

Mechanical

5-degree-of-freedom (DOF) mass,

massless-spring, and damper model of P/A

motion response of the lumbar spine.

The spring element of each FJS is assumed

to have a linear force-deflection

relationship, following Hooke’s law, F ⫽ kx,

where k is the stiffness coefficient (N/m)

and x is the deflection (m

180

(L. L.

Nicholson et

al., 2003)

Manual (Objective)

Mechanical device for stiffness testing was

a hydraulic device incorporating a spring-

return plunger in a water-filled cylinder

Clinician judged: whether the second

stiffness stimulus was more or less stiff

than the first

Elastic stiffness, defined as the force (in

Newtons) required to displace a stiffness

stimulus by 1 mm.

(Chiradejnant

et al., 2003)

Manual


Reference-based protocol

A stiffness reference device was used to

anchor judgements of stiffness based on an

11-point scale. Raters were also told to

concentrate on the loading portion of the

force-displacement curve when trying to

match the stiffness.

Stiffness expressed in terms of the amount

of force applied to the displacement

produced (i.e., stiffness)

(Shirley et al.,

2003)

Mechanical

The Stiffness Assessment Machine Force – displacement Stiffness is defined as the average slope of

the linear region of the force-displacement

curves for oscillation cycles 2 through 5

(Colloca et al.,

2003)

Manual

P/A spinal stiffness assessment Lumbar: PA manipulative thrusts with

modified Activator Adjusting Instrument at

L4 and L5

Biomechanical assessments of the spine

using motion palpation procedures for the

presence of “fixation” (increased stiffness or

restricted mobility)

Mechanical

A motorized vertical/horizontal table. An

Activator Adjusting Instrument (AAI)

equipped with a preload control frame and

impedance head (load cell and

accelerometer) was then used to deliver PA

manipulative thrusts

Force – velocity No definition of stiffness reported

181

(Colloca and

Keller, 2004)

Mechanical

Handheld impulsive mechanical device

equipped with an impedance head (load

cell and accelerometer)

Force – acceleration Apparent mass or apparent mass modulus is

the ratio of the force input and acceleration

response of the spine. The apparent mass is

a measure of the dynamic stiffness of the

spine since it is directly related to the

mechanical impedance and apparent

stiffness.

(R. Lee et al.,

2005)

Manual

P/A mobilisation Spinal stiffness is simply determined

according to the magnitude of the movement

detected or perceived by clinicians. (does

not take into account the loads exerted onto

the spine).

Previous definitions of spinal stiffness did

not take into account the magnitude of force

applied and the geometry of the spine.

(Abbott et al.,

2005)

Manual

The central posteroanterior passive

accessory intervertebral motion (PAIVM)

test

The passive physiological intervertebral

motion (PPIVM) test

Practitioner-judged: hypomobility (PA

pressures and intersegmental movement.

Kinetics relevant to spinal segmental

motion, such as stiffness, viscoelasticity, or

force-displacement characteristics.

Parameters of segmental mobility, such as

stiffness or viscoelasticity.


182

(Sran et al.,

2005)

Manual

P/A mobilisation It can be applied at an individual spinous

process to assess stiffness at a specific

segmental level.

Stiffness is a term used to describe the force

needed to achieve a certain deformation of a

structure.\

Mechanical

Precision optoelectronic camera system and

a custom spine testing machine

Moment – angular rotation Stiffness during PA mobilization was

determined as the slope of the PA force

versus T6–T7 rotation angle curve for the

loading portion of the curve between the two force limits (50–200 N)

(Tsung et al.,

2005)

Manual

Clinician applied mobilisation to the

lumbar spine by which the 3-dimensional

movements of the lumbar spine were

measured by an electromagnetic motion

tracking system

Load – deformation The load-deformation characteristics would

allow one to assess the stiffness of the spine

that could be altered by clinical pathologies.

Axial rotation stiffness of the lumbar spine,

which was defined as the ratio of the

amplitude of the twisting moment to the

amplitude of the axial rotation of the spine.

The bending stiffness of the spine was

derived from the relationship between the

mobilisation force and the change in spinal curvature.

