Chronic spinal pain (CSP) is a large problem in the western world. Most of the current treatments are focusing on input mechanism (peripheral elements like muscles/joints) and output mechanism (motor control) of pain. There is an increasing evidence that patients with CSP have altered central mechanisms like central sensitization and brain abnormalities. This paper presents an approach with more focus on central (processing) mechanisms.
The approach suggested is divided in three phases and focuses on both therapeutic pain neuroscience education and cognition-targeted motor control training. Phase 1 focuses on therapeutic pain neuroscience education. Phase 2 started once the patient has adopted adaptive beliefs regarding CSP. This phase includes exercise therapy with specific emphasis on spine motor control training. The last phase focuses on dynamic and functional exercise to make a transfer to daily life activities. > From: Nijs et al., Phys Ther (2014) (Epub ahead of print). All rights reserved to the American Physical Therapy Association.
Dance is becoming more popular especially with the advent of numerous dancing reality shows, not to mention popular dance-based workouts such as Zumba. As a result, we – medical doctors – are seeing an increasing number of dance-related injuries.
This study looked at 500 dancers at the dance festival of Joinville (Brasil) over a period of 12 months. Dancers were broken into 4 groups: classical ballet, jazz/contemporary, tap/folk dance and street dance, based on biomechanical characteristics, the degree of motor demand and physiological aspects related to training in each group. 627 injuries were reported in 377 dancers, with overall incidence of dance injury being 70%. The most common anatomical region injured in the different groups was ankle/foot in classical dance, thigh/leg in contemporary/jazz, knee in tap/folk dance while there was no significant injury occurrence in different anatomical regions with street dance.
The following were identified as risk factors for dance injuries: age and weight in jazz/contemporary dance; greater height in classical ballet; shorter height in tap/folk dance; and greater weekly frequency of practice in classical ballet and jazz/contemporary dance > from Soares Campoy et al.; Clin J Sport Med. 21 (2011) 493-498. All rights reserved by Lippincott Williams & Wilkins.
One of the strongest predictors of sustaining a low back injury (LBI) is a previous history of enduring the same injury. This suggests that our screening processes upon discharge may not be sensitive enough to detect more subtle dysfunctional movement patterns that may render an individual more vulnerable to re-injury. The aim of the current study was to determine whether neuromuscular patterns remained altered amongst a group of participants who had experienced a LBI and were subsequently deemed ‘recovered.’
EMG data was obtained via surface electrotrodes positioned over specific abdominal and back extensor sites amongst 33 LBI individuals and compared to that of 54 asymptomatic controls. All subjects performed a symmetrical lift and replace task in two reaches. The LBI group demonstrated higher activation amplitudes in all muscles examined (except for the posterior external oblique), along with greater co-activation between abdominal and back extensor sites compared to controls. Furthermore, the LBI group exhibited altered responses within local abdominal and back extensor sites during increased physical demands.
These findings support the hypothesis that residual alterations in neuromuscular patterning persist despite conventional outcomes indicating recovery > Butler et al,; J Electromyogr Kinesiol (2012) article in press. All rights reserved to Elsevier Ltd.
Shoulder impingement is a major contributor to either the development or progression of rotator cuff disease and biceps tendinopathy. In asymptomatic individuals, elevation in any plane includes scapulothoracic upward rotation, posterior tilting and internal or external rotation; motions, which are the result of complex, coupled interactions between SC and AC joints. Taking these interactions and data derived from modeling studies into account, the primary role of the upper trapezius seems to be to retract the clavicle at the SC joint. The middle and lower trapezius and serratus anterior produce scapulothoracic upward rotation relative to the clavicle; additionally the serratus anterior contributes to posterior tilting. It is important to appreciate biomechanical evidence, such as AC and SC joint interactions, muscle function and possible mechanisms of abnormal movement patterns when rehabilitating patients presenting with shoulder pain in order to select specific interventions > from Ludewig et al.; Manual Therapy 16 (2011) 33-39. All rights reserved to Elsevier.
This single blinded, prospective, randomised controlled trial study was carried out to whether or not a multi-modal treatment program (MMT) is more effective than exercise therapy (ET) for the treatment of long-standing adductor-related groin pain.
Athletes with pain at the proximal insertion of the adductor muscles on palpation and resisted adduction for at least two months were included this study.
ET: a home-based ET and a structured return to running program with instruction on three occasions from a sports physical therapist.
MMT: Heat, manual therapy followed by stretching and a return to running program.
Outcome was assessed at 0, 6, 16 and 24 weeks.
Athletes who received MMT returned to sports quicker (12.8 weeks) than athletes in the ET group (17.3 weeks). Only 50-55% of athletes in both groups made a full return to sports.
