Participants with restricted dominant shoulder internal rotation range of motion demonstrate no side-to-side difference in humeral head translation; and no difference before and after joint mobilization: a pilot study

[Purpose] To compare humeral head translation (HHT) during shoulder elevation between dominant and non-dominant shoulders in participants with limited dominant shoulder internal rotation range of motion (ROM). To determine if joint mobilization alters HHT, and if relationships exist between the bicipital forearm angle and HHT. [Participants and Methods] Fifteen (9 female) participants (age 25.7 ± 6.8 years) with a minimum 15-degree dominant shoulder internal rotation ROM deficit compared to the opposite shoulder participated. All participants underwent bicipital forearm angle (BFA) measurements and ultrasound imaging to measure acromiohumeral and posterior glenohumeral distances in 3 positions: Resting, 90 degrees of shoulder flexion, and 60 degrees of shoulder abduction with full external rotation. Ultrasound images were used to calculate HHT. Participants' dominant shoulders underwent posterior glide mobilization, followed immediately by repeated ultrasound images and ROM measures. [Results] There was no dominant to non-dominant shoulder, or before and after mobilization HHT differences. No correlations existed between bicipital forearm angles and HHT or ROM gains after mobilization. [Conclusion] Participants with internal rotation ROM loss demonstrated symmetrical HHT. Joint mobilization increased ROM, but HHT was unchanged. No relationships existed between BFA and HHT.

Association of neutrophil to lymphocyte ratio with bone mineral density in post-menopausal women: a systematic review and meta-analysis

BACKGROUND

We conducted a systematic review and meta-analysis to compare the neutrophil lymphocyte ratio (NLR) levels between women with post-menopausal osteopenia or osteoporosis to those with normal bone mineral density (BMD).

METHODS

We used Web of Science, PubMed, and Scopus to conduct a systematic search for relevant publications published before June 19, 2022, only in English language. We reported standardized mean difference (SMD) with a 95% confidence interval (CI). Because a significant level of heterogeneity was found, we used the random-effects model to calculate pooled effects. We used the Newcastle-Ottawa scale for quality assessment.

RESULTS

Overall, eight articles were included in the analysis. Post-menopausal women with osteoporosis had elevated levels of NLR compared to those without osteoporosis (SMD = 1.03, 95% CI = 0.18 to 1.88, p = 0.017, I2 = 98%). In addition, there was no difference between post-menopausal women with osteopenia and those without osteopenia in neutrophil lymphocyte ratio (NLR) levels (SMD = 0.58, 95% CI=-0.08 to 1.25, p = 0.085, I2 = 96.8%). However, there was no difference between post-menopausal women with osteoporosis and those with osteopenia in NLR levels (SMD = 0.75, 95% CI=-0.01 to 1.51, p = 0.05, I2 = 97.5%, random-effect model).

CONCLUSION

The results of this study point to NLR as a potential biomarker that may be easily introduced into clinical settings to help predict and prevent post-menopausal osteoporosis.

New clinical decision tool to assist physical therapists with joint mobilization application to the pediatric population

Joint mobilizations are well-established and extensively researched treatment modality for adults. However, it remains largely unexplored in the pediatric population. Physical therapists hesitate to perform joint mobilization on children because of lack of knowledge, concern for the developing skeletal system, and the paucity of research on the topic. The aim of this article is to present a decision tool created for a continuing education course with the purpose to instruct pediatric therapists in the safe and effective use of joint mobilizations in children. It is based on the pediatric paradigm of developmental and functional assessment to best address the concerns and preferences of physical therapists (PTs). To advance research in pediatric joint mobilization, PTs should listen to the concerns of pediatric therapists and respond to those concerns with effective, evidence-supported training. This decision tree will serve as a resource for the education of pediatric therapists in the safe and effective use of joint mobilizations.

Pediatric neck pain of a 10-year-old child with cervical spinal tumor evaluated and managed in direct access physical therapy: a case report

INTRODUCTION

Differential diagnosis of pediatric neck pain requires age-appropriate communication and assessment tools. Recognizing these age-related nuances is critical, emphasizing the role of physical therapists in assessing and managing pediatric patients while ruling out severe pathologies.

