72 Evaluation of digital images of bovine embryos

Bovine embryo transfer is an assisted reproductive technology that enables cattle producers to reach their reproductive, genetic, and financial goals. Proper evaluation of embryo quality and developmental stage is key to the success of the embryo transfer industry and is often acquired “on the job” as there are few embryo evaluation training opportunities. The goals of this project were to develop a bank of digital images of invivo-produced bovine embryos, and to evaluate interrater reliability and variation of grade and stage scores and the assessment of the integrity of the zona pellucida (ZP) using an online platform. Frozen/thawed bovine embryos (Day 7) were placed in a commercially available holding medium, and images were captured using a high-resolution camera (112× magnification). Survey participants (n=89) responded to questions on demographic and embryo evaluation experience and assigned grades and stages and evaluated the integrity of the ZP in 58 embryo images (the IETS embryo evaluation rubric was provided). The variation among raters within and between demographic categories was analysed using the “kappaetc” package with weights for ordinal variables (grade and stage) in Stata version 14.2 (StataCorp). The Kruskal–Wallis test was used to assess whether variation [measured as interquartile range (IQR)] in grade and stage ratings within individual were significantly different (P=0.05) by demographic factors. Overall, interrater reliability (measured by Cohen’s Kappa, κ) for stage was moderate (κ=0.57), whereas identification of grade and the ZP was substantial (κ=0.69 and 0.73, respectively). Interrater reliability for grade was significantly lower among those with ≤2 years (n=17) of experience (κ=0.44) compared with those having 3–9 years (n=29; κ=0.57) and ≥10 years (n=43; κ=0.64). Similarly, interrater agreement for stage was significantly lower for those with ≤2 years of experience (κ=0.58) compared with those having 3–9 years (κ=0.68) and ≥10 years (κ=0.75). Interrater agreement for stage was higher for those who did not use the IETS rubric compared with those who did (κ=0.73 vs. κ=0.63, respectively), and the variability was highest for Stage 6 and lowest for Stage 4 embryos. No demographic variables were significantly associated with interrater reliability for the integrity of the ZP. The variability of stage ratings (IQR) within individual significantly increased with more years of experience, with greatest IQR among those with ≥10 years of experience. The IQR within individual for grade decreased with increasing length of time rating, with the lowest IQR for the longest duration spent on rating the embryos. Overall, there was a moderate to substantial interrater agreement in embryo evaluation, which increased with experience. Further, evaluation of bovine embryo digital images may be a useful training tool instead of or in conjunction with a “hands-on” experience. Future surveys will involve multiple images of the same embryo and video to enhance the evaluation process and increase interrater reliability.

12 Artificial insemination and embryo transfer results in ewes during a long daylength period

Sheep are polyestrous, short-day breeders (∼11h of daylength), and exhibit oestrus approximately every 16–17 days during the breeding season, usually in late September to late December in the Northern Hemisphere. Progressive sheep producers often use assisted reproductive techniques such as laparoscopic AI and ovarian hyper-stimulation, embryo collection, and embryo transfer (ET) to increase genetic gain, and strive to have early December lambs to target specific show markets, which dictates AI or ET during the late summer. This field trial compared pregnancy rates following AI or ET in July and August (∼14h of daylength) in southwest Virginia (36–38′12″ N). Ewes (AI, n=83; ET recipients, n=33) were synchronized using a modified Ovsynch protocol involving intravaginal progesterone implants for 14 days, prostaglandin F2α (intramuscular) 48h before expected oestrus, and PG600 (IM) and gonadotrophin-releasing hormone (intramuscular) 52 to 54h and 16h before AI, respectively. Ewes were subjected to AI (frozen/thawed semen) regardless of whether they displayed signs of oestrus, and ewes selected as embryo recipients were subjected to a similar protocol but instead received 1 or 2 embryos (based upon the number of viable embryos produced per embryo donor) 6 days following the AI of the embryo donors. Ovarian hyper-stimulation of the embryo donors (n=13) was enabled by twice-daily FSH injections [totalling 350–455IU of Folltropin V (10–13mL)] for the 4 days before AI. Six days following AI, embryos were recovered surgically from the embryo donors (n=13) and yielded an average (±s.e.m.) of 6.6±1.2 total ova, 4.7±1.1 transferable quality embryos, and 1.9±0.8 unfertilized ova per collection. Pregnancy was detected using transrectal ultrasonography at ∼30 days of gestation and the pregnancy rates were analysed using Chi-squared. There was a tendency (P=0.092) for more pregnancies to be established following ET (22/33; 66%) compared with AI (41/83; 49%). There was no statistical relationship between AI ewes or ET recipient ewes that became pregnant relative to whether they displayed signs of oestrus or not. Embryo transfer was a more successful approach to produce pregnancies in ewes compared with AI during long daylength periods in this field trial. Further, ova from hyper-stimulated embryo donor ewes experienced a very high fertilization rate. Future studies will evaluate the ova capability directly via laparoscopic aspiration of ovarian follicles and IVF and evaluation of hyper- and non-hyper-stimulated follicular waves (using transrectal ultrasonography) and endocrine dynamics during different long and short daylength periods. Extending the opportunity to generate embryos and offspring regardless of daylength will assist aggressive sheep producers in reaching their reproductive, financial, and genetic goals.