The multi-modal program resulted in a significantly quicker return to sports than ET plus return to running but neither treatment was very effective > from Wier et al.; Manual Therapy 16 (2011) 148-154. All rights reserved to Elsevier Ltd.
Postoperative pulmonary complications affect 13% of patients undergoing upper abdominal laparotomy. This study measured the incidence of postoperative pulmonary complications, risk factors for the diagnosis of postoperative pulmonary complications and barriers to physiotherapy mobilisation.
Two surgical wards in a tertiary Australian hospital were used for the prospective Observational cohort study. 72 patients undergoing high-risk abdominal surgery (participants in a larger trial evaluating a novel model of medical co-management) were recruited.
The incidence of post-op pulmonary complications was 39%. Incision type and time to mobilise away from the bed were independently associated with a diagnosis of post-op pulmonary complications. Patients were 3.0 (95% CI 1.2 to 8.0) times more likely to develop a post-op pulmonary complication for each day they did not mobilise away from the bed.
52% of patients had a barrier to mobilisation away from the bed on the first post-op day, with the most common barrier being hypotension. Development of a post-op pulmonary complication increased median hospital length of stay (16 vs 13 days; P = 0.046). This study demonstrated an association between delayed mobilisation and postoperative pulmonary complications. RCTs are indicated to test the role of early mobilisation in preventing postoperative pulmonary complications in patients undergoing high-risk upper abdominal surgery > from Haines et al.; Physiotherapy (2013) Ahead of Print. All rights reserved to the Chartered Society of Physiotherapy.
In a previous summary, the adverse effect of static stretching on H:Q ratios was discussed. Despite the ongoing debate, static stretching remains the most widely used method of preparing for exercise. This study investigated the acute effects of static hamstring stretching on biomechanical characteristics of the running gait cycle.
34 recreational athletes were recruited and allocated to either the intervention or the control group. In both groups, hamstrings flexibility was assessed and then running kinematic data at the preferred treadmill running speed (2.9±0.5 m*s-1) were collected using reflective markers and a motion-analysis system. The control group rested in between measurements, while the intervention group received assisted 3 static hamstring stretches; subsequently, hamstrings flexibility and running kinematics were determined again at the preferred treadmill running speed (3.1±0.5 m*s-1).
The results show that three static hamstring stretches do not affect pelvis, hip or knee kinematics in the running gait cycle. Both groups showed a similar increase in hamstring length, probably resulting from the first running interval. > From: Davis Hammonds et al., J Athl Train 47 (2012) 5-14. All rights reserved to the National Athletic Trainers’ Association, Inc.
Chronic Low Back Pain (CLBP) is a major health problem in the world. This summary describes the main finding of a supplement in the journal Acta Orthopaedica which is based on the doctoral thesis by Paul Willems. In CLBP-patients imaging often reveals degenerative findings of the disc or facet joints. However those findings can also be observed in the asymptomatic population.
Lumbar spinal fusion can be beneficial for some people. However it is difficult to predict which individual patient will benefit. Many surgeons make use of some test that are assumed to predict the outcome of spinal fusion. The three most common used tests are 1) immobilization in lumbosacral orthosis, provocative discography and trial immobilization by temporary external transpedicular fixation.
The studies presented in this thesis concluded that none of those three tests are proven by current evidence. Also no patient characteristics are available for whom spinal fusion is an effective treatment. Several studies have currently shown that conservative treatment results in similar outcomes compared to spinal fusion. Conservative treatment has less complications, morbidity and costs. Therefore spinal fusion should not be proposed as a standard treatment for CLBP. > From: Willems, Acta Orthopaedica (Suppl. 349) 84 (2013) 1-37. All rights reserved to Informa Healthcare Ltd.
After ACL reconstruction, complications can occur in several ways. Early recognition and management is important to optimize patient outcome. In this summary the most prevalent complications that are important for a physical therapist are presented.
Loss of motion after ACL reconstruction can be caused by scar tissue that attaches within the intercondylar notch on the tibial side (los of extension) and scar within the gutters and suprapatellar pouch region (los of flexion). Incorrect tunnel placement can also result in a limited range of motion. Other causes of extension problems can be caused by a tightened capsule (after a meniscal repair), MCL scarring, hamstring tightness or posterior capsular scarring. Full extension and 90 degrees of flexion should be achieved after 2 weeks. When a patient complains about instability, graft failure should be considered. Graft failure could be caused by surgical technical errors, graft incorporation failure and trauma. Infections after ACL reconstruction do not occur often (about 1%). However one should be alert for symptoms like increased pain and swelling and erythema and drainage from the surgical incisions.
