A narrative review of manual muscle testing and implications for muscle testing research

Modified Squat Test for Predicting Knee Muscle Strength in Older Adults

BACKGROUND

Methods for evaluating the strength of the knee extensor muscles play a vital role in determining the functionality of the lower limbs and monitoring any alterations that occur over time in older individuals. This study assessed the validity of the Modified Squat Test (MST) in predicting knee extensor muscle strength in older adults.

METHODS

This study included a total of 110 older adults. We collected demographic information such as sex, age, body weight, height, and thigh circumference. Muscle strength was assessed by measuring the maximum voluntary isometric contraction of the knee extensors, and by performing the MST (5 and 10 repetitions) and single-leg standing balance test. Stepwise multiple linear regression analysis was used to investigate multiple factors impacting the prediction of knee extensor strength.

RESULTS

Factors such as age, sex, thigh circumference, performance on the single-leg standing eye-open (SSEO) task, and the time required to complete the 10 MST repetitions together explained 77.8% of the variation in knee extensor muscle strength among older adults. We further developed a predictive equation to calculate strength as follows: strength = 36.78 - 0.24 (age) + 6.16 (sex) + 0.19 (thigh circumference) + 0.05 (SSEO) - 0.54 (time required to complete 10 MST repetitions) ± 5.51 kg.

CONCLUSION

The 10-repetition MST is an invaluable instrument for establishing an equation to accurately predict lower limb muscle strength.

Motor priming to enhance the effect of physical therapy in people with spinal cord injury

CONTEXT

Brain-Computer Interface (BCI) is an emerging neurorehabilitation therapy for people with spinal cord injury (SCI).

OBJECTIVE

The study aimed to test whether priming the sensorimotor system using BCI-controlled functional electrical stimulation (FES) before physical practice is more beneficial than physical practice alone.

METHODS

Ten people with subacute SCI participated in a randomized control trial where the experimental (N = 5) group underwent BCI-FES priming (∼15 min) before physical practice (30 min), while the control (N = 5) group performed physical practice (40 min) of the dominant hand. The primary outcome measures were BCI accuracy, adherence, and perceived workload. The secondary outcome measures were manual muscle test, grip strength, the range of motion, and Electroencephalography (EEG) measured brain activity.

RESULTS

The average BCI accuracy was 85%. The experimental group found BCI-FES priming mentally demanding but not frustrating. Two participants in the experimental group did not complete all sessions due to early discharge. There were no significant differences in physical outcomes between the groups. The ratio between eyes closed to eyes opened EEG activity increased more in the experimental group (theta Pθ = 0.008, low beta Plβ = 0.009, and high beta Phβ = 1.48e-04) indicating better neurological outcomes. There were no measurable immediate effects of BCI-FES priming.

CONCLUSION

Priming the brain before physical therapy is feasible but may require more than 15 min. This warrants further investigation with an increased sample size.

Peripheral nerve regeneration following scaffold-free conduit transplant of autologous dermal fibroblasts: a non-randomised safety and feasibility trial

BACKGROUND

The use of Bio 3D nerve conduits is a promising approach for peripheral nerve reconstruction. This study aimed to assess their safety in three patients with peripheral nerve defects in their hands.

METHODS

We describe a single institution, non-blinded, non-randomised control trial conducted at Kyoto University Hospital. Eligibility criteria included severed peripheral nerve injuries or a defect in the region distal to the wrist joint not caused by a congenital anomaly; a defect with a length of ≤20 mm in a nerve with a diameter ≤2 mm; failed results of sensory functional tests; ability to register in the protocol within 6 months from the day of injury; refusal of artificial nerve or autologous nerve transplantation; age 20-60 years; and willingness to participate and provide informed written consent. Six weeks before transplantation, skin was harvested, dermal fibroblasts were isolated and expanded, and Bio 3D nerve conduits were created using a Bio 3D printer. Bio 3D nerve conduits were transplanted into the patients' nerve defects. The safety of Bio 3D nerve conduits in patients with a peripheral nerve injury in the distal part of the wrist joint were assessed over a 48-week period after transplantation.

RESULTS

No adverse events related to the use of Bio 3D nerve conduits were observed in any patient, and all three patients completed the trial.

CONCLUSIONS

Bio 3D nerve conduits were successfully used for clinical nerve reconstruction without adverse events and are a possible treatment option for peripheral nerve injuries.

Balancing ability of patients with lumbar spinal canal stenosis

PURPOSE

To determine the relationship between postural sway and the severity of lumbar spinal canal stenosis as well as the effect on postoperative improvement.

METHODS

Stabilometry was performed before and 6 months after surgery in 52 patients (29 men and 23 women; mean age, 74.1 ± 7.8 years) who underwent decompression surgery for lumbar spinal canal stenosis. The environmental area (EA; the area surrounding the circumference of the stabilogram) and locus length per EA (L/EA) were evaluated. The patients were divided into moderate (n = 22) and severe (n = 30) groups according to the severity of canal stenosis. Patient characteristics and parameters were compared between the groups before and after surgery, including the visual analog scale (VAS) score for leg pain, Oswestry Disability Index (ODI), EA, and L/EA. In addition, factors affecting EA and L/EA were evaluated using multiple regression analysis.