An evaluation of the EOLAS psychoeducation programme for service users: An innovative approach to collaboration between clinicians and ‘experts by experience’

Introduction

Psychoeducation for service users has been shown in several recent meta-analyses to improve adherence with treatment, decrease rehospitalization rates and improve various measures of quality of life. The 8-week EOLAS Programme for service users with schizophrenia or bipolar disorder is unique in being designed, co-facilitated and evaluated collaboratively by both clinician and peer representatives. EOLAS forms part of the service plan of the national Health Service in Ireland.

Aims and objectives

To evaluate the impact of the EOLAS programme on participants’ perceived knowledge, confidence, advocacy, recovery attitudes and hope.

Methodology

Anonymised questionnaires were administered to participants before and after completion of the EOLAS Programme.

All survey participants were invited to attend for interview to examine qualitatively their experience of the programme. Interviews were recorded and subjected to thematic analysis.

Results

Forty-five subjects completed pre- and post-programme questionnaires (participation rate = 55%).

Significant improvements (P < 0.05) were identified across each of the 5 domains examined (i.e. perceived knowledge, confidence, advocacy, recovery attitudes, hope). Expressed satisfaction with the programme was high (95%).

At interview, participants (n = 12) particularly valued:

– the opportunity to ask questions of the psychiatrist e.g. about medication;

– improving self-care skills e.g. monitoring early warning signs of relapse;

– co-facilitation by a peer, which provided extra credibility and inspired hope;

– sharing experiences with peers.

Conclusions

The EOLAS programme succeeds in meeting the needs of the participants across the target domains. This success depends on the unique collaboration between clinicians and peer experts on which EOLAS is based.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Intra-operative fiducial-based CT/fluoroscope image registration framework for image-guided robot-assisted joint fracture surgery

Purpose

Joint fractures must be accurately reduced minimising soft tissue damages to avoid negative surgical outcomes. To this regard, we have developed the RAFS surgical system, which allows the percutaneous reduction of intra-articular fractures and provides intra-operative real-time 3D image guidance to the surgeon. Earlier experiments showed the effectiveness of the RAFS system on phantoms, but also key issues which precluded its use in a clinical application. This work proposes a redesign of the RAFS’s navigation system overcoming the earlier version’s issues, aiming to move the RAFS system into a surgical environment.

Methods

The navigation system is improved through an image registration framework allowing the intra-operative registration between pre-operative CT images and intra-operative fluoroscopic images of a fractured bone using a custom-made fiducial marker. The objective of the registration is to estimate the relative pose between a bone fragment and an orthopaedic manipulation pin inserted into it intra-operatively. The actual pose of the bone fragment can be updated in real time using an optical tracker, enabling the image guidance.