A physical therapist plays an important role in signaling complications. Therefore the status and function of the knee should be examined continuously during rehabilitation. > From: Heard et al., Sports Med Arthrosc Rev 21 (2013) 106-112. All rights reserved to Lippincott Williams & Wilkins.
Stability in the glenohumeral joint is preserved by passive and active structures. The glenoid labrum limits translations of the humeral head and supports the concavity compression mechanism by increasing the depth of the glenoid fossa. The most common injury to the labrum is the superior labrum anterior posterior (SLAP) tear; this condition is common in overhead throwing athletes, due to alterations in shoulder kinematics and repetitive end-range stresses imparted on the glenohumeral joint.
Several theories propose mechanisms that may cause SLAP tears: they might be the result of either a deceleration traction or a “peel-back” injury from the tendon of the long head of the biceps. Another potential cause could be a superior migration of the humeral head as a result of contracture of the posterior capsule, also leading to the condition referred to as a glenohumeral internal rotation deficit (GIRD).
Physical examination should contain an assessment of the glenohumeral and scapular range of motion and kinematics, and strength testing of especially the rotator cuff muscles. Although specific tests cannot accurately diagnose SLAP lesions, either alone or as a cluster, the active compression (O’Briens) test, the crank test and Speed’s test are the most sensitive. Nonoperative management should be aimed at improving muscle strength and endurance and restoring glenohumeral and scapulothoracic motion; exercises are initiated preferrably after pain has resolved. > From: Knesek et al., Am J Sports Med 41 (2013) 444-460. All rights reserved to The Author(s).
Bilateral transtibial amputees (BTA) often demonstrate considerable hip-hiking and other gait compensatory movements. This increases the chances of falling and uses a lot of energy. This study hopes to understand the role of upper body motions on BTA gait and balance. Subjects were ask to walk over a level walk way at three different speeds: slowest comfortably possible, normal and comfortable fast. This was completed with first one, then a different prosthetic configuration, always the same on both sides. Data was collected by use of motion capture and compared to able-bodied control subjects. The BTA’s walking speed was so much slower than that of able-bodied controls that only the BTA’s fast walking speed could be used.
BTA’s showed significantly greater shoulder abduction and lateral trunk flexion ROM. However, exaggerated motion is primarily isolated to the coronal plane and accompanied by greater step width. Due to the trunk movements the centre of mass is often projected towards the edges of the base of support, combined with the BTA’s lack of ankle musculature to compensate, this places the walker at increased risk of falling. The authors conclude that any attempt to reduce the lateral sway would increase stability and reduce fall risk for patients. > From: Major et al., J Gait Post (2013) (Epub ahead of print). All rights reserved to Elsevier B.V.
Two-point discrimination (TPD) is a tool broadly used in clinical practice. Decreased tactile acuity and cortical reorganization have been observed in several neurological diseases and chronic pain statessuch as CRPS, phantom limb pain, chronic back pain and painful OA. TPD is used to assess tactile acuity, which is considered as a clinical sign of cortical changes. Besides its frequent use, the reliability and precision of the measurements have not been determined.
The intra- and inter-rater reliability, bias and variability of TPD was measured at the back, neck, hand and foot of 28 healthy participants, measured by 28 clinicians (physiotherapists). Clinicians received training in the use of mechanical callipers and followed a standardized protocol.
The results indicate good intra-rater reliability, which mean that the reliability of TPD point in individual clinicians is reliable for the neck, back, hand and foot using callipers. TPD measures assessed by different clinicians were only reliable for the neck and foot Due to the large variability, caution should be taken when interpreting changes in tactile acuity in individual patients, especially when measures are taken by more than one clinician. Clinical experience did not seem to have an effect on TPD measures. > From: Catley et al., Rheumatology (2013) (Epub ahead of print). All rights reserved to the British Society of Rheumatology.
Triathletes and Ironman triathletes often engage in extremely intense sport sessions, which involve a considerable amount of pain and stress. The aim of this study was to investigate the possible effect of extreme long-term exercise and stress on pain perception. Participants were 19 (ironman) triathletes (10 men) and 17 non-athletes (7 men), who exercised regularly. Pain thresholds and pain tolerance were measured using heat and cold stimuli and a visual analogue scale to measure the perceived pain intensity. Conditioned pain modulation (CMP) was used to test the diffuse noxious inhibitory control system (DNIC). Questionnaires were used to assess some of the psychological factors that can predict pain outcomes.