RESULTS

Age (p = 0.031), preoperative EA (p < 0.001), preoperative L/EA (p = 0.032), and sagittal vertical axis (p = 0.033) were significantly different between groups. The VAS score and ODI significantly improved postoperatively in both groups (p < 0.001). The EA significantly improved postoperatively only in the severe group (p < 0.001), whereas the L/EA did not significantly improve in either group. Multiple regression analysis showed that only the severity of canal stenosis was significantly associated with preoperative EA (p = 0.030), whereas age (p = 0.040) and severity of canal stenosis (p = 0.030) were significantly associated with preoperative L/EA. Diabetes was significantly associated with postoperative EA (p = 0.046) and L/EA (p = 0.030).

CONCLUSION

The severity of canal stenosis affected abnormal postural sway, which improved after decompression surgery.

Reliability and validity of new isokinetic strength assessment for rotator cuff muscles in a muscle architecture-based position

Background/aim

Isokinetic strength assessment of the rotator cuff muscle is frequently applied in a variety of shoulder postures, but none of these consider muscular architecture, which is one of the most important aspects of improving strength development. This study aimed to examine the test and retest reliability and validity of the muscle architecture-based position (MABP), which is 25° abduction and 20° external rotation, in healthy subjects to be able to select a better isokinetic assessment position for shoulder rotator cuff muscles.

Materials and methods

A total of 54 healthy males with a mean age of 21.0 ± 1.2 years and mean body mass index of 22.8 ± 1.7 kg/m2 completed an isokinetic measurement session. All of the tests were performed on an IsoMed 2000 isokinetic dynamometer concentrically and eccentrically for both upper limbs at 60°/s angular velocity. All of the participants completed 3 measurement sessions: the first represented the isokinetic testing and was performed in the scapular neutral position (SNP) (45° shoulder flexion and abduction), the second represented the MABP (25° abduction and 20° ER) for shoulder rotator cuff muscles, and the third represented the test and retest of the MABP.

Results

The correlations between the 2 techniques for assessing concurrent validity ranged from 0.908 to 0.994. The values obtained from the MABP were higher than those obtained in the SNP. There was no systematic bias for any measurements between the MABP and the retest of the MABP (p > 0.05). The intraclass correlation coefficients representing the test and retest reliability results for each variable measured with the MABP was higher than 0.98 and this value was considered as excellent reliability.

Conclusion

In conclusion, the MABP can be used to assess the isokinetic strength of the rotator cuff muscles safely and confidently, with increased quantities of force being released and measurement at optimal muscle tension.

Structured Manual Muscle Testing of the Lower Limbs

An accurate and reliable neurological examination is pivotal in diagnosing patients with neurological and neurosurgical conditions. Despite the advancement of neuroscientific knowledge and the ever-progressing technologies and modalities that are being adopted to help achieve the challenge of accurate diagnosis, the neurologic examination is still crucial in both ambulatory and emergency settings. It provides the physician a tool to recognise neurologic involvement in certain disease states, and thereby allow proper work-up and treatment for patients. A basic neurologic examination can be performed rapidly with practice. Manual muscle testing of the lower limbs was carried out in accordance with a bedside clinical examination involving a clinical personnel examiner and a patient. This testing was performed in a rostro-caudal manner, starting from the hip and progressing to the toes. The neurological exam can be intimidating to perform for a lot of physicians. Deficiencies in accurate muscle testing have always presented a challenge for medical students and clinicians. By referring to the examination methods mentioned in our text and with the help of related video, it is our aim to improve the quality of neurological examination among medical personnel so that diseases may be recognised and managed earlier in their course.

Repeated measurements of Adaptive Force: Maximal holding capacity differs from other maximal strength parameters and preliminary characteristics for non-professional strength vs. endurance athletes

The Adaptive Force (AF) reflects the neuromuscular capacity to adapt to external loads during holding muscle actions and is similar to motions in real life and sports. The maximal isometric AF (AFiso_max) was considered to be the most relevant parameter and was assumed to have major importance regarding injury mechanisms and the development of musculoskeletal pain. The aim of this study was to investigate the behavior of different torque parameters over the course of 30 repeated maximal AF trials. In addition, maximal holding vs. maximal pushing isometric muscle actions were compared. A side consideration was the behavior of torques in the course of repeated AF actions when comparing strength and endurance athletes. The elbow flexors of n = 12 males (six strength/six endurance athletes, non-professionals) were measured 30 times (120 s rest) using a pneumatic device. Maximal voluntary isometric contraction (MVIC) was measured pre and post. MVIC, AFiso_max, and AF_max (maximal torque of one AF measurement) were evaluated regarding different considerations and statistical tests. AF_max and AFiso_max declined in the course of 30 trials [slope regression (mean ± standard deviation): AF_max = -0.323 ± 0.263; AFiso_max = -0.45 ± 0.45]. The decline from start to end amounted to -12.8% ± 8.3% (p < 0.001) for AF_max and -25.41% ± 26.40% (p < 0.001) for AFiso_max. AF parameters declined more in strength vs. endurance athletes. Thereby, strength athletes showed a rather stable decline for AF_max and a plateau formation for AFiso_max after 15 trials. In contrast, endurance athletes reduced their AF_max, especially after the first five trials, and remained on a rather similar level for AFiso_max. The maximum of AFiso_max of all 30 trials amounted 67.67% ± 13.60% of MVIC (p < 0.001, n = 12), supporting the hypothesis of two types of isometric muscle action (holding vs. pushing). The findings provided the first data on the behavior of torque parameters after repeated isometric-eccentric actions and revealed further insights into neuromuscular control strategies. Additionally, they highlight the importance of investigating AF parameters in athletes based on the different behaviors compared to MVIC. This is assumed to be especially relevant regarding injury mechanisms.