Results

Experiments on phantom and cadavers demonstrated the accuracy and reliability of the registration framework, showing a reduction accuracy (sTRE) of about \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$0.88~\pm 0.2\,\hbox {mm}$$\end{document}0.88±0.2mm (phantom) and \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$1.15\pm 0.8\,\hbox {mm}$$\end{document}1.15±0.8mm (cadavers). Four distal femur fractures were successfully reduced in cadaveric specimens using the improved navigation system and the RAFS system following the new clinical workflow (reduction error \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$1.2\pm 0.3\,\hbox {mm}$$\end{document}1.2±0.3mm, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$2\pm 1{^{\circ }})$$\end{document}2±1∘).

Conclusion

Experiments showed the feasibility of the image registration framework. It was successfully integrated into the navigation system, allowing the use of the RAFS system in a realistic surgical application.

Identification of novel antimalarial chemotypes via chemoinformatic compound selection methods for a high-throughput screening program against the novel malarial target, PfNDH2: increasing hit rate via virtual screening methods

Malaria is responsible for approximately 1 million deaths annually; thus, continued efforts to discover new antimalarials are required. A HTS screen was established to identify novel inhibitors of the parasite's mitochondrial enzyme NADH:quinone oxidoreductase (PfNDH2). On the basis of only one known inhibitor of this enzyme, the challenge was to discover novel inhibitors of PfNDH2 with diverse chemical scaffolds. To this end, using a range of ligand-based chemoinformatics methods, ∼17000 compounds were selected from a commercial library of ∼750000 compounds. Forty-eight compounds were identified with PfNDH2 enzyme inhibition IC₅₀ values ranging from 100 nM to 40 μM and also displayed exciting whole cell antimalarial activity. These novel inhibitors were identified through sampling 16% of the available chemical space, while only screening 2% of the library. This study confirms the added value of using multiple ligand-based chemoinformatic approaches and has successfully identified novel distinct chemotypes primed for development as new agents against malaria.

Identification, design and biological evaluation of bisaryl quinolones targeting Plasmodium falciparum type II NADH:quinone oxidoreductase (PfNDH2)

A program was undertaken to identify hit compounds against NADH:ubiquinone oxidoreductase (PfNDH2), a dehydrogenase of the mitochondrial electron transport chain of the malaria parasite Plasmodium falciparum. PfNDH2 has only one known inhibitor, hydroxy-2-dodecyl-4-(1H)-quinolone (HDQ), and this was used along with a range of chemoinformatics methods in the rational selection of 17 000 compounds for high-throughput screening. Twelve distinct chemotypes were identified and briefly examined leading to the selection of the quinolone core as the key target for structure–activity relationship (SAR) development. Extensive structural exploration led to the selection of 2-bisaryl 3-methyl quinolones as a series for further biological evaluation. The lead compound within this series 7-chloro-3-methyl-2-(4-(4-(trifluoromethoxy)benzyl)phenyl)quinolin-4(1H)-one (CK-2-68) has antimalarial activity against the 3D7 strain of P. falciparum of 36 nM, is selective for PfNDH2 over other respiratory enzymes (inhibitory IC₅₀ against PfNDH2 of 16 nM), and demonstrates low cytotoxicity and high metabolic stability in the presence of human liver microsomes. This lead compound and its phosphate pro-drug have potent in vivo antimalarial activity after oral administration, consistent with the target product profile of a drug for the treatment of uncomplicated malaria. Other quinolones presented (e.g., 6d, 6f, 14e) have the capacity to inhibit both PfNDH2 and P. falciparum cytochrome bc₁, and studies to determine the potential advantage of this dual-targeting effect are in progress.