(Hodges et al.,

2005)

Mechanical

The Spinal Physiotherapy Simulator (SPS) Force – displacement No definition of stiffness reported

Manual

183

(Fernández-de-

las-Peñas et al.,

2005)

Manual lateral glide test Cervical goniometric device manufactured

Manual segmental stiffness characteristics

such as hypomobility and Intervertebral

motion restriction.


(Maitland et

al., 2005)

Manual

P/A spinal stiffness assessment P/A oscillatory forces to the spine to assess

vertebral movement and its resistance, (i.e.,

spinal stiffness.)

Assessing spinal stiffness is suggested to

reflect mechanical properties.

P/As are intended to localize and assess the

dysfunctional intervertebral movement.

Therapists use information from PA motion

assessment to guide manual treatment

choices.


(Snodgrass et

al., 2006)

Manual

P/A spinal stiffness assessment Therapists use their perception of a spine’s

resistance to movement

Stiffness is a measure of force and

displacement (i.e., nonlinear resistance to

movement—or stiffness)

(Wilder et al.,

2007)

Manual

P/A spinal stiffness (in chiropractic, the

method might be called motion palpation or

joint end-play assessment).

The clinician typically will use the palm of

his or her hand to press on the spine and

feel for restricted movement.


Mechanical

Mechanically assisted indentation

Posteroanterior stiffness device


Manual

184

(Owens et al.,

2007)

P/A spinal stiffness assessment Practitioner-judged: Stiff or not stiff on a 2-

level scale to assess spinal joint stiffness

(yes or no).

Co-measure: Range of motion and

tenderness


Mechanically assisted

Mechanically assisted indentation

Posteroanterior stiffness device


(Snodgrass et

al., 2008)

Mechanical

The cervical spine stiffness assessment

device

Force – displacement Stiffness was defined as the slope of the

linear region of the force-displacement

curve (coefficient K).

(Stanton and

Kawchuk,

2008)

Mechanical

Assisted indentation Force – displacement P/A stiffness is a combined response of soft

tissue deformation and rigid body displacement.

(Gombatto et

al., 2008)

Mechanical

Passive movement device and a six-

camera, three-dimensional motion capture

system consisting of a table, platform,

moveable cradle, two force transducers,

and a guide

Torque – angular displacement In the biomechanics literature, stiffness is

often defined as the slope of the torque-

angle curve

(Tuttle et al.,

2008a)


Passive movement assessment device

(PMAD)


Use of displacement/stiffness

interchangeably

Manual

185

(Tuttle et al.,

2008b)

P/A spinal stiffness assessment Practitioner-judged unilateral P/A to

segment selected by physiotherapist as

being hypomobile and most likely to be

contributing to symptoms.



Posteroanterior Movement Assessment

Device (PMAD)


(Ferreira et al.,

2009)

Manual

P/A spinal stiffness assessment Practitioner-judged: stiffness (PA

pressures) on an 11-point scale, assisted by

a stiffness reference device. Raters were

also told to concentrate on the loading

portion of the force-displacement curve

when trying to match the stiffness.


Mechanical


(van Trijffel et

al., 2009)

Manual

Passive intervertebral motion (PIVM) Practitioner-judged; Maitland’s movement

diagram for grading mobility and a three-

point scale (hypomobile, normal,

hypermobile)

For classifying end-feel, scales were used

with terms like ‘hard’, ‘empty’, ‘springy’,

and ‘stiff’ reported most often.


Manual (survey instrument)

186

(Abbott et al.,

2009)

The central posteroanterior passive

accessory intervertebral motion (PAIVM)

test

The passive physiological intervertebral

motion (PPIVM) test

Survey instrument distributed to New

Zealand Manipulative Physiotherapists. In

the first question, participants were asked to

choose (on a Likert scale) how accurate

they believe each of the physical

assessment procedures (PAIVMs and

PPIVMs) are for estimating the quantity of

movement present at a lumbar segment. In

the second question, participants were

asked the quantity of movement present at a

lumbar segment. In the second question,

participants were asked if they believe that

it is possible, from the clinical examination,

to recognise restricted or excessive lumbar

segmental motion.