Emotional Imagery Influences the Adaptive Force in Young Women: Unpleasant Imagery Reduces Instantaneously the Muscular Holding Capacity

The link between emotions and motor function has been known for decades but is still not clarified. The Adaptive Force (AF) describes the neuromuscular capability to adapt to increasing forces and was suggested to be especially vulnerable to interfering inputs. This study investigated the influence of pleasant and unpleasant food imagery on the manually assessed AF of elbow and hip flexors objectified by a handheld device in 12 healthy women. The maximal isometric AF was significantly reduced during unpleasant vs. pleasant imagery and baseline (p < 0.001, dz = 0.98−1.61). During unpleasant imagery, muscle lengthening started at 59.00 ± 22.50% of maximal AF, in contrast to baseline and pleasant imagery, during which the isometric position could be maintained mostly during the entire force increase up to ~97.90 ± 5.00% of maximal AF. Healthy participants showed an immediately impaired holding function triggered by unpleasant imagery, presumably related to negative emotions. Hence, AF seems to be suitable to test instantaneously the effect of emotions on motor function. Since musculoskeletal complaints can result from muscular instability, the findings provide insights into the understanding of the causal chain of linked musculoskeletal pain and mental stress. A case example (current stress vs. positive imagery) suggests that the approach presented in this study might have future implications for psychomotor diagnostics and therapeutics.

Exercise Prescription Improve the Rehabilitation of a Child With Viral Encephalitis Sequelae: A Case Report

This study conducted a personalized exercise prescription intervention on a child with viral encephalitis sequelae (VES). The purpose was to observe the rehabilitation process from the aspects of brain activation, and the curative effects on balance function and gait. A further aim was to explore the possible nerve biomechanical mechanisms between the extent of brain activation and the improvement in balance function and gait. A 12-week exercise prescription was used as the treatment method, and functional near-infrared spectroscopy (fNIRS), balance function test system, plantar pressure distribution system, and 3D gait system were used to assess the effects of the rehabilitation process pre and post the intervention. Following the exercise prescription intervention: (1) fNIRS showed that brain activation in the S1-D1, S1-D2, S1-D3, S2-D1, S3-D2, S3-D3, S4-D3, S5-D5, S5-D6, S5-D7, S7-D6, S7-D7, S8-D7, and S8-D8 increased significantly (P < 0.05). (2) The balance test showed that the area of motion ellipse and movement length of the child with eyes open decreased significantly and area of motion ellipse, back and forth swing, left and right swing and movement length of the child with eyes closed all decreased significantly (P < 0.05). (3) The static plantar pressure distribution demonstrated that the pressure center of the left and right foot decreased significantly (P < 0.05) from 5.3° dislocation in a straight line in the sagittal plane to 1°; an increment of the pressure loading was found on the forefoot of both feet compared with what was recorded in the pre-test. (4) The testing results of the 3D gait system showed that she had a shortened time of unilateral support phase and prolonged swing phase on the affected leg (P < 0.05), compared to that of the non-affected leg. Furthermore, the dual support phase had also been prolonged (P < 0.05). Conclusion: 12 weeks' individualized exercise training can enhance the activation in the motor areas and improve balance function and gait in a child with VES.

Case Study: Intra- and Interpersonal Coherence of Muscle and Brain Activity of Two Coupled Persons during Pushing and Holding Isometric Muscle Action

Inter-brain synchronization is primarily investigated during social interactions but had not been examined during coupled muscle action between two persons until now. It was previously shown that mechanical muscle oscillations can develop coherent behavior between two isometrically interacting persons. This case study investigated if inter-brain synchronization appears thereby, and if differences of inter- and intrapersonal muscle and brain coherence exist regarding two different types of isometric muscle action. Electroencephalography (EEG) and mechanomyography/mechanotendography (MMG/MTG) of right elbow extensors were recorded during six fatiguing trials of two coupled isometrically interacting participants (70% MVIC). One partner performed holding and one pushing isometric muscle action (HIMA/PIMA; tasks changed). The wavelet coherence of all signals (EEG, MMG/MTG, force, ACC) were analyzed intra- and interpersonally. The five longest coherence patches in 8−15 Hz and their weighted frequency were compared between real vs. random pairs and between HIMA vs. PIMA. Real vs. random pairs showed significantly higher coherence for intra-muscle, intra-brain, and inter-muscle-brain activity (p < 0.001 to 0.019). Inter-brain coherence was significantly higher for real vs. random pairs for EEG of right and central areas and for sub-regions of EEG left (p = 0.002 to 0.025). Interpersonal muscle-brain synchronization was significantly higher than intrapersonal one, whereby it was significantly higher for HIMA vs. PIMA. These preliminary findings indicate that inter-brain synchronization can arise during muscular interaction. It is hypothesized both partners merge into one oscillating neuromuscular system. The results reinforce the hypothesis that HIMA is characterized by more complex control strategies than PIMA. The pilot study suggests investigating the topic further to verify these results on a larger sample size. Findings could contribute to the basic understanding of motor control and is relevant for functional diagnostics such as the manual muscle test which is applied in several disciplines, e.g., neurology, physiotherapy.