Identification, design and biological evaluation of heterocyclic quinolones targeting Plasmodium falciparum type II NADH:quinone oxidoreductase (PfNDH2)

Following a program undertaken to identify hit compounds against NADH:ubiquinone oxidoreductase (PfNDH2), a novel enzyme target within the malaria parasite Plasmodium falciparum, hit to lead optimization led to identification of CK-2-68, a molecule suitable for further development. In order to reduce ClogP and improve solubility of CK-2-68 incorporation of a variety of heterocycles, within the side chain of the quinolone core, was carried out, and this approach led to a lead compound SL-2-25 (8b). 8b has IC₅₀s in the nanomolar range versus both the enzyme and whole cell P. falciparum (IC₅₀ = 15 nM PfNDH2; IC₅₀ = 54 nM (3D7 strain of P. falciparum) with notable oral activity of ED₅₀/ED₉₀ of 1.87/4.72 mg/kg versus Plasmodium berghei (NS Strain) in a murine model of malaria when formulated as a phosphate salt. Analogues in this series also demonstrate nanomolar activity against the bc₁ complex of P. falciparum providing the potential added benefit of a dual mechanism of action. The potent oral activity of 2-pyridyl quinolones underlines the potential of this template for further lead optimization studies.

The future of scattered trees in agricultural landscapes

Mature trees scattered throughout agricultural landscapes are critical habitat for some biota and provide a range of ecosystem services. These trees are declining in intensively managed agricultural landscapes globally. We developed a simulation model to predict the rates at which these trees are declining, identified the key variables that can be manipulated to mitigate this decline, and compared alternative management proposals. We used the initial numbers of trees in the stand, the predicted ages of these trees, their rate of growth, the number of recruits established, the frequency of recruitment, and the rate of tree mortality to simulate the dynamics of scattered trees in agricultural landscapes. We applied this simulation model to case studies from Spain, United States, Australia, and Costa Rica. We predicted that mature trees would be lost from these landscapes in 90-180 years under current management. Existing management recommendations for these landscapes--which focus on increasing recruitment--would not reverse this trend. The loss of scattered mature trees was most sensitive to tree mortality, stand age, number of recruits, and frequency of recruitment. We predicted that perpetuating mature trees in agricultural landscapes at or above existing densities requires a strategy that keeps mortality among established trees below around 0.5% per year, recruits new trees at a rate that is higher than the number of existing trees, and recruits new trees at a frequency in years equivalent to around 15% of the maximum life expectancy of trees. Numbers of mature trees in landscapes represented by the case studies will decline before they increase, even if strategies of this type are implemented immediately. This decline will be greater if a management response is delayed.

Two-step synthesis of achiral dispiro-1,2,4,5-tetraoxanes with outstanding antimalarial activity, low toxicity, and high-stability profiles

A rapid, two-step synthesis of a range of dispiro-1,2,4,5-tetraoxanes with potent antimalarial activity both in vitro and in vivo has been achieved. These 1,2,4,5-tetraoxanes have been proven to be superior to 1,2,4-trioxolanes in terms of stability and to be superior to trioxane analogues in terms of both stability and activity. Selected analogues have in vitro nanomolar antimalarial activity and good oral activity and are nontoxic in screens for both cytotoxicity and genotoxicity. The synthesis of a fluorescent 7-nitrobenza-2-oxa-1,3-diazole (NBD) tagged tetraoxane probe and use of laser scanning confocal microscopy techniques have shown that tagged molecules accumulate selectively only in parasite infected erythrocytes and that intraparasitic formation of adducts could be inhibited by co-incubation with the iron chelator desferrioxamine (DFO).

A radical approach to minimally invasive total hip replacement: surgical technique and pre-clinical test data

Currently total hip replacement surgery using minimally invasive techniques is a fast developing field. However, all reports concern adaptations of surgical techniques with adapted instruments using conventional implants. These conventional implants limit the minimal invasiveness to some extent. In this paper a new system is reported featuring a new surgical approach, new instrumentation and a new implant design. The purpose of this study was to introduce the system and to assess the feasibility of the system in terms of stability, range of motion and wear characteristics. The pre-clinical tests indicated that the factor of safety for this type of design is smaller than for conventional implants. However, the results show adequate performance of the system, which suggests that further development and testing is justified to advance the system for clinical use.