Quality of resistance (e.g. greater or lesser

stiffness, force-displacement relationship)

(Stanton and

Kawchuk,

2009)

Manual

P/A spinal stiffness assessment Practitioner judged; The resulting

impression formed by the clinician during

the pressure test is then used to judge if the

spine is too compliant (hypermobility), too

stiff (hypomobility), or within normal

limits.


Mechanical

Assisted indentation device Force – displacement Global Stiffness expressed as the slope of

the force-displacement data

Mean Maximal Stiffness expressed in terms

of the peak force/peak displacement

Manual

187

(Snodgrass et

al., 2009)

P/A mobilisation 1 of 4 grades as defined by (Maitland et al.,

2005) their choice of grade determined by

their interpretation of a patient's spinal

stiffness and the treatment aims

The level of resistance or stiffness of the

mobilized subjects' tissues would likely

affect the level of force applied for

particular mobilization grades.

Mechanical

Cervical spine stiffness was measured

using a Customised device that applied 5

consecutive mechanical force oscillations

with a steel probe at a speed of 1 Hz to the

spinous processes of C2 and C7.

Force – displacement Stiffness was defined as the mean slope of

the linear portions of the force-displacement

curves for oscillations 2 through 5.

(Tuttle et al.,

2009)


Passive Movement Assessment Device

(PMAD)


(Reiman,

2009)

Mechanical

Spinal Indentation to determine posterior-

anterior spinal stiffness, asymptomatic

subjects who used bracing demonstrated a

significantly larger increase in spinal

stiffness than those who used hollowing.


(Vaillant et al.,

2010)


Variable rate force/displacement (VRFD)

device.


Manual

188

(Campbell and

Snodgrass,

2010)

P/A mobilisation Therapist assessment of differences in the

amount, behaviour, and quality of PA

stiffness between adjacent vertebral levels

is used to identify symptomatic joints

Stiffness is described as the perceived

resistance through intervertebral joint range

of movement during the application of

manual forces applied by therapists

Mechanical

Custom-designed stiffness assessment

device

Force – displacement Stiffness was defined as the average slope of

the linear region of the force-displacement curves for oscillation cycles 2 through 5.

(Snodgrass et

al., 2010b)

Manual

P/A mobilisation Physiotherapy students applied Grades I to

IV central and unilateral PA mobilisation to

C2 and C7 of one asymptomatic subject.


Mechanical

Cervical spine stiffness was determined

using a device that measures force and

simultaneous displacement during the

application of five mechanical force

oscillations with a rubber-tipped steel

probe.

Force – displacement Stiffness was defined as the average slope of


curves for Cycles 2 to 5, as the probe travels

in the P/A direction.

(Snodgrass et

al., 2010a)

Manual

P/A mobilisation This technique consists of a rhythmic

oscillatory force applied to the spinous or

articular process of a vertebra.


Mechanical

Spinal stiffness of the C2 and C7 spinous

process was measured using a custom-

designed device that applied a standard PA

Force – displacement Stiffness was defined as the mean slope of


curves for oscillations 2 through 5.

189

mobilisation force oscillating at 1 Hz for 5

cycles.

(Rey-Eiriz et al., 2010)

Manual


Cervical spine gliding test

Practitioner judged; Posterior-anterior

cervical spine gliding to determine the

presence of joint hypomobility over the C3-

C4, C4-C5, and C5-C6 levels.


(Stamos-

Papastamos et

al., 2011)

Mechanical

A custom-made wooden and padded

treatment plinth securely screwed on a

nonconductive force platform. An

electromagnetic tracking system recording

at 100 Hz, was used to measure spinal

angular displacement during force

application for the calculation of bending

stiffness and to measure lumbar flexion and

extension ROM.

Load – deformation Bending stiffness as applied in this study as

the relationship between load and

deformation modelling the spine during 3 –

point bending

(Fritz et al.,

2011)

Mechanical

Spinal stiffness was assessed using a

mechanized indentation


(Kumar and

Stoll, 2011)

Mechanical

The Therapeutic Spinal Mobiliser Load – deformation Stiffness was defined as the relationship

between load and deformation

(Kumar, 2011) Mechanical

The Therapeutic Spinal Mobiliser Load – displacement No definition of stiffness reported

190

(Haas et al.,

2011)

Subjective – self-report measure

VAS – Secondary outcomes included

immediate post-treatment stiffness.