CASE DESCRIPTION

A 10-year-old male presented to physical therapy with a five-week history of increasing neck pain. A thorough history and segmental cervical examination considering the patient's age and development, led to patient referral to the emergency department. This case underscores the significance of comprehensive evaluation in pediatric neck pain management.

OUTCOMES

The patient was diagnosed with Langerhans Cell Histiocytosis (LCH). LCH primarily affects children and is treated with chemotherapy. Chemotherapy reduced the tumor, revealing C2 vertebral body damage. The patient underwent C1-C3 fusion surgery, a standard procedure for atlanto-occipital region stabilization in children. The patient was advised to restrict motion for 6 months while monitoring for tumor growth.

DISCUSSION-CONCLUSION

Pediatric neck cancer presents diagnostic challenges due to varied symptoms, but research highlights specific indicators to assist with differential diagnosis. This case emphasizes the need to recognize the complexities of pediatric neck pain and perform a thorough age-appropriate evaluation.

Incidence and Risk Factors for Bone Stress Injuries in United States Air Force Special Warfare Trainees

OBJECTIVES

To determine (1) the incidence rate of lower extremity (LE) bone stress injuries (BSIs) in United States Air Force Special Warfare (AFSPECWAR) trainees during the first 120 days of training, and (2) factors associated with sustaining a LE BSI.

DESIGN

Retrospective cohort study.

METHODS

AFSPECWAR Airmen (n = 2,290, mean age = 23.7 ± 3.6 years) entering an intensive 8-week preparatory course "SW-Prep" between October 2017 and May 2021. We compared anthropometric measurements, previous musculoskeletal injury (MSKI), fitness measures, and prior high-impact sports participation in those that did and did not suffer a BSI during the 120-day observation period using independent t-tests and chi-square tests. A multivariable binary logistic regression was used to determine factors associated with suffering a BSI.

RESULTS

A total of 124 AFSPECWAR trainees suffered a BSI during the surveillance period, yielding an incidence proportion of 5.41% and an incidence rate of 1.4 BSIs per 100 person-months. The multivariate logistic regression revealed that lower 2-minute sit-up scores, no prior history of participation in a high-impact high-school sport, and a history of prior LE MSKI were associated with suffering a BSI. A receiver operator characteristic curve analysis yielded an area under the curve (AUC) of 0.727.

CONCLUSION

BSI incidence proportion for our sample was similar to those seen in other military settings. Military trainees without a history of high-impact sports participation who achieve lower scores on sit-ups tests and have a history of LE MSKI have a higher risk for developing a LE BSI during the first 120 days of AFSPECWAR training.

Effect of verbal instructions on trunk muscle activity during volitional preemptive abdominal contraction

OBJECTIVE

This study investigated the effect of Verbal Instruction (VI) strategies on trunk muscle contraction among healthy subjects. The effect of three VI Abdominal Drawing-In Maneuver (ADIM) and two VI Abdominal Bracing Maneuver (ABM) strategies on left Internal (LIO) and External Oblique (LEO) and bilateral superficial Multifidi (sMf) activation was examined.

DESIGN

Within-subjects, repeated measure design.

METHODS

Surface EMG (sEMG) measured LIO, LEO, and sMf activity in 28 subjects (mean age 23.5 ± 5.5 years). Testing included five supine hook-lying and five quiet standing conditions.

RESULTS

One-way ANOVAs demonstrated no significant main effect for ADIM or ABM in supine or standing (p > .05). Muscle activation amplitudes during VPAC conditions demonstrated higher mean values for standing versus supine (p < .05) except for two conditions involving LEO. Friedman Tests for dominant strategy demonstrated a significant main effect for ADIM-VI and ABM-VI strategies. Post-hoc testing generally showed the dominant strategy to be significantly higher versus others.

CONCLUSION

No single preferred VI cue for ADIM or ABM was observed. Each subject's dominant strategy dictated the most suitable VI. Standing was preferred for LIO and sMf activation, whereas position did not change LEO activation. Non-significant correlations between all muscle pairings during all ADIM and ABM strategies were observed. These findings may suggest the need for healthcare providers who understand the intricacies of trunk stability to teach and monitor VPAC with either ADIM or ABM options.