Supraspinatus Fatty Infiltration Correlation with Handgrip Strength, Shoulder Strength, and Validated Patient-Reported Outcome Measures in Patients with Rotator Cuff Tears

Introduction

The purpose of this study was to investigate the relationships between supraspinatus atrophy on magnetic resonance imaging (MRI) and other objective parameters in patients with rotator cuff tears. It was hypothesized that high-grade supraspinatus fatty infiltration would be correlated negatively with handgrip strength, shoulder strength, and patient-reported outcome measures (PROMs).

Methods

Patients with MRI-proven rotator cuff tears treated by a single sports medicine fellowship-trained orthopaedist at a single institution underwent comprehensive preoperative evaluation including bilateral handgrip and shoulder strength measurements with dynamometers and multiple online questionnaires from the Surgical Outcomes SystemTM (Arthrex, Naples, FL). Available shoulder MRIs were reviewed to grade supraspinatus fatty infiltration severity according to the 5-tier Goutallier system and an alternate 3-tier classification scheme. Difference analysis and Spearman (rho) rank order correlation were applied to the collected data to define the relationships between supraspinatus fatty infiltration and key variables including handgrip strength, shoulder strength, and scores derived from the shoulder PROMs.

Results

Ninety of the 121 patients enrolled in the study had shoulder MRIs available for review. There was no correlation found between supraspinatus fatty infiltration and handgrip strength, shoulder abduction strength, or any of the seven common shoulder PROM scores evaluated. There was statistically significant, albeit weak, correlation between MRI-derived fatty infiltration and shoulder external rotation strength.

Conclusions

Contrary to the hypothesis, high-grade supraspinatus fatty infiltration is largely unrelated to and should not be considered predictive of handgrip strength, shoulder strength, or common shoulder PROM scores.

Customized Manual Muscle Testing for Post-Stroke Upper Extremity Assessment

In neuro-rehabilitation, the assessment of post-stroke patients’ motor function of damaged upper extremities (UEs) is essential. Clinicians need clear and concise assessment instruments to monitor progress recorded in intensive rehabilitation sessions. One such instrument is Manual Muscle Testing (MMT), which, in our view, requires a modified scoring model aimed at improving the assessment process of patients’ motor and functional UE status, and recording their step-by-step-progress, especially if patients undergo a short length of hospitalization (of about 10 therapy days). Hence, this paper presents a new scoring system developed by the authors. This systemresults in a more precise MMT grading scale, which has more grades and can provide a more specific muscular assessment, while offering more clarity in quantifying patients’ progress after physical therapy. A prospective study was made of 41 post-stroke patients with upper extremity (UE) impairments. To determine the validity of the assessment tool for hypothesizing, and the unidimensionality and internal consistency of the customized model, exploratory and confirmatory factor analysis (CFA) with a structural equation model (SEM), Cronbach’s Alpha, and Pearson correlation coefficients were used with Fugl−Meyer (FM) assessments, the Modified Ashworth Scale (MAS), AROM, and the Modified Rankin Scale (MRS). Considering the unidimensionality of the instrument used, we performed a linear regression to identify whether certain movements performed segmentally by the manually evaluated muscles influence the measured manual score of the whole UE. All indices suggested a good model fit, and a Cronbach’s Alpha of 0.920 suggested strong internal consistency. The Pearson correlation coefficient of the MMT-customized score with AROM was 0.857, p < 0.001; that with FMUE was 0.905, p < 0.001; that with MRS was −0.608, p = 0.010; and that with MAS was −0.677, p < 0.001. The linear regression results suggest that wrist extensors, shoulder abductors, and finger flexors can influence the manual assessment of the muscle strength of the whole UE, thereby improving post-stroke patient management. The results of our research suggest that, using the proposed scoring, MMT may be a useful tool for UE assessment in post-stroke patients.

Acute Palliative Physical Therapy Services for a Patient With Metastatic Rectal Cancer and Subsequent Spinal Cord Compression

Colorectal cancer is the third most common cause of cancer-related deaths with approximately 40%-50% of people diagnosed experiencing subsequent metastases. Surgery is the only curative treatment for colorectal cancer, although chemotherapy and radiation are often used neoadjuvantly or adjuvantly to decrease recurrence rates and improve survival. Many individuals experience adverse effects and physical impairments secondary to extensive medical treatment. Therefore, the purpose of this case is to signify the important role of physical therapy in the continuum of care of a patient diagnosed with metastatic rectal cancer and subsequent spinal cord compression. The patient was a 70-year-old male admitted to the hospital for lower extremity (LE) numbness and weakness secondary to metastatic rectal cancer. Seventeen months prior to hospitalization, he was diagnosed with rectal cancer and underwent neoadjuvant chemotherapy and radiation followed by laparoscopic abdominoperineal resection with posterior prostatectomy en bloc with a colostomy. Adjuvant chemotherapy included FOLFIRI. While hospitalized, the patient experienced spinal cord compression secondary to metastasis and elected decompressive laminectomy with discectomy for palliation. Due to the poor prognosis of metastatic rectal cancer, the patient’s functional mobility and independence declined throughout hospitalization. The patient was able to achieve one of two personal goals; he was able to tolerate sitting in an upright position for his daughter’s wedding but unfortunately did not return home prior to expiration. Although the patient suffered eventual mortality, consistent physical therapy allowed him to achieve a major life goal, serving as an important motivator and improved quality of life (QoL) even in end-of-life conditions. Unfortunately, physical therapy services are often overlooked and under-utilized in patients with terminal conditions receiving palliative care, despite the growing body of literature supporting the benefits. By utilizing rehabilitation in reverse as well as skilled maintenance, physical therapy assists in maintaining mobility and achieving personal goals of individuals with terminal cancer, thus improving QoL even with a poor prognosis.