The Electromyographic Activity of Thoracic Paraspinal Muscles Identified as Abnormal With Palpation

OBJECTIVE

The aim of this study was to compare the electromyographic (EMG) activity of deep muscles in the thoracic paravertebral gutter (PVG) detected as abnormal to palpation (AbPT) and reported as tender by the subject with muscles underlying nontender (NT), normal to palpation sites under various experimental conditions.

METHODS

Twelve subjects (mean age, 25.42 years; range, 22-43 years) participated in this study. Fine-wire, bipolar intramuscular electrodes were inserted, under real-time ultrasonic guidance, into the deep paravertebral muscle mass underlying 1 AbPT and 2 NT sites (1 segment above and below the AbPT site) in the thoracic PVG regions. Electromyographic activity was recorded under the following conditions: resting prone, prone active trunk extension, application of pressure (300 kPa) to adjacent spinous processes, resting seated, passive and active seated trunk rotation, and supporting 2-kg weights in outstretched arms.

RESULTS

Mean EMG activity was highest at the AbPT site, relative to NT sites, under all conditions, with a significant between-group effect of site (F2,31 = 4.13, P = .03) and large between-group effect size (eta2 = 0.21). There was also a trend for lower percentage change from baseline resting at the AbPT sites, relative to the NT sites, in response to the demand of other conditions. There were large variations in EMG activity within and between individuals, and large SDs accompanied the mean values of EMG activity in all cases.

CONCLUSION

Increased motor activity may be a contributing factor to tissue changes in the PVG detected with palpation. However, caution must be used when interpreting these results because of the large variations, small sample size, and issues associated with EMG normalization.

The Stability of the Femoral Component of a Minimal Invasive Total Hip Replacement System

In this study, the initial stability of the femoral component of a minimal invasive total hip replacement was biomechanically evaluated during simulated normal walking and chair rising. A 20 mm diameter canal was created in the femoral necks of five fresh frozen human cadaver bones and the femoral heads were resected at the smallest cross-sectional area of the neck. The relatively short, polished, taper-shaped prostheses were cemented centrally in this canal according to a standardized procedure. A servohydraulic testing machine was used to apply dynamic loads to the prosthetic head. Radiostereophotogrammetric analysis was used to measure rotations and translations between the prosthesis and bone. In addition, the reconstructions were loaded until failure in a static, displacement-controlled test. During the dynamic experiments, the femoral necks did not fail and no macroscopical damage was detected. Maximal values were found for normal walking with a mean rotation of about 0.2° and a mean translation of about 120 μm. These motions stabilized during testing. The mean static failure load was 4714 N. The results obtained in this study are promising and warrant further development of this type of minimal invasive hip prosthesis.

Fauna-habitat relationships: a basis for identifying key stand structural attributes in temperate Australian eucalypt forests and woodlands

We review a representative sample of the literature concerning fauna-habitat relationships in temperate Australian eucalypt forests and woodlands as a basis for identifying some key stand structural attributes in these ecosystems. Our review identifies 56 studies in south-east and south-west Australia in which the presence or abundance of different fauna were significantly associated with vegetation structural attributes at the scale of a stand. The majority of these studies concern bird, arboreal mammal, and ground mammal habitat requirements, with relatively few studies addressing the habitat requirements of reptiles, invertebrates, bats or amphibians. We identify 34 key structural attributes from these 56 studies, by grouping similar attributes, and then representing each group with a single generic attribute. Relatively few of these attributes are incorporated into indices used to quantify fauna habitat. We highlight the need for a quantitative method for selecting which key attributes should form the basis for an index of structural complexity or other surrogate measure of faunal diversity.

Paraspinal muscles and intervertebral dysfunction: part two

BACKGROUND

One of the diagnostic characteristics of the manipulable spinal lesion--a musculoskeletal disturbance that is claimed to be detected with manual palpation and corrected with manipulation--is said to be altered segmental tissue texture. Little evidence for the nature of abnormal paraspinal tissue texture exists, but indirect evidence from experimental studies supports the plausibility of the concept of protective muscle spasm, although investigations of increased paraspinal electromyography (EMG) associated with low back pain suggests complex changes in motor control rather than simple protective reflexes.