No verbal descriptors provided No definition of stiffness reported on VAS

(Snodgrass et

al., 2012)

Manual

Manual assessment of spinal stiffness Stiffness is usually assessed manually using

practitioner judgment to determine whether

a joint is hypo- or hypermobile.

From the practitioner’s perspective, spinal

stiffness can be described as the perceived

resistance of the spine during the application

of a manually applied force

Stiffness expressed in terms of hypo- or

hypermobility.

Mechanical

Structured review of spinal stiffness

measurement

Force – displacement Spinal stiffness operationally defined as the

relationship between force and

displacement.

(Manning et

al., 2012)

Manual

Passive intervertebral motion-cervical

segmental side bending test

Practitioner judged; Side-bending motion

performed at each cervical joint from C2–

C3 to C6–C7, allowing segmental

synkinetic rotation and extension to occur.

Each joint was assessed for hypomobility, hard end- feel, and pain provocation.


(Tiantian et al.,

2012)

Mechanical

Mechanically assisted P/A spinal stiffness Force – displacement No definition of stiffness reported

(Snodgrass and

Rhodes, 2012)

Mechanical

Mechanical spinal indentation Force – displacement Stiffness defined as the slope of the linear

portion of the force-displacement curve

191

(Kumar, 2012) Manual

P/A spinal stiffness assessment No subjective measure of spinal stiffness The resistance to motion on force

application, that is, the stiffness

Mechanical

The Therapeutic Spinal Mobilizer Load – displacement No definition of stiffness reported

(Triano et al.,

2013)

Manual

Palpatory assessment (motion palpation)

I. Passive physiologic/accessory

motion. II. Joint springing

III. Overpressure testing

Motion palpation uses examiner guided

motions to manually monitor the relative

displacement of bony landmarks through

the skin surface. Motions are categorized as

being limited/restricted; excessive/unstable

or aberrant, suggesting a deviation in path

at some point within the range of motion.

During the process of tissue palpation, the

examiner attempts to assess the relative

stiffness (conversely, compliance) to

postural or applied load to a segment.

(Shum et al.,

2013)

Manual

Grade III central P/A mobilisation Curvature, bending stiffness

(force/displacement) of the lumbar spine

and onset of pain on application of PA to

L4 at forces between 50N and 250N at 50N

intervals.

Stiffness is defined as the resistance of this

beam to the bending deformation caused by

PA mobilization.

Mechanical

Force plate Load – deformation Stiffness is defined as the resistance of this

beam to the bending deformation caused by

PA mobilization. This definition is

consistent with that used in the conventional

engineering method

Mechanical

192

(Descarreaux et al., 2013)

Mechanical spinal indentation Force – time No definition of stiffness reported

(A. Y. L.

Wong et al.,

2013)

Mechanical

Mechanical spinal indentation Force – displacement No definition of stiffness reported

(Xia et al.,

2014)

Manual

Manual palpation assessment of spine

stiffness

During the hand palpation assessment, the

participants lie face down on a custom-

made chiropractic treatment table with

force plates embedded under the cushions

that support the thoracic and pelvic regions

and acquire the palpatory force transmitted

through the participant. The clinician

applies a gentle anteriorly directed force

consistent with the level typically used

during examination to the vertebral levels

L1 to L5.

Stiffness describes in terms of the perceived

spinal resistance to manually applied force.