Sustained versus repetitive standing trunk extension results in greater spinal growth and pain improvement in back pain:A randomized clinical trial

BACKGROUND

McKenzie standing trunk extension exercises have been used for the management of low back pain (LBP). However, no study to date has investigated the effect of standing trunk extension postures on spinal height and clinical outcomes.

OBJECTIVE

To evaluate in subjects with LBP following a period of trunk loading how spinal height, pain, symptoms' centralization and function outcome measures respond to two standing postures interventions: (1) repetitive trunk extension (RTE) and (2) sustained trunk extension (STE).

METHODS

A consecutive sample of convenience of people with LBP were recruited to participate in 2-session physical therapy using either RTE or STE in standing.

RESULTS

Thirty participants (18 women) with a mean age of 53 ± 17.5 years completed the study. The first session resulted in spinal height increase (spinal growth) of 2.07 ± 1.32 mm for the RTE intervention and 4.54 ± 1.61 mm for the STE group (p< 0.001; ES = 1.67), while the second session (2-week following the first session) resulted in spinal growth of 2.39 ± 1.46 mm for the RTE group and 3.91 ± 2.06 mm for the STE group (p= 0.027; ES = 0.85). The STE group presented with the larger reduction in most pain from 6 to 2 as compared to the RTE group from 6 to 4 between Session 1 and Session 2 (p< 0.001). There was no difference between the groups in Modified Oswestry score and symptoms centralization (p= 0.88 and p= 0.77, respectively).

CONCLUSION

People with LBP experienced greater spine growth and improvements of pain during standing STE as compared to RTE. People with LBP could use such postures and movements to alleviate their LBP and improve spine height while in a weight bearing position.

Upper limb neurodynamic mobilization disperses intraneural fluid in cervical nerve roots: A human cadaveric investigation

BACKGROUND

Cervical radiculopathy is a common cause of neck pain with resultant intraneural edema and impaired nerve function. One strategy to treat radiculopathy is neurodynamic mobilization (NDM); however, little is known about the effect of this treatment on nerve tissue fluid dynamics.

OBJECTIVE

Investigate the impact of upper limb, median nerve-biased NDM on longitudinal intraneural fluid dispersion in the C5,C6,C7 nerve roots in un-embalmed cadavers.

DESIGN

In situ repeated measures.

METHODS

Human cadavers (n = 8) were dissected to expose and inject C5,C6,C7 cervical nerve roots with a dying agent. Initial longitudinal dye spread was recorded after dye spread stabilization. Cadavers were taken through 150 repetitions of upper limb, median nerve-biased NDM followed by dye spread re-measurement. Paired-samples t-tests with Bonferroni correction (α = 0.017) were used to compare pre-vs post-NDM dye spread measurements at C5,C6,C7 nerve roots; a one-way repeated measures ANOVA (α = 0.05) was used to examine differences between change scores for C5,C6,C7 nerve roots.

RESULTS

Median nerve-biased NDM resulted in significant intraneural longitudinal dye spread at C5 and C6 nerve roots of 0.6 ± 0.6 mm and 3.4 ± 3.9 mm, respectively (p < 0.014). Dye spread was not significant at C7 nerve root (0.4 ± 0.7 mm). There was no between root difference in change of longitudinal dye spread between C5, C6, and C7 nerve roots.

CONCLUSIONS

The results of this study show median nerve-biased NDM produced internal fluid movement within C5 and C6 cervical nerve roots. Results provide insight regarding possible mechanism of action and feasibility of NDM in treatment of patients with cervical radiculopathy.

The trapeziometacarpal screw home torque mechanism as a clinical indicator of the posterior joint ligament complex integrity: A cadaveric investigation

BACKGROUND

To date, no clinical test provides specific objective information on the integrity of key ligamentous support of the trapeziometacarpal (TMC) joint.

PURPOSE

To examine the potential of the TMC joint screw home torque mechanism (SHTM) in estimating the integrity of the posterior ligament complex in older adult population. STUDY DESIGN: Cross-sectional laboratory-based study.