Disgusting odours affect the characteristics of the Adaptive Force in contrast to neutral and pleasant odours

The olfactomotor system is especially investigated by examining the sniffing in reaction to olfactory stimuli. The motor output of respiratory-independent muscles was seldomly considered regarding possible influences of smells. The Adaptive Force (AF) characterizes the capability of the neuromuscular system to adapt to external forces in a holding manner and was suggested to be more vulnerable to possible interfering stimuli due to the underlying complex control processes. The aim of this pilot study was to measure the effects of olfactory inputs on the AF of the hip and elbow flexors, respectively. The AF of 10 subjects was examined manually by experienced testers while smelling at sniffing sticks with neutral, pleasant or disgusting odours. The reaction force and the limb position were recorded by a handheld device. The results show, inter alia, a significantly lower maximal isometric AF and a significantly higher AF at the onset of oscillations by perceiving disgusting odours compared to pleasant or neutral odours (p < 0.001). The adaptive holding capacity seems to reflect the functionality of the neuromuscular control, which can be impaired by disgusting olfactory inputs. An undisturbed functioning neuromuscular system appears to be characterized by a proper length tension control and by an earlier onset of mutual oscillations during an external force increase. This highlights the strong connection of olfaction and motor control also regarding respiratory-independent muscles.

Adaptive Force and emotionally related imaginations - preliminary results suggest a reduction of the maximal holding capacity as reaction to disgusting food imagination

The link between emotions and motor control has been discussed for years. The measurement of the Adaptive Force (AF) provides the possibility to get insights into the adaptive control of the neuromuscular system in reaction to external forces. It was hypothesized that the holding isometric AF is especially vulnerable to disturbing inputs. Here, the behavior of the AF under the influence of positive (tasty) vs. negative (disgusting) food imaginations was investigated. The AF was examined in n = 12 cases using an objectified manual muscle test of the hip flexors, elbow flexors or pectoralis major muscle, performed by one of two experienced testers while the participants imagined their most tasty or most disgusting food. The reaction force and the limb position were measured by a handheld device. While the slope of force rises and the maximal AF did not differ significantly between tasty and disgusting imaginations (p > 0.05), the maximal isometric AF was significantly lower and the AF at the onset of oscillations was significantly higher under disgusting vs. tasty imaginations (both p = 0.001). A proper length tension control of muscles seems to be a crucial functional parameter of the neuromuscular system which can be impaired instantaneously by emotionally related negative imaginations. This might be a potential approach to evaluate somatic reactions to emotions.

Muscle activation in specific regions of the trapezius during modified Kendall manual muscle tests

CONTEXT

Manual muscle tests (MMTs) are often used when assessing shoulder pathologies. For the trapezius, individual MMTs are used to selectively test the upper (UTR), middle (MTR), and lower (LTR) trapezius regions. It is assumed that MMTs for each region preferentially recruit the corresponding muscle fibres and produce a "maximal" contraction; however, it is unknown if this is true.

OBJECTIVE

To determine if maximum voluntary isometric contractions (MVICs) for the upper (UT-MVIC), middle (MT-MVIC), and lower (LT-MVIC) trapezius, adapted from the Kendall MMTs, recruit the corresponding trapezius regions.

DESIGN

Cross-Over.

SETTING

Laboratory.

PARTICIPANTS

20 young, healthy individuals.

INTERVENTION

Participants performed three repetitions of each MVIC. High density surface electromyography was collected from the UTR, MTR, and LTR.

MAIN OUTCOME MEASURES

Root mean square (excitation) of the UTR, MTR, and LTR.

STATISTICAL ANALYSIS

Three, one-way repeated measures ANOVAs.

RESULTS

UTR excitation: There was a significant increase in UTR excitation during the LT-MVIC compared to the UT-MVIC (p = .016), and MT-MVIC (p < .001). MTR excitation: There was a significant increase in MTR excitation during the MT-MVIC compared to the UT-MVIC (p = .001), and a significant increase in MTR excitation during the LT-MVIC compared to the UT-MVIC (p < .001). There was also a significant increase in MTR excitation during the LT-MVIC compared to the MT-MVIC (p < .001). LTR excitation: There was a significant increase in LTR excitation during the MT-MVIC (p < .001) and LT-MVIC (p < .001) compared to the UT-MVIC.