Mechanical

Hand-held instrument device Force – displacement No definition of stiffness reported

(Snodgrass et

al., 2014)

Manual

Grade III central PA at most painful spinal

level; 1Hz for 60 s x 3; mobilization

applied at either LF (30N) or HF (90N)

at the selected painful level Immediately

before and after intervention, and at a

follow-up 4d later

Co-measures; Cervical flexion-extension

and rotation ROM (goniometry) and ROM

at pain onset in the most painful movement

PA stiffness expressed in terms of

force/displacement

Mechanical

193

Mechanical spinal indentation Force – displacement Stiffness was defined as the slope of the

linear portion of the force-displacement

curve averaged over cycles 2 through 5 (N/mm)

(Gudavalli et

al., 2014)

Manual

P/A spinal stiffness assessment Doctor of Chiropractic (DCs) use manual

palpation to subjectively assess the relative

"stiffness" (resistance) of spinal

articulations

Spinal stiffness (e.g. the perceived spinal

resistance to manually applied force)

Stiffness expressed in terms of resistance of

spinal articulations

(Koppenhaver

et al., 2014)

Manual

P/A spinal stiffness assessment Practitioner judged; manual spinal stiffness

assessment of L1-L5. The stiffness of each

vertebral segment (L1-L5) was recorded as

“hypomobile”, “normal”, or “hypermobile”

based upon the clinician's perception of the

amount of force used and the resultant

segmental displacement.

Stiffness expressed in terms of

“hypomobile”, “normal”, or “hypermobile

(Ingram et al.,

2015)

Mechanical

Cervical spine stiffness assessment device. Force – displacement The relationship between the displacement

of the indenter probe and the concurrent

resistance to movement represents spinal

stiffness

(A. Y. L.

Wong et al.,

2015)

Mechanical


Mechanical

194

(Buzzatti et al.,

2015)

Zebris CMS20 ultrasound-based motion

tracking system

Thrust – displacement No definition of stiffness reported

(Gregory Neil

Kawchuk et

al., 2015)

Mechanical


(A. Y. L.

Wong et al.,

2016)

Mechanical


(Björnsdóttir et

al., 2016)

Mechanical

P/A Pressure Puffin Force – displacement Stiffness expressed in terms of the

(derivatives of displacement on force)

(Xia et al.,

2017)

Manual

Posterior-anterior spinal stiffness over the

spinous processes of the lumbar spine

Practitioner Judged; anteriorly directed

force over each lumbar segment

sequentially from L5 to L1.

Stiffness operationally defined in this study

as the quantitative measure of the resistance

to motion.

Mechanical

Hand-held instrument device consists of a

force transducer and infrared smart markers

for accurate force and displacement

measurement.

Automated device method, a

programmable indenter applied force

anteriorly up to 60 N with a force feedback

control.

Force – displacement Stiffness operationally defined in this study

as the quantitative measure of the resistance

to motion.

Manual

195

(Wong and

Kawchuk,

2017)

P/A spinal stiffness assessment To examine spinal stiffness, a clinician

applies a manual PA force to the lumbar

spine in general or to a spinal landmark

(e.g., spinous process). The clinician then

perceives the stiffness/movement of the

spine.


The definitions for hypo/hypermobility

remain ambiguous

Mechanical

Systematic review

Mechanical spinal stiffness testing devices Force – displacement No definition of stiffness reported

(Stanton et al.,

2017)

Subjective self-report measure

Numerical Rating Scale (stiffness)

101 point 0 – 100

Established participants subjective

measures of stiffness based on how they

‘felt’ ranging from “not stiff at all” to “most

stiff imaginable”.

No definition of stiffness reported on

Numerical Rating Scale

Stiffness is often described as a perceived

resistance to movement, feelings of stiffness

may be a learned concept for what is

actually a feeling of a lack of movement

velocity

Mechanical

Mechanical spinal stiffness testing devices Force – displacement No definition of stiffness reported

(Brown et al.,

2017)

Mechanical (Dynamic)

Verte Track System (dynamic mechanical

indentation roller)

Force – displacement Terminal stiffness is defined as the ratio of

the maximal applied force (60 N) to the

maximal resultant displacement.

196

(Holt et al.,

2018)

Manual

P/A spinal stiffness assessment Manual posteroanterior force to a specific

body landmark (e.g., spinous process) or to

a spinal region in general (e.g., lumbar) by

a clinician, and then the clinician perceives

the corresponding spinal movement or

stiffness.