METHODS

Twenty cadaver hands presenting with various degrees of TMC joint degradation ranging from none to severe osteoarthritis (OA) were radiographed in multiple positions to establish their degeneration status, joint mobility, and amount of dorsal subluxation at rest and with the application of the SHTM. Comparisons and correlations between degeneration status, joint mobility, subluxation reduction and ligament status obtained from dissection were calculated.

RESULTS

No significant statistical correlation was demonstrated with the subluxation reduction ratio of the SHTM and the combined ligament complex value however, a moderate negative correlation was found with dorsal central ligament injury at 21 Nm (τb = -0.46, p < 0.05) and 34 Nm (τb = -0.45, p < 0.05). A statistically significant reduction of radial subluxation of the TMC joint was observed between the subluxation at rest (M = 5.2, SD = 1.9) and subluxation with SHTM of 21 Nm (M = 4.4, SD = 2.4), t (19) = 3.2, p = 0.01, 95% CI [0.3, 1.4] and subluxation with SHTM of 34 Nm (M = 4.3, SD = 2.6), t (19) = 2.6, p = 0.02, 95% CI [0.2, 1.5].

CONCLUSION

Our results did not support the SHTM as indicator of the TMC posterior ligament complex integrity however, it demonstrated 100% stabilization effect with non-arthritic TMC population.

Mentorship and self-efficacy are associated with lower burnout in physical therapists in the United States: a cross-sectional survey study

PURPOSE

This study investigated the prevalence of burnout in physical therapists in the United States and the relationships between burnout and education, mentorship, and self-efficacy.

METHODS

This was a cross-sectional survey study. An electronic survey was distributed to practicing physical therapists across the United States over a 6-week period from December 2020 to January 2021. The survey was completed by 2,813 physical therapists from all states. The majority were female (68.72%), White or Caucasian (80.13%), and employed full-time (77.14%). Respondents completed questions on demographics, education, mentorship, self-efficacy, and burnout. The Burnout Clinical Subtypes Questionnaire 12 (BCSQ-12) and self-reports were used to quantify burnout, and the General Self-Efficacy Scale (GSES) was used to measure self-efficacy. Descriptive and inferential analyses were performed.

RESULTS

Respondents from home health (median BCSQ-12=42.00) and skilled nursing facility settings (median BCSQ-12=42.00) displayed the highest burnout scores. Burnout was significantly lower among those who provided formal mentorship (median BCSQ-12=39.00, P=0.0001) compared to no mentorship (median BCSQ-12=41.00). Respondents who received formal mentorship (median BCSQ-12=38.00, P=0.0028) displayed significantly lower burnout than those who received no mentorship (median BCSQ-12=41.00). A moderate negative correlation (rho=-0.49) was observed between the GSES and burnout scores. A strong positive correlation was found between self-reported burnout status and burnout scores (rrb=0.61).

CONCLUSION

Burnout is prevalent in the physical therapy profession, as almost half of respondents (49.34%) reported burnout. Providing or receiving mentorship and higher self-efficacy were associated with lower burnout. Organizations should consider measuring burnout levels, investing in mentorship programs, and implementing strategies to improve self-efficacy.

Research from Low-Income and Middle-Income Countries will Benefit Global Health and the Physiotherapy Profession, but it Requires Support

Disparities in research publications are common in the physiotherapy and rehabilitation fields.1 A small proportion of published research arises from low-income and middle-income countries (LMICs),1,2 home to 85% of the world's population. Systems-level, institutional-level, and individual-level factors contribute to these disparities. With urgent and unified actions, global health and the standard of physiotherapy research in LMICs can be improved and strengthened. In this editorial, we will discuss the challenges encountered by researchers from LMICs in conducting and publishing high-quality research and propose potential strategies to address these challenges.

Lack of standardization in dry needling dosage and adverse event documentation limits outcome and safety reports: a scoping review of randomized clinical trials

OBJECTIVES

Examine: (1) whether variability in dry needling (DN) dosage affects pain outcomes, (2) if effect sizes are clinically important, and (3) how adverse events (AE) were documented and whether DN safety was determined.