CONCLUSIONS

The UT-MVIC and MT-MVIC do not necessarily recruit the corresponding trapezius regions more than the other MVICs. Rather, the LT-MVIC appears to produce the greatest excitation in all trapezius regions. Additional research is needed; however, clinicians should be aware that maximal contractions may not always recruit the desired musculature when forming a clinical interpretation.

Biomechanical muscle stiffness measures of extensor digitorum explain potential mechanism of McArdle sign

BACKGROUND

McArdle sign is a phenomenon of impaired gait and muscle weakness that occurs with neck flexion, immediately reversible with neck extension. A recent report measured the specificity of this sign for multiple sclerosis by measuring differences in peak torque of the extensor digitorum between neck extension and flexion.

METHODS

This substudy included 73 participants (29 multiple sclerosis, 20 non-multiple sclerosis myelopathies, 5 peripheral nerve disorders, and 19 healthy controls). The effect of neck position was assessed on muscle stiffness and neuromechanical error of the extensor digitorum.

FINDINGS

Patients with multiple sclerosis had greater neuromechanical error (sum of squared error of prediction) compared to controls (P = 0.023) and non-multiple sclerosis myelopathies (P = 0.003). Neuromechanical error also provided improved sensitivity/specificity of McArdle sign. Peak torque, muscle stiffness, and neuromechanical error could distinguish multiple sclerosis from other myelopathies with 80% specificity and 97% sensitivity (AUC = 0.95).

INTERPRETATION

A decrease in muscle stiffness and neuromechanical error in neck flexion compared to extension are additional indicators for a diagnosis of multiple sclerosis. Analysis of muscle stiffness may provide insights into the pathophysiology of this specific clinical sign for multiple sclerosis. Furthermore, muscle stiffness may provide an additional accurate, simple assessment to evaluate multiple sclerosis therapeutic interventions and disease progression.

Manual Muscle Testing-Force Profiles and Their Reproducibility

The manual muscle test (MMT) is a flexible diagnostic tool, which is used in many disciplines, applied in several ways. The main problem is the subjectivity of the test. The MMT in the version of a "break test" depends on the tester's force rise and the patient's ability to resist the applied force. As a first step, the investigation of the reproducibility of the testers' force profile is required for valid application. The study examined the force profiles of n = 29 testers (n = 9 experiences (Exp), n = 8 little experienced (LitExp), n = 12 beginners (Beg)). The testers performed 10 MMTs according to the test of hip flexors, but against a fixed leg to exclude the patient's reaction. A handheld device recorded the temporal course of the applied force. The results show significant differences between Exp and Beg concerning the starting force (padj = 0.029), the ratio of starting to maximum force (padj = 0.005) and the normalized mean Euclidean distances between the 10 trials (padj = 0.015). The slope is significantly higher in Exp vs. LitExp (p = 0.006) and Beg (p = 0.005). The results also indicate that experienced testers show inter-tester differences and partly even a low intra-tester reproducibility. This highlights the necessity of an objective MMT-assessment. Furthermore, an agreement on a standardized force profile is required. A suggestion for this is given.

Chiropractic Management of a Patient With Radial Nerve Entrapment Symptoms: A Case Study

Objective

This report describes the case of a patient with chronic radial nerve entrapment symptoms managed with chiropractic care. We propose a complementary functional neurologic assessment of muscle function in different positions that could reveal muscle dysfunctions absent with standard test position.

Clinical Features

A 45-year-old man presented to a private chiropractic clinic with a throbbing pain 5 cm above the right lateral elbow epicondyle radiating onto the back of the lower arm and increasing after using a mouse when working on a computer. A Mill test and a Cozen test created pain near the lateral epicondylitis. The use of complementary functional neurologic assessment for radial nerve entrapment showed changes in manual muscle testing after tests were done in different positions to increase the compression on the nerve.

Intervention and Outcome

Chiropractic management was performed, including myofascial therapy, spinal and proximal radioulnar joint adjustments, neural mobilization, and the use of a splint. After 7 days (2 treatments), the patient showed no elbow pain even if he worked on his computer using a mouse. After a 2-year follow-up, no recurrence was reported.

Conclusion

In this case of radial nerve entrapment symptoms, the patient benefited from chiropractic management using standard chiropractic, applied kinesiology, and neural mobilization techniques. The complementary functional neurologic assessment of radial nerve entrapment proposed revealed muscles dysfunctions absent with the standard test position. These changes in manual muscle testing were useful to determine the possible sites of entrapment in order to direct the therapeutic efforts to these locations.

Psychometric Properties of Lower Extremity Strength Measurements Recorded in Community Settings in Independent Living Older Adults

BACKGROUND

A uniaxial load cell device provides an alternative, easy and inexpensive way to quantify muscle strength in different settings outside the clinic and research labs. So, the purpose of the study was to examine the test-retest reliability and the construct validity of lower extremity strength performance using an uniaxial load cell device.

METHODS

A total of 131 subjects (85% female, mean age 80 ± 8 years) were included for the validity aim, and a sample of 38 subjects were enrolled in the reliability testing (89% female, mean age 76 ± 7 years). For the strength measurements were assessed with a portable load cell for three consecutive trials. Test-retest reliability was assessed over two testing visits occurring one week apart. Spearman's rank correlation coefficient was used to test convergent validity with other mobility-related measurements construct validity at baseline.