OBJECTIVES

To review the literature for evidence that may support or refute proposed explanations for clinically observed altered paraspinal tissue texture associated with the manipulable spinal lesion. This review aims to highlight areas that require further research and make recommendations for future studies. Data Source MEDLINE and CINAHL databases were searched using various combinations of the keywords paraspinal, muscle, palpation, EMG, spine, low back pain, pain, myofascial, hardness, manipulation, reliability, and somatic dysfunction, along with searching the bibliographies of selected articles and textbooks. Data Extraction All relevant data were used.

RESULTS

Decreased paraspinal muscle activity and strength associated with low back pain is well established, and there is evidence of changes in muscle fiber composition and localized selective multifidus atrophy. Disturbances in microcirculation have been implicated in nonparaspinal muscle pain. The effect of spinal manipulation on paraspinal EMG activity is inconclusive but promising.

CONCLUSION

Little direct evidence exists to support the existence or nature of paraspinal tissue texture change that is claimed to be detected with palpation. The proposal of segmental reflex paraspinal muscle contraction was not supported, at least in association with low back pain. There appears to be a complex relationship between deep paraspinal muscle inhibition during dynamic activity and nonvoluntary guarding behavior during static activity. The relationship between these findings and palpable tissue change is speculative, but increased activity, decreased activity, or both may be responsible for paraspinal tissues detected as abnormal with palpation. Recommendations are outlined for future research.

Paraspinal muscles and intervertebral dysfunction: part one

BACKGROUND

One of the diagnostic characteristics of the manipulable spinal lesion--a musculoskeletal disturbance detected by manual palpation and corrected with manipulation--is said to be altered segmental tissue texture. Various manual therapy authors have speculated on the possible nature of this tissue change, with some authors hypothesizing that it represents deep segmental muscle overactivity.

OBJECTIVES

To review the literature relating to the detection and nature of altered paraspinal tissue texture, proposed explanations for altered tissue texture, evidence for the plausibility of paraspinal muscle spasm, and evidence of muscle dysfunction associated with low back pain (LBP).

DATA SOURCE

MEDLINE and CINAHL databases were searched using various combinations of the keywords paraspinal, muscle, palpation, EMG, spine, low back pain, pain, myofascial, hardness, manipulation, reliability, and somatic dysfunction, along with searching the bibliographies of selected articles and textbooks.

DATA EXTRACTION

All relevant data were used.

RESULTS

Little direct evidence exists for the nature of abnormal paraspinal tissue texture detected by palpation. Palpation for tenderness is more reliable than palpation for tissue texture change. Indirect evidence from animal studies and experimental muscle inflammation support the plausibility of protective paraspinal muscle contraction. Increased paraspinal electromyographic (EMG) activity observed in subjects with LBP appears to be a result of voluntary and nonvoluntary changes in motor control, modified by psychophysiological responses to perceived stress rather than a simple protective reflex.

CONCLUSION

Although little direct evidence exists of the nature of clinically detected paraspinal tissue texture change, the concept of reactive muscle contraction appears plausible. Increased paraspinal EMG activity associated with LBP does not appear to be mediated by a simple protective reflex.

Cleft sternum: case report and literature review

The isolated sternal cleft is a rare congenital anomaly that presents from birth to adulthood. We describe the late presentation and management in a child with this condition. The modern investigative and operative options are reviewed.

Access to health services in Ireland for people with Multiple Sclerosis and Motor Neurone Disease

We conducted a telephone questionnaire to determine the utilisation of hospital and community based services by patients with Motor Neurone Disease and Multiple Sclerosis in Ireland. 94 MND and 188 MS patients participated in the study. MND patients were more likely to have free medical care than MS patients, despite legislation favouring the converse. Severely disabled MND patients were more successful at accessing free community-based services than were severely disabled MS patients. Private medical insurance conferred no advantage when obtaining services or purchasing equipment. Many patients were unaware of the specific roles of the various clinical professionals. There are significant deficiencies in patients' ability to access multidisciplinary services. Voluntary organisations often bridge the gap in service provision. An investment in services for people with chronic neurological disability is urgently required.