On average, triathletes practised 6 times more hours a week then controls and their level of fear of pain was significantly lower than that of controls. The exhibited CMP in triathletes was significantly more powerful compared to controls. No differences in pain thresholds was observed between triathletes and controls, but a significant group difference was found in pain tolerance, with triathletes exhibiting a higher threshold. Pain tolerance is often attributed to the ability or willingness to endure pain. In triathletes this could signify the motivational aspects of pain, but may also stem from a habituation effect. > From: Geva et al., PAIN (2013) (Epub ahead of print). All rights reserved to the International Association for the Study of Pain. Published by Elsevier B.V.
Rotator Cuff Tendinopathy (RCT) is a common source of shoulder pain characterised by persistent and/or recurrent problems for a proportion of sufferers. The aim of this study was to pilot the methods proposed to conduct a substantive study to evaluate the effectiveness of a self-managed loaded exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy.
A single-centre pragmatic unblinded parallel group pilot randomised controlled trial was conducted on 24 participants with RCT. The intervention was a programme of self-managed loaded exercise. The control group received usual physiotherapy treatment. Baseline assessment comprised the Shoulder Pain and Disability Index (SPADI) and the Short-Form 36, repeated three months post randomisation. 100% retention was attained with all participants completing the SPADI at three months. Exercise adherence rates were excellent (90%).
The mean change in SPADI score was −23.7 points for the self-managed exercise group and −19.0 points for the usual physiotherapy treatment group. The difference in three-month SPADI scores was 0.1 (95% CI −16.6 to 16.9) points in favour of the usual physiotherapy treatment group.
In keeping with previous research, which indicates the need for further evaluation of self-managed loaded exercise for RCT, these methods and the preliminary evaluation of outcome offer a foundation and stimulus to conduct a substantive study. > From: Littlewood et al., Physiotherapy (2013) (Epub ahead of print). All rights reserved to Elsevier Ltd.
Alzheimer's Disease (AD) is a worldwide epidemic and has devastating consequences for not only the patient, but family and caregivers also. A lot of thought and research capacity is spent on treating this disease. This study examined the impact of walking on cognitive functioning over a year.
104 patients with early to mid-stage AD were recruited and were administered the Mini-Mental State Examination, Geriatric Depression Scale, and the Blessed-Roth Dementia Rating Scale. Their caregivers completed the Yale Physical Activity Scale, Profile of Mood States, the Neuropsychiatric Inventory, and the Functional Abilities Questionairre.
The results after 1 year showed that those with a low initial activity level gradually decreased activity level over time, which was paired with a decrease in cognition and affect/mood. The subject sample was divided into active and sedentary groups based on their Yale profile. Those more sedentary showed significant decrease in cognition while active subjects did not show a significant decline. Furthermore, those with a higher level of activity (walking over 2h/week) actually showed a significant increase in cognition scores.
This study adds to the growing body of knowledge showing the benefits of exercise in chronic conditions. Further research with more structured activities and controls will help improve our knowledge on the effects of exercise and cognition among people with Alzheimer's Disease. > From: Winchester et al. Arch Gerontol Geriatr 56 (2013) 96-103. All rights reserved to Elsevier Ireland Ltd.
The knee joint seems only a simple articulation: motions between femur and tibia are mainly confined to flexion and extension. Nevertheless, there is something unique in the contour and shape of the medial and lateral femoral condyles and their corresponding menisci. Below you find 6 hypotheses regarding the anatomy and arthrokinematics of the knee joint. Which of these hypotheses are correct?
A. The medial condyle is more massive than his lateral counterpart;
B. The lateral condyle has a smaller posteroanterior diameter;
C. The lateral meniscus is smaller than the medial meniscus and has an "O"-formed shape;
D. The medial meniscus is interconnected with the popliteal muscle;
E. The popliteal muscle unlocks end range rotation of the knee joint when extending;
F. The lateral meniscus is more mobile than the medial meniscus and because of that it has a higher rupture prevalence.
>> Stay tuned for the answer to this question, which will be posted in 8 hours! <<
Anterior cruciate ligament (ACL) tears are very common with around 200,000 tears occurring per year in the US and resulting in 80-90,000 surgical repairs. But not all patients elect to get surgery yet they still want to stay relatively active. Excessive tibial rotation is commonly seen in both ACL-deficient and ACL-reconstructed knees and is thought to predispose to early-onset osteoarthritis.
The authors wanted to see if knee braces can restrict tibial rotation in ACL-deficient knees during high loading activities, thus providing more stability. They recruited 21 males with unilateral ACL tears and similar demographics, and using an 8 camera system they observed knee motion during walking, descending stairs and pivoting while wearing a prophylactic brace; patellofemoral sleeve and then unbraced.