RESULTS

Strength measurements showed good to excellent reliability in most of the measured parameters with intraclass correlation coefficients range from 0.89 to 0.99 and were correlated with mobility measurements with Spearman rho range from 0.21 to 0.38.

CONCLUSION

The portable uni-axial load cell to measure lower extremity strength provides reliable measurements in community settings.

CHARACTERIZATION OF CERVICAL SPINE IMPAIRMENTS IN CHILDREN AND ADOLESCENTS POST-CONCUSSION

BACKGROUND

Patients with concussion may present with cervical spine impairments, therefore accurate characterization of cervical post-concussion impairments is needed to develop targeted physical therapy interventions.

PURPOSE

To characterize the type, frequency and severity of cervical impairments in children and adolescents referred for physical therapy after concussion.Study design: Retrospective, descriptive study.

METHODS

A retrospective analysis was conducted for 73 consecutive children and adolescents who received cervical physical therapy following a concussion. Data was classified into six broad categories. The frequency and intensity of cervical impairments within and across the categories was reported.

RESULTS

Ninety percent of patients demonstrated impairments in at least three out of five assessment categories whereas 55% demonstrated impairments in at least four out five assessment categories. Of the five assessment categories, posture (99%) and myofascial impairment (98%) demonstrated highest impairment frequency followed by joint mobility (86%) and muscle strength (62%). Cervical joint proprioception was the least commonly evaluated assessment category.

CONCLUSION

High prevalence of cervical spine impairments was observed in the subjects included in this study with muscle tension, joint mobility, and muscle strength being most commonly affected. The categories of impairments examined in this cohort were consistent with the recommendations of the most recent clinical practice guidelines for neck pain. This study provides preliminary data to support the framework for a cervical spine evaluation tool in children and adolescents following concussion.

LEVEL OF EVIDENCE

Level 4.

The Chiropractic Vertebral Subluxation Part 7: Technics and Models From 1962 to 1980

OBJECTIVE

The purpose of this paper is to review and discuss the history of chiropractic vertebral subluxation (CVS) theories and models between 1962 and 1980.

DISCUSSION

This period was marked by several innovative texts from Weiant, Homewood, and Harper, and Canadian Memorial Chiropractic College's Segmental Neuropathy. Technique developers during this period increased the complexity of models from upper cervical to full spine. The textbooks built upon previous theories, the scientific literature, work by Speransky, and instrumentation research. The texts influenced decades of research and theory. Weiant's book surveyed the medical and scientific literature on CVS. Harper integrated modern neurophysiology with D. D. Palmer's theories integrated with other chiropractic models based on research such as Weiant's photoelectric instrumentation. Homewood's book integrated Selye, Speransky, Verner, and several other models, which led to his neurodynamic model of CVS. Segmental Neuropathy was a completely new innovation of chiropractic theory with neurophysiology. Collaboration among authors developed into several new models. Chiropractic vertebral subluxation was viewed as a global neurological phenomenon and a neurodystrophic process. Technique models from Goodheart, Nimmo, Toftness, Ward, Gonstead, Grostic, Gregory, and Pierce laid the foundation for modern practices.

CONCLUSION

The CVS theories during this period were complex and almost unrecognizable from previous theories. The inclusion of every major theory laid the foundation for this period's wide set of models, research, and methods.

Intramedullary central neurocytoma of the thoracic spinal cord: A case report and literature review

Central neurocytomas (CNs) are rare benign tumors located in the central nervous system with a good prognosis. These tumors are predominantly located in the lateral ventricle near the foramen of Monro or in the third ventricle. Similar tumors that are located outside the ventricle are also called extraventricular neurocytomas, and have an even lower morbidity. Until now, several tumors have been identified in the thalamus, cerebellum, pons, medulla oblongata and spinal cord. In total, 24 cases of neurocytomas located in the spinal cord have been reported in English journals. The present study reported a patient with an intramedullary central neurocytoma of the thoracic spinal cord, diagnosed from clinical features, imaging findings, pathology and immunohistochemistry. The present case report also outlined the prognosis of the patient and reviewed the literature currently available on CNs located in the spinal cord.

Standing balance and strength measurements in older adults living in residential care communities

Research on balance and mobility in older adults has been conducted primarily in lab-based settings in individuals who live in the community. Although they are at greater risk of falls, residents of long-term care facilities, specifically residential care communities (RCCs), have been investigated much less frequently. We sought to determine the feasibility of using portable technology-based measures of balance and muscle strength (i.e., an accelerometer and a load cell) that can be used in any RCC facility. Twenty-nine subjects (age 87 ± 6 years) living in RCCs participated. An accelerometer placed on the back of the subjects measured body sway during different standing conditions. Sway in antero-posterior and mediolateral directions was calculated. Lower extremity strength was measured with a portable load cell and the within-visit reliability was determined. Assessments of grip strength, gait speed, frailty, and comorbidity were also examined. A significant increase in postural sway in both the AP and ML directions occurred as the balance conditions became more difficult due to alteration of sensory feedback (p < 0.001) or reducing the base of support (p < 0.001). There was an association between increased sway and increased frailty, more comorbidities and slower gait speed. All strength measurements were highly reliable (ICC = 0.93-0.99). An increase in lower extremity strength was associated with increased grip strength and gait speed. The portable instruments provide inexpensive ways for measuring balance and strength in the understudied RCC population, but additional studies are needed to examine their relationship with functional outcomes.