The operational definition of the Stiffest

Spinal Site for this study was the spinal

location of maximal resistance to palpatory

pressure, as perceived by the clinician,

which is a force-displacement relationship

(Pagé et al.,

2018)

Mechanical

Mechanical spinal indentation Force – displacement The global stiffness was defined as the slope

of the straight line (represented by the dotted

line) best fitting the data between 10 and 45

N

The terminal stiffness as the ratio of the

variation of the load and the variation of the

displacement between 10 and 45 N ([L1-

L2]/[D1-D2]

(Dugailly et

al., 2018)

Mechanical

Cervical stiffness measurements were

achieved in axial rotation using a

customized device

Torque – angular displacement. No definition of stiffness reported

Mechanical

197

(Tuttle and

Hazle, 2018)

Multiple modelling studies and in vivo

measurements of PA movements.

Force – displacement Stiffness is the change in force per unit

change in displacement. In other words,

stiffness is the slope or first derivative of

force-displacement curves. Compliance,

which is the inverse of stiffness, is

sometimes used to indicate a comparable

perception.

(Swanenburg

et al., 2018)

Mechanical

Computer-assisted analytical device – P/A

stiffness

The instrument measured tissue compliance

according to the concept of impulse

response


(Hadizadeh et

al., 2019)

Mechanical (Dynamic)

Verte Track System (dynamic mechanical

indentation roller)


(Kawchuk et Mechanical (Dynamic)

al., 2019) Manual posteroanterior force in

conjunction with a computer-controlled

indentation probe.


Total

segmental

stiffness

assessment (n = 106)

Total objective (Mechanical) outcome

measures = 73

Total subjective (Manual) outcome

measures = 62 Total Measures = 135

Yes definition = 75

No definition = 60

Total = 135

198

Total studies

(n= 333)

Total subjective measures = 124

Total objective measures = 175

No Measures = 3

Total indicators = 60

Total = 362

Yes definition = 122

No definition = 240

Total = 362

199

Appendix G: Alternative descriptors

Table showing segmental assessment descriptors

Synonyms

(Maher, Simmonds, et al., 1998) ► toe compliance

► friction

► resistance

► hypomobile

► restricted

► noncompliant

► limited Hypomobile

► tight

► firm

► inelastic

► thick

► non-springy

► blocked

► active recoil

► reactive

► rubbery

► boggy

(Binkley et al., 1995; Triano et al., 2013) ► hypomobility

(Keller et al., 2000) ► Less mobility

(Abbott et al., 2005; Nicholson et al., 2000) ► hardness

(Owens et al., 2007; Colloca et al., 2003) ► fixation

(Campbell & Snodgrass, 2010; Gudavalli et al., 2014; Lee et al., 1993;

Snodgrass et al., 2009, 2010b) ► resistance

(Maher and Adams, 1995b) ► range of motion

200

► end-feel

► spasm

► viscosity

(Haas et al., 2011; Maher and Adams, 1995a) ► end play restriction

(Manning et al., 2012) ► Hard end-feel

(Fernández-de-las-Peñas et al., 2005; Rey-Eiriz et al., 2010) ► Gliding, end-feel and resistance of zygapophyseal joints

(Simmonds et al., 1995) ► ‘Feel’ and extent of movement

Antonyms

(Maher, Simmonds, et al., 1998) ► elastic

► springy

► hypermobile

► loose

► yielding

► friction-free

► undue give

► compliant

► spasm-free

► smooth

► free running

► resistance-free

► soft

► well-oiled

► spongy

► squashy

► separately

(Binkley et al., 1995) ► hypermobility

(Kumar, 2011, 2012; Stanton and Kawchuk, 2009; Triano et al., 2013) ► Compliance

201

Appendix H: Surrogate measures

Table showing surrogate measures of segmental spinal stiffness

► Spinal stiffness is a measurement of spinal translation, defined as the displacement of spinal and paraspinal tissues due to the application of a posterior

to anterior (P-A) load at a spinal segment. (Snodgrass et al., 2012)

► Jull and bullocks use of the term "motion" to describe the combined measure of both displacement and resistance to that displacement (Jull and

Bullock, 1987) ► Jull and Bullock seem to be using the word "motion" as a synonym for stiffness (Jull and Bullock, 1987).