They found that although bracing reduced tibial rotation in ACL-deficient knees, it couldn’t fully restore normative values. They did observe less tibial rotation with a brace compared to unbraced condition and proposed that wearing a knee brace could have potential benefit in patients with ACL-deficient knees, especially in high-demand athletic activities. They also found that the simple knee sleeve did not restore tibial rotation to the same extent as the brace, but it was still better than unbraced results. > From: Giotis et al., Clin J Sport Med 23 (2013) 287-92. All rights reserved to Lippincott Williams and Wilkins. Image taken from: stack.com
Prolonged sitting time is a well-established health risk factor. Already in the 50’s a 2-fold risk of myocardial infarction has been demonstrated in London bus drivers compared to active bus conductors. However, as previous conclusions from reviews of sedentary behavior and health outcomes in adults beyond just TV viewing times were based on a small number of studies and did not allow for a meta-analysis, the aim of the present systematic review and meta-analysis was to quantitatively synthesize observational evidence relating sitting time to 1) diabetes, 2) cardiovascular (CV) disease, 4) CV mortality and all-cause mortality.
4,835 articles were identified. Due to strict inclusion criteria using measures of time spent in sedentary behaviors and not defining sedentary behavior as an absence of moderate-to-vigorous physical activity (MVPA), 18 studies remained (16 prospective, 2 cross-sectional, included 794,577 participants). Higher levels of sedentary time were associated with a significantly increased risk of diabetes (+112%), CV disease (+147%), CV mortality (+90%) and all-cause mortality (+49%).
The reported associations between sedentary time and clinical outcomes were largely independent of physical activity, indicating that deleterious effects of prolonged sitting are not mediated through lower amounts of MVPA. In this context evidence emerged that interrupting prolonged sitting with 2-min bouts of light activity every 20 min reduces postprandial glucose and insulin levels in overweight/obese adults by 23% and 24%, respectively. > From: Wilmot et al., Diabetologia 55 (2012) 2895-2905. All rights reserved to Springer-Verlag.
Nerve roots separate into the anterior ramus (which supplies the limbs and the anterior part of the trunk) and the posterior ramus, which innervates the skin, muscles and joints of the back. The current study analyzed the anatomy of the posterior ramus in the lumbar region, utilizing photographs, 3D laser scanners and computer modeling on 8 dissected specimens.
The posterior ramus of the spinal nerve is now described as dividing into 3 branches -lateral, intermediate and medial-. The lateral branch goes dorsally and laterally, innervates the iliocostalis muscle from the transverse process and becomes a cutaneous nerve on the side of the spine and top of the buttock (cluneal nerves). The intermediate branch runs between the longissimus and iliocostalis muscles from the accessory process, towards an area of skin medial to the lateral branch dermatome. Finally, the medial branch goes more medially from the mammillary process and supplies the region closest to the spine and can extend to 2 levels down; this includes the facet joints, the multifidus muscle and the skin of the midline of the spine.
Thanks to their specificities, the 3 branches of the posterior ramus of the nerve root are very important in the management of low back pain, as they innervate paraspinal muscles, facet joints and skin of the back and buttock. > From: Saito et al., Anesthesiology 118 (2013) 88-94. All rights reserved to the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins.
Knee osteoarthritis (KOA) is often studied in pharmaceutical trials of drugs with focus on the analgesic and/ or anti-inflammatory properties. However, there is accumulating evidence that central and peripheral changes are just as prominent as the nociceptive and neurogenic processes. In this study, 37 subjects with KOA were compared with 35 controls for psychophysical characteristics; thermal, mechanical, and functional wind-up; thermal and mechanical after sensations; and pressure algometry.
The majority of subjects had abnormalities to pinprick (41% were hyperalgesic and 27% were hypoesthetic). Compared to controls, the more painful knee was hypoesthetic to cold detection, had lower pressure-pain thresholds and twice the pain ratings of controls after stair climb. Subjects had greater but not significant differences thermal wind-up, thermal and mechanical aftersensations.
Both peripheral (PS) and central sensitisation (CS) have been implicated to be prominent in OA. There is accumulating evidence to support complex heterogeneous mechanisms. Whether these results actually distinguish between PS and CS needs to be carefully studied with validated technologies that can distinguish between peripheral and central processes. > From: Harden et al., J Pain 14 (2013) 281-289. All rights reserved to the American Pain Society.
High tibial osteotomy (HTO) and distal femoral osteotomy (DFO) are effective techniques in the treatment of knee monocompartmental osteoarthritis, osteochondral lesions and joint instability. A literature review demonstrates that at each stage of surgery complications may occur. The aim was to summarize current literature over the last 10 years on the complications of osteotomy around the knee. Both prospective and retrospective studies were considered. The focus here is on postoperative complications:
- Superficial infection of 1-9% and deep infection of 0.5-4.7% were reported in a recent review. However, information on infection rate varied considerably between studies.