Patient positioning and spinal locking for lumbar spine rotation manipulation

High velocity low amplitude (HVLA) thrust techniques are widely used by many manual therapists to treat low back pain. There is increasing evidence that spinal manipulation produces positive patient outcomes for acute low back pain. HVLA thrust techniques are associated with an audible release in the form of a pop or cracking sound that is widely accepted to represent cavitation of a spinal zygapophyseal joint. This audible release distinguishes these techniques from other manual therapy interventions. When using long lever HVLA thrust techniques spinal locking is necessary to localize forces and achieve cavitation at a specific vertebral segment. A critical factor in applying lumbar spine manipulation with minimal force is patient positioning and spinal locking. A knowledge of coupled movements of the lumbar spine aids an understanding of the patient positioning required to achieve spinal locking consistent with maximal patient comfort and cooperation. Excessive rotation can result in pain, patient resistance and failed technique. This masterclass presents a model of patient positioning for the lumbar spine that minimizes excessive use of rotation to achieve spinal locking prior to the application of the thrust.

Intraexaminer and interexaminer reliability for palpation of the cranial rhythmic impulse at the head and sacrum

BACKGROUND

A range of health care practitioners use cranial techniques. Palpation of a cranial rhythmic impulse (CRI) is a fundamental clinical skill used in diagnosis and treatment with these techniques. There has been little research establishing the reliability of CRI rate palpation.

OBJECTIVE

This study aimed to establish the intraexaminer and interexaminer reliability of CRI rate palpation and to investigate the "core-link" hypothesis of craniosacral interaction that is used to explain simultaneous motion at the cranium and sacrum.

DESIGN

Within-subjects, repeated-measures design.

SUBJECTS

Two registered osteopaths, both with postgraduate training in diagnosis and treatment, using cranial techniques, palpated 11 normal healthy subjects.

METHODS

Examiners simultaneously palpated for the CRI at the head and the sacrum of each subject. Examiners indicated the "full flexion" phase of the CRI by activating silent foot switches that were interfaced with a computer. Subject arousal was monitored using heart rate. Examiners were blind to each other's results and could not communicate during data collection.

RESULTS

Reliability was estimated from calculation of intraclass correlation coefficients (2,1). Intrarater reliability for examiners at either the head or the sacrum was fair to good, significant intraclass correlation coefficients ranging from +0.52 to +0.73. Interexaminer reliability for simultaneous palpation at the head and the sacrum was poor to nonexistent, ICCs ranging from -0.09 to +0.31. There were significant differences between rates of CRI palpated simultaneously at the head and the sacrum.

CONCLUSIONS

The results fail to support the construct validity of the "core-link" hypothesis as it is traditionally held by proponents of craniosacral therapy and osteopathy in the cranial field.

Inter-examiner and intra-examiner agreement for assessing sacroiliac anatomical landmarks using palpation and observation: pilot study

Despite the paucity of research into the reliability of static palpation, it is still employed extensively as a diagnostic tool by manual medicine practitioners. This study tested the inter- and intra-examiner agreement of ten senior osteopathic students using static palpation on ten asymptomatic subjects. Four assessments of the posterior superior iliac spine (PSIS), sacral sulcus (SS), and the sacral inferior lateral angle (SILA) on every subject by all examiners resulted in 1200 assessments in total. Kappa (Kg) yielded intra-examiner agreement that ranged between less-than-chance to substantial for the SILA (Kg=-0.05 to 0.69; mean Kg=0.21), and slight to moderate for the PSIS (Kg=0.07 to 0.58; mean Kg=0.33) and the SS (Kg=0.02 to Kg=0.60; mean Kg=0.24), with 50% significant beyond the 0.05 level. Inter-examiner agreement was slight (PSIS Kg=0.04; SILA Kg=0.08; SS Kg=0.07) and significant at the 0.01 level. Intra-examiner agreement was greater than inter-examiner agreement, which was consistent with existing palpation reliability studies. The poor reliability of clinical tests involving palpation may be partially explained by error in landmark location.