METHODS

Nine databases were searched for randomized controlled trials (RCTs) investigating DN in symptomatic musculoskeletal disorders. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale. Included RCTs met PEDro criteria #1 and scored > 7/10. Data extraction included DN dosage, pain outcome measures, dichotomous AE reporting (yes/no), and AE categorization. Clinically meaningful differences were determined using the minimum clinically important difference (MCID) for pain outcomes .

RESULTS

Out of 22 identified RCTs, 11 demonstrated significant between-group differences exceeding the MCID, suggesting a clinically meaningful change in pain outcomes. Nine documented whether AE occurred. Only five provided AEs details and four cited a standard means to report AE.

DISCUSSION

There was inconsistency in reporting DN dosing parameters and AE. We could not determine if DN dosing affects outcomes, whether DN consistently produces clinically meaningful changes, or establish optimal dosage. Without more detailed reporting, replication of methods in future investigations is severely limited. A standardized method is lacking to report, classify, and provide context to AE from DN. Without more detailed AE reporting in clinical trials investigating DN efficacy, a more thorough appraisal of relative risk, severity, and frequency was not possible. Based on these inconsistencies, adopting a standardized checklist for reporting DN dosage and AE may improve internal and external validity and the generalizability of results.

Innovative seated vertical lumbar traction allows simultaneous computer work while inducing spinal height changes similar to supine lying

BACKGROUND

Lumbar intervertebral disc height loss has been associated with spinal height change (SHC) and low back pain (LBP), including stenosis. Non-invasive methods to improve disc height loss require forms of lying down, which are unconducive to computer work.

OBJECTIVE

Intermittent vertical traction (VT) integrated with seated computer work may provide ergonomic alternatives for increasing SHC to promote LBP relief. The primary aim was to develop and introduce a safe VT prototype and dosage to induce and measure SHC. Prototype comfort and LBP ratings were exploratory secondary aims.

METHODS

Forty-one participants were stadiometry-measured for pre- and post-intervention SHC from seated VT at 35% body weight removed, supine lying (SL), and sitting at a computer (SIT) without VT. Pain ratings were recorded for those self-reporting LBP. VT prototype evaluations were compiled from a 3-question, 7-point Likert-style survey.

RESULTS

SHC increased by 3.9 ± 3.4 mm in VT, 1.7 ± 3.4 mm in SIT, and 4.3 ± 3.1 mm in SL (P< 0.000). Post hoc findings were significant between VT and SIT (P< 0.000), and SL and SIT (P< 0.000). VT and SL LBP ratings both decreased, but not SIT.

CONCLUSION

Intermittent seated VT is a promising alternative for postural relief during seated computer work, producing SHC similar to lying down without compromising workflow.

Safe Administration and Low Healthcare Utilization Following Musculoskeletal Corticosteroid Injections by U. S. Military Physical Therapists

INTRODUCTION

Musculoskeletal (MSK) injuries make up a significant proportion of conditions treated by military healthcare providers during wartime. Though many common MSK injuries may benefit from corticosteroid injection (CSI), a shortage of qualified military clinicians has led to diminished access to appropriate care. Longer wait times to receive treatment pose detrimental effects on military readiness and have garnered the attention of military leaders. One solution was the development of advanced training for United States Air Force physical therapists (USAF PTs) to gain clinical privileges in administering CSI. The objectives of this study were to determine in USAF PTs (1) the prevalence of those with privileges to administer CSI; (2) the type and (3) safety of MSK CSI administered; (4) incidence of CSI complications; (5) healthcare utilization following CSI; and (6) barriers to obtaining and practicing CSI privileges.

MATERIALS AND METHODS

United States Air Force PTs with CSI privileges received instructions to follow a link to an anonymous Google survey. Electronic medical record reviews were conducted by three USAF PTs to determine the occurrence and severity of CSI complications provided by USAF PTs and advanced healthcare providers (AHPs). The principal investigator conducted further review of the patients' electronic medical records to calculate healthcare utilization following CSI administered by USAF PTs. A hospital administrator selected cases of similar diagnoses treated with CSI by USAF AHPs. The number selected cases treated by AHPs are similar to the number of CSI cases treated by USAF PTs.

RESULTS

Eleven USAF PTs held CSI privileges. No major complications associated with CSI were recorded. Of the 95 CSI cases treated by USAF PTs, 27 (28.4%) reported increased pain compared to 24 (27.9%) of 86 CSI cases treated by AHPs (P = .94). Healthcare utilization for the number of follow-up visits, imaging, and additional laboratory tests following CSI by USAF PTs was lower compared to AHPs (chi-square; P < .0069).

CONCLUSION

Nine percentage of USAF PTs held CSI privileges. United States Air Force PTs were equally safe as AHPs who administered CSI and associated with a lower rate of healthcare utilization following the intervention. Training USAF PTs to administer CSI could be the standard for all USAF PTs who meet qualification requirements. Adoption of similar training and credentialing policies for civilian PTs warrants further exploration.

Variability of Intradiscal Pressure During Cervical Spine Posterior-Anterior Mobilization: A Cadaveric Investigation

OBJECTIVES

The purpose of this study was to investigate in cadaveric specimens the reliability of measuring cervical intradiscal pressure (CIDP) and if posterior-anterior (PA) mobilizations targeting the cervical spine were associated with CIDP changes.

METHODS

Cervical PA mobilizations were performed on the spinous processes of 7 (3 men, 4 women) cadaveric specimens using a servo-controlled linear actuator to provide 25N and 45N forces. CIDP measurements were performed at C4-5, C5-6, C6-7, and C7-T1 intervertebral discs (IVDs) using a fiberoptic catheter system that recorded CIDP for each IVD cervical segment. To assess CIDP measurement reliability, the intraclass correlation coefficient (ICC [3,k]) was calculated. Repeated measures Friedman analysis of variance assessed effect of cervical mobilizations on CIDP for before, during, and immediately after mobilization at 25N and 45N forces for each cervical IVD segment.

RESULTS

All CIDP measurements demonstrated excellent reliability (ICC >0.98). During the 25N mobilizations, the median CIDP varied from -0.12 to 0.91 (interquartile range, 5.22-5.36), while for 45N mobilizations the median ranged from -0.94 to 1.21 (interquartile range, -7.74 to 43.49). These changes were not statistically significant (P > .40) during 25N and 45N PA mobilizations, with the exception of C5-6 CIDP at 25N and 45N (P = .05 and .018, respectively).

CONCLUSION

There was high CIDP variability between cadavers during and after mobilization. Mobilizations of 1 cervical vertebra resulted in both CIDP increase or decrease at adjacent and remote cervical IVD segments that were not consistent. Cervical PA mobilizations produced variable CIDP changes at adjacent and remote cervical segments in cadavers.

Tai Chi Improves Brain Functional Connectivity and Plasma Lysophosphatidylcholines in Postmenopausal Women With Knee Osteoarthritis: An Exploratory Pilot Study

Objective: A pre/post pilot study was designed to investigate neurobiological mechanisms and plasma metabolites in an 8-week Tai-Chi (TC) group intervention in subjects with knee osteoarthritis.

Methods: Twelve postmenopausal women underwent Tai-Chi group exercise for 8 weeks (60 min/session, three times/week). Outcomes were measured before and after Tai Chi intervention including pain intensity (VAS), Brief Pain Inventory (BPI), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), plasma metabolites (amino acids and lipids), as well as resting-state functional magnetic resonance imaging (rs-fMRI, 10 min, eyes open), diffusion tensor imaging (DTI, 12 min), and structural MRI (4.5 min) in a subgroup. Clinical data was analyzed using paired t-tests; plasma metabolites were analyzed using Wilcoxon signed-rank tests; and rs-fMRI data were analyzed using seed-based correlations of the left and right amygdala in a two-level mixed-effects model (FSL software). Correlations between amygdala-medial prefrontal cortex (mPFC) connectivity and corresponding changes in clinical outcomes were examined. DTI connectivity of each amygdala was modeled using a Bayesian approach and probabilistic tractography. The associations between neurobiological effects and pain/physical function were examined.

Results: Significant pre/post changes were observed with reduced knee pain (VAS with most pain: p = 0.018; WOMAC-pain: p = 0.021; BPI with worst level: p = 0.018) and stiffness (WOMAC-stiffness, p = 0.020), that likely contributed to improved physical function (WOMAC-physical function: p = 0.018) with TC. Moderate to large effect sizes pre/post increase in rs-fMRI connectivity were observed between bilateral mPFC and the amygdala seed regions (i.e., left: d = 0.988, p = 0.355; right: d = 0.600, p = 0.282). Increased DTI connectivity was observed between bilateral mPFC and left amygdala (d = 0.720, p = 0.156). There were moderate-high correlations (r = 0.28–0.60) between TC-associated pre-post changes in amygdala-mPFC functional connectivity and pain/physical function improvement. Significantly higher levels of lysophosphatidylcholines were observed after TC but lower levels of some essential amino acids. Amino acid levels (alanine, lysine, and methionine) were lower after 8 weeks of TC and many of the lipid metabolites were higher after TC. Further, plasma non-HDL cholesterol levels were lower after TC.

Conclusion: This pilot study showed moderate to large effect sizes, suggesting an important role that cortico-amygdala interactions related to TC have on pain and physical function in subjects with knee osteoarthritis pain. Metabolite analyses revealed a metabolic shift of higher lyso-lipids and lower amino acids that might suggest greater fatty acid catabolism, protein turnover and changes in lipid redistribution in response to TC exercise. The results also support therapeutic strategies aimed at strengthening functional and structural connectivity between the mPFC and the amygdala. Controlled clinical trials are warranted to confirm these observed preliminary effects.

Intracapsular pressures in the flexion-abduction-external rotation and flexion-adduction-internal rotation tests and their comparison with classic hip range of motion: A cadaveric assessment

Background Flexion-Abduction-External-Rotation and Flexion-Adduction-Internal-Rotation tests are used to reproduce pain at the hip during clinical assessment. As pain can be elicited by high intracapsular pressure, no information has been provided regarding intracapsular pressure during these pain provocative tests. Methods Eight hip joints from four cadaveric specimens (78.5 ± 7.9 years) were assessed using intra-osseous tunnels reaching the lateral and acetabular compartments. To simulate synovial liquid, 2.7 ml of liquid were inserted in both compartments using adaptor injectors. Optic pressure transducers were used to measure pressure variations. Pressures were compared between compartments in each test and between tests for each compartment. Both tests were compared with uniplanar movements. Findings The Flexion-Adduction-Internal-Rotation test showed a significant difference between pressure measured in the lateral (27.17 ± 42.63 mmHg) and acetabular compartment (-26.80 ± 29.26 mmHg) (P < 0.006). The pressure measured in the lateral compartment during the Flexion-Adduction-Internal-Rotation test (27.17 ± 42.63 mmHg) was significantly higher than in the Flexion-Abduction-External-Rotation test (-8.09 ± 15.09 mmHg) (P < 0.010). The pressure measured in the lateral compartment in the Flexion-Abduction-External-Rotation test was significantly lower than during internal rotation (P = 0.011) and extension (P = 0.006). Interpretation High intracapsular pressure is correlated with greater pain at the hip. Clinicians should assess pain with caution during the Flexion-Adduction-Internal-Rotation test as this test showed high intracapsular pressures in the lateral compartment. The Flexion-Abduction-External-Rotation is not influenced by high intra-capsular pressures.

Abdominal bracing changes lower quarter muscle activity but not reach distances during active forward reach on an unstable surface

OBJECTIVE

This study examined the effects of abdominal bracing maneuver (ABM) performance on stable and unstable surfaces on active forward reach (AFR) distance as a measure of trunk control, measuring changes in reach distance and muscle activation patterns.

DESIGN

Single-group, repeated measures design.

METHODS

Twenty-eight subjects (mean age 25 ± 5.09 years) performed an AFR with and without ABM while on stable and unstable surfaces. Lower quarter muscle activity and forward reach distances were recorded.

RESULTS