- Delayed union occurred with an incidence of 4-8.5% and was more frequent with osteotomies distal to the tibial tubercle because of the low healing potential of the bone below the metaphysis. The incidence of nonunion after HTO has been reported to be as high as 1-5.7%.
- Neural complications of osteotomies around the knee are most likely to involve the peroneal nerve. The most commonly reported complication was peroneal nerve palsy with an incidence of as high as 20%. Extensor hallucis longus is the most common muscle deficit. Incidence of thrombosis was 10.8% on average with the highest incidence within 4 days postoperatively.
Conclusion: The first essential step to ensure optimal results is the careful selection of patients. While opening wedge is technically more accurate, it is associated with a higher incidence of osteotomy failure, nonunion and delayed union. Closing wedge osteotomy is more likely associated with inaccuracy of correction of the deformity. > From: Vena et al., Sports Med Arthrosc Rev 21 (2013) 113-120. All rights reserved to Lippincott Williams & Wilkins.
Pain and fatigue associated with fibromyalgia can interfere with daily function, work and social activities. Although the cause for fibromyalgia is unknown, it is generally accepted that there is enhanced central excitability and reduced pain inhibition. Mainstream treatments for fibromyalgia focuses on pain relief to allow those patients to function better.
Because TENS works by reducing central excitability and activating central inhibition pathways, this group tested the hypothesis that TENS would reduce pain and fatigue and improve function and hyperalgesia in people with fibromyalgia. The results showed that TENS decreases pain and fatigue during or directly after application, compared to placebo or no TENS (by 1-time 30-minutes treatment). Moreover there was a decrease in pain and fatigue during movement. Pain threshold was decreased at the location of TENS application and outside the site.
In conclusion, TENS might be considered as an additional nonpharmacological treatment option. Furthermore, TENS could potentially be used during physical activity, as movement pain in people with fibromyalgia is a significant barrier to exercise and leads to a sedentary lifestyle. A reduction in pain with movement might be expected to increase physical activity levels and improve quality of life. > From: Dailey et al., Pain 154 (2013) 2554-2562. All rights reserved to Elsevier Ltd.
Injury to the ankle syndesmosis accounts for up to 24% of all ankle sprains, and is commonly associated with persistent disability and prolonged recovery. Part of this is possibly due to delayed or missed diagnosis, therefore highlighting the importance of accurate clinical tests to facilitate early detection of ankle syndesmosis injury. The aim of the current study was to investigate the accuracy of four commonly used clinical diagnostic tests to identify a sydnesmosis injury.
87 participants presenting to numerous clinics with an ankle sprain injury were investigated over a two-week period. Clinical presentation, dorsiflexion-external rotation stress test, dorsiflexion lunge with compression test, squeeze test and ankle syndesmosis ligament palpation were all compared to each participant’s MRI findings. An inability to perform a single-leg hop was the clinical presentation that had the highest sensitivity amongst those who had a syndesmosis injury. Of the clinical tests, the squeeze test had the highest specificity, whilst both the dorsiflexion-external rotation stress test and syndesmosis ligament tenderness were the most sensitive.
These results suggest that a combination of clinical tests is likely to yield a more accurate diagnosis of an ankle syndesmosis sprain compared to one single test. Numerous positive findings for the above clinical tests should prompt the referral for further investigations under the suspicion of a syndesmosis injury. > From: Sman et al., Brit J Sport Med (2013) (Epub ahead of print). All rights reserved to BMJ Journals.
The outcome of meniscal repair at the time of ACL reconstruction is significant better than during isolated meniscal surgery without knowing the cause of this. This study focused on the possible explanation by measuring the release of growth factors (that could stimulate healing) after both meniscectomy with or without ACL reconstruction.
Only joint PDGF (platelet-derived growth factor) was significant higher in surgery with ACL reconstruction compared to isolated meniscal surgery. PDGF is one of the first secreted growth factor after tissue injury. The increased level of PDGF after surgery with ACL reconstruction could play a role in the better outcome. However, until now no clinical data are available on the direct effect of growth factors on meniscus repair in human. > From: De Girolamo et al., Knee Surg Sports Traumatol Arthrosc (2013) (Epub ahead of print). All rights reserved to Springer.
Dermatomal charts vary and previous studies have demonstrated significant individual subject variation (see publication on the 11th of April). This article analysed distribution of L5 and S1 dermatomes.