► According to Maitland, movement is synonymous with the term motion (Maitland et al., 2005)

► Accessory motion is defined as movement at a joint that cannot be performed voluntarily but can be performed passively by an external force.

► Accessory motion evaluation is performed to establish relative segmental stiffness (hypermobility and hypomobility) (Binkley et al., 1995)

► The segment of interest is classified as hypomobile, normal, or hypermobile, based on the clinician’s perception of stiffness (Stanton and Kawchuk,

2009) ► Too compliant (hypermobility), too stiff (hypomobility), or within normal limits (Maitland et al., 2001).

► In clinical practice, stiffness is usually assessed manually using practitioner judgment to determine whether a joint is hypo- or hypermobile (Snodgrass

et al., 2012). ► Clinicians measure both motion and resistance to motion, or spinal stiffness. (Koppenhaver et al., 2014)

► P/A Spinal stiffness is defined in the studies as at least one level (L1 - L5) being rated as “hypomobile” or “hypermobile” on a 3-point scale

(hypomobile, normal, hypermobile). (Koppenhaver et al., 2014) ► Anecdotal evidence suggests that spinal stiffness restricts motion (Kumar, 2012)

► Maitland"' uses the words "resistance" and "stiffness" interchangeably (Maitland et al., 2005)

► Absence of “fixations”, ‘’resistance or compliance’’ (Nicholson et al., 2003)

► Viscoelasticity (force application and the corresponding displacement velocity) (Wong and Kawchuk, 2017)

► Stabilise (Colloca and Keller, 2004)

► Stability (Ferreira et al., 2009; Shirley et al., 2003)

► Stiffness or movement (Snodgrass et al., 2010b; Viner and Lee, 1995;)

► Displacement (Tiantian et al., 2012; Tuttle et al., 2009)

► Movement response to load (Kiviniemi et al., 2001)

► Joint range perceived (Snodgrass et al., 2010b)

► Flexibility impairment (Dugailly et al., 2018)

► The association of low back pain and spinal stiffness and consequent impact on the spinal motion (Kumar, 2011).

200

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Declaration Name of candidate: Joel Moses

This Thesis/Dissertation/Research Project entitled: Defining and measuring objective

and subjective spinal stiffness: A scoping review, is submitted in partial fulfillment for

the requirements for the Unitec degree of

Principal Supervisor: Sylvia Hach Associate Supervisor/s: Jesse Mason CANDIDATE’S DECLARATION I confirm that:

• This Thesis/Dissertation/Research Project represents my own work;

• The contribution of supervisors and others to this work was consistent with the

Unitec Regulations and Policies.

• Research for this work has been conducted in accordance with the Unitec

Research Ethics Committee Policy and Procedures, and has fulfilled any

requirements set for this project by the Unitec Research Ethics Committee.

Research Ethics Committee Approval Number: .................................................

Candidate Signature: ……….……………………………………. Date: 23/03/2020

Student number: 1458167

Unitec Institute of Technology TE WHARE WANANGA 0 WAIRAKA

Full name of author: Joel Ranui Moses

ORCID number (Optional): …………………………………………

Full title of thesis/dissertation/research project (‘the work’): Defining and measuring objective and subjective spinal stiffness: A scoping review.

School: School of Community studies.

Degree: MOst

Year of presentation: 2020

Principal Supervisor: Sylvia Hach

Associate Supervisor: Jesse Mason

Permission to make open access I agree to a digital copy of my final thesis/work being uploaded to the Unitec institutional repository and being made viewable worldwide.

Copyright Rights: Unless otherwise stated this work is protected by copyright with all rights reserved. I provide this copy in the expectation that due acknowledgement of its use is made.

AND

Copyright Compliance: I confirm that I either used no substantial portions of third party copyright material, including charts, diagrams, graphs, photographs or maps in my thesis/work or I have obtained permission for such material to be made accessible worldwide via the Internet.

Signature of author: ………………………………………...

Date: 23/03/2020

Defining and measuring objective and subjective spinal stiffness

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