Optimal Joint Positions for Manual Isometric Muscle Testing

CONTEXT

Manual isometric muscle testing is a common clinical technique that is used to assess muscle strength. To provide the most accurate data for the test, the muscle being assessed should be at a length in which it produces maximum force. However there is tremendous variability in the recommended positions and joint angles used to conduct these tests, with little apparent objective data used to position the joint such that muscle force production is greatest.

OBJECTIVE

To use validated anatomically and biomechanically-based musculoskeletal models to identify the optimal joint positions in which to perform manual isometric testing.

DESIGN

In silico analysis.

MAIN OUTCOME MEASURE

The joint position which produces maximum muscle force for 49 major limb and trunk muscles.

RESULTS

The optimal joint position for performing a manual isometric test was determined.

CONCLUSION

Using objective anatomical models that take into account the force-length properties of muscles, we identified joint positions in which net muscle force production was predicted to be maximal. This data can help health care providers to better assess muscle function when manual isometric strength tests are performed.

The Geriatric Driver: Factors That Influence When to Stop Driving

The increase in the growth of the elderly population in the past 2 decades has been paralleled by an increase in the number of active elderly drivers. Consequentially, this growth has been accompanied by a rise in fatal road-related accidents. Due to age-related fragility, elderly drivers are more susceptible to injuries and death following a road-related accident. The increased risk of accidents has become a growing public health issue and has led to certain guidelines and restrictions for elderly drivers. Moreover, the cognitive and physiological decline that exacerbates with age has encouraged preventative measures aimed at optimizing their ability to operate motor vehicles. Some of these include yearly vision, cognitive, motor, and mental assessment tests. Results obtained from these tests may help suggest when an elderly driver becomes unsuitable to drive.

Conservative management of an elite ice hockey goaltender with femoroacetabular impingement (FAI): a case report

OBJECTIVE

To detail the presentation of an elite male ice hockey goaltender with cam-type femoroacetabular impingement (FAI) and acetabular labral tears. This case will outline the prevalence, clinical presentation, imaging criteria, pathomechanics, and management of FAI, with specific emphasis on the ice hockey goaltender.

CLINICAL FEATURES

A 22-year old retired ice hockey goaltender presented to a chiropractor after being diagnosed by an orthopaedic surgeon with MRI confirmed left longitudinal and chondral flap acetabular labral tears and cam-type femoroacetabular impingement (FAI). As the patient was not a candidate for surgical intervention, a multimodal conservative treatment approach including manual therapy, electroacupuncture and rehabilitation exercises were implemented.

SUMMARY

FAI is prevalent in ice hockey players, particularly with goaltenders. Both skating and position-dependent hip joint mechanics involved in ice hockey may exacerbate or contribute to acquired and congenital forms of symptomatic FAI. As such, practitioners managing this population must address sport-specific demands in manual therapy, rehabilitation and physical training, to improve functional outcomes and prevent future injury.

T-cell lymphoma with POEMS syndrome

Angioimmunoblastic T-cell lymphoma (AITL) is a unique subtype of peripheral T-cell lymphoma. POEMS syndrome is a rare paraneoplastic syndrome caused by an underlying plasma cell disorder (PCD). The occurrence of AITL with POEMS syndrome has rarely been reported in the literature. The current study presents the case of a 53-year-old male who presented with a rapidly proliferative lymph node on the left neck, which was identified as an AITL on biopsy. The patient also exhibited the complications of polyneuropathy, M-proteinemia, hepatosplenomegaly, left ventricular hypertrophy, endocrinopathy and skin changes, and was therefore diagnosed with POEMS syndrome. To the best of our knowledge, the present study is the first to report a case of AITL with POEMS syndrome. The findings in this case suggest that the aberrant clones of B cells can also be caused by AITL.

Assessment of muscular strength with the modified sphygmomanometer test: what is the best method and source of outcome values?

Background

Tests that are usually employed for the clinical assessment of muscular strength have notable disadvantages. The Modified Sphygmomanometer Test (MST) is a promising method because it is low-cost and provides objective measures.

Objectives

To investigate the most adequate method and sources of outcome values for the assessment of strength with the MST.

Method

Methodological study with 40 healthy adults (22.98±2.26 years), who did not practice physical activity regularly. The strength of the flexors and extensors of the elbow and knee, the handgrip of the dominant side and anterior trunk flexors were randomly assessed with portable dynamometers and the MST (bag and cuff adaptations, and sphygmomanometer without adaptation) by a single examiner. An independent examiner read and recorded the values. The sources of the investigated outcome values were the first trial and the means of two and three trials. One-way ANOVAs and Pearson Correlation Coefficients were used for the analyses (α=0.05).

Results

For the MST methods applied to assess all muscular groups, similar values were found for all sources of outcome values (0.01<F<0.26; 0.77<p<1.00) with significant and positive correlations between the measures obtained with the dynamometers (0.51<r<0.94; p<0.003).

Conclusions

All MST methods showed adequate results for the assessment of strength in healthy individuals, and after familiarization, only one trial was sufficient to provide reliable measures. The sphygmomanometer without adaptation is not time consuming, compared to the other adaptations, and showed the capability of measuring higher values of strength. The bag method was easily trained to be used and stabilized.