Subjects included had a proven nerve root compression (NRC); radiologically and surgically. In the study subjects were asked to complete a diagram of their pain and pins and needles distribution. The results showed a significant overlap of dermatomes, as most patients indicated pain or pins and needles in more than one dermatomal area. For example from the patients with L5 NRC, 22% showed pain in the front of the leg, 61% pain on the back of the leg and 13% in both, front and back.
The main conclusions from this article are:
- Individual subject variation is significant.
- Self-reported distribution of pain and pins and needles from a single NRC extends over many dermatomes.
- The most frequently indicated dermatome does not often correspond to the actual anatomical root affected.
- Patient self-report is an unreliable method of identification of the level of NRC.
> From: Taylor et al., Spine 12 (2013) 995-998. All rights reserved to Lippincott Williams & Wilkins.
The aim of this study was to examine the clinical effectiveness of a stepped care approach over a 12-month period after an acute whiplash injury and to estimate the costs and costs-effectiveness.
A total of 3851 patients were recruited for the trial. In step 1, patients received either usual care advice (mostly advice to exercise) or The whiplash Book/active management advice. In step 2 participants with persistent symptoms received either a single session of advice from a physiotherapist or up to six sessions of physiotherapy treatment ranging from manual therapy, exercise to brief psychological interventions and advice.
There were no significant differences observed in any outcomes between usual care and active management advice. The physiotherapy package resulted in improvements in neck disability at 4 months in comparison with a single advice session, but these effects were small at the population level. However, an important benefit of the physiotherapy package was a reduction in workdays lost, and as such, the intervention may prove cost-effective at the societal level. > From: Lamb et al., Health Technol Assess 16 (2012) 49. All rights reserved to Queen’s Printer and Controller of HMSO.
In the majority of shoulder pathologies, an accessory alteration in scapular kinematics is present – it is commonly presumed that a reduction in upward rotation and posterior tilt during arm elevation lead to narrowing of the subacromial space, and may therefore cause impingement. Consequently, the evaluation of scapular movements is an integral part of the clinical examination of the shoulder.
This study investigated the interrater reliability of mobility tests of the shoulder girdle as proposed by Stenvers & Overbeek (1977) in both patients suffering from a slight restriction of shoulder flexion and asymptomatic controls.
There was a 82-92% percentage of agreement between two independent assessors. Three of the four tests individually had kappa values ranging from 0.63-0.79; one test had a kappa value of 0.84. When applying a rule of at least three positive tests out of four to clinically diagnose restricted scapular movement, the cluster had a kappa value of 0.74. The authors conclude that there is substantial reliability for the four mobility tests. >
From: Baertschi et al., BMC Musculoskelet Disord 14 (2013) 315. Distributed under the terms of the Creative Commons Attribution License.
It has been proposed that a large subgroup of patients with Non Specific Chronic Low Back Pain (NSCLBP) presents with a primary deficit in motor control and proprioception, which contributes to their ongoing NSCLBP disorder. Furthermore, when NSCLBP patients are analyzed and compared to pain-free participants, differences in parameters including posture and muscle activation are apparent. Repositioning Error (RE) is a way of measuring trunk kinematics and involves participants trying to reproduce a target body position, which may be a more appropriate measure of lumbopelvic proprioception. Increased RE may reflect altered sensory input or motor output, impaired central nervous system (CNS) processing, or be related to levels of pain, fear, motivation, or concentration.
This study measured RE in 15 patients with NSCLBP and 15 pain free participants. Lumbo-pelvic RE, pain, functional disability, fear-avoidance and kinesiophobia were evaluated. Participants were asked to reproduce a target position (neutral lumbo-pelvic posture) after 5 s of slump sitting. RE was compared in each group.
The results showed increased lumbo-pelvic RE in NSCLBP patients, who were undershooting the target position. Overall, RE was only weakly to moderately correlated with measures of pain, disability or fear. The deficits observed are consistent with findings of altered motor control in patients with NSCLBP. > From: O'Sullivan et al., Man Ther 18 (2013) 526-532. All rights reserved to Elsevier Ltd.
Functional deficits in the lower extremity persist long after athletes return to sport following an ACL reconstruction. It is essential to develop objective, performance-based assessments to identify potential lower extremity deficits in the latter stages of rehabilitation following ACL reconstruction. The aim of the current study was to determine whether existing bilateral tests could be modified to expose unilateral deficits and compare them the currently utilised single-leg hop tests.
18 patients who returned to sport less than one-year post-ACL reconstruction were matched with controls. Differences in functional performance between the groups were compared via a number of tests.
While all tests requiring bilateral involvement of both lower extremities showed no group differences, the limb symmetry index on the distance measures of the single-limb tests were able to differentiate between the ACL-reconstruction and control group.
These findings suggest that unilateral assessments should be utilised to identify deficits in performance post-ACL reconstruction. > From: Myer et al., J Orthop Sports Phys Ther (2014) (Epub ahead of print). All rights reserved to the Journal of Orthopaedic & Sports Physical Therapy
Entrapment neuropathies (such as carpal tunnel syndrome, piriformis syndrome, meralgia paraesthetica, etc.) are thought to be driven by local peripheral nerve mechanisms, however, they do not always follow a clear dermatomal, myotomal or sclerotomal pattern. This masterclass reviews the local, peripheral and central mechanisms and their consequence in diagnosis and treatment.
Nerve compression causes neuroinflammation (via glial and immune cells activation and inflammatory mediators) in the peripheral nerve, dorsal root ganglion and spinal chord; it also induces glial cells activation in the midbrain and thalamus, and cortical reorganisation, such as in the somatosensory cortex. These mechanisms can explain the wide spread and variety of symptoms.
Clinical (symptoms, neurological examination, provocation tests, neurodynamics, palpation) and diagnostic (electrodiagnostics, quantitative sensory testing, imaging) tests are available but lack validity.
Conservative treatment aims at normalising peripheral input and reducing central sensitisation; this may include neurophysiology education, advice, nerve gliding, strengthening, stretching, home exercise programme, passive mobilisation and other modalities. NSAIDs may help in the short term, but there is a need for drugs that target neuroinflammation. > From: Schmid et al., Man Ther 18 (2013) 449-457. All rights reserved to Elsevier Ltd.
The optimal criteria for return to sport following an acute hamstring injury is currently unknown due to a lack of evidence-based guidelines. A number of recent studies have highlighted the potential importance of normalisation of isokinetic strength as a distinct clinical marker to facilitate the decision as to when an athlete is ready to return to sport. The aim of this study was to investigate isokinetic measurements in MRI-positive hamstring injuries.
52 professional football players underwent isokinetic strength testing following a standardised rehabilitation program. A contralatetal deficit of more than 10% was considered abnormal.
There was no significant difference in mean isokinetic peak torques and 10% isokinetic deficits in players without reinjury compared with reinjured players at 2 months post-initial rehabilitation.
These results suggest that normalisation of isokinetic strength is not an essential criteria for return to sport following an acute hamstring strain in professional football players. Therefore, the possible association between isokinetic strength deficits and reinjury remains elusive. >
From: Tol et al., Br J Sports Med (2014) (Epub ahead of print). All rights reserved to BMJ Publishing Group Ltd.
The term subacromial impingement syndrome (SIS) encompasses a wide range of disorders, including rotator cuff syndrome, tendinopathy of the various rotator cuff tendons and bursitis in the shoulder region. The prescription of analgesics (often NSAIDs) and corticosteroid injections is common in primary care. This systematic review sought to determine and present an evidence-based overview of the effectiveness of pharmaceuticals in the treatment of SIS.
Interestingly, although their frequent application, there is no evidence for the effectiveness of corticosteroid injections or corticosteroid injections plus NSAIDs versus NSAIDs alone for SIS in the short term yet; even when compared to placebo interventions, no conclusive evidence is available on the effectiveness of both corticosteroid injections as well as corticosteroid injections plus NSAIDs.
More evidence is needed to determine the effectiveness of corticosteroid injections for treating SIS. This review has also highlighted a lack of evidence for the applications of simple analgesics (such as paracetamol), mild opioids (codeine phosphate) and other commonly prescribed NSAIDs in the treatment of SIS: oral ibuprofen seems to provide the most pain relief in the short term. >
From: Van der Sande et al., Arch Phys Med Rehabil 94 (2013) 961-76. All rights reserved to the American Congress of Rehabilitation Medicine
Studies have shown that a conflict between proprioception, vision, and motor intention can induce altered body sensations and alleviate chronic pain in some conditions. The aim of this study was to investigate reactions to incongruent mirror movement in healthy participants.
A mirror setup (with a whiteboard as a control) was used that included congruent and incongruent hand and arm movements in 113 healthy participants. The authors assessed any occurrence of unusual sensations such as pain, the sensation of missing or additional limbs and changes in weight or temperature.
In the present study, the feeling of an extra limb was the most frequently reported unusual sensation. Only in 2% of the participants did the mirror feedback elicit pain. Overall, there is a large individual variability when using mirror feedback. A patients susceptibility and the way mirror feedback is used might have important implications for the efficacy of mirror therapy for chronic syndromes such as phantom limb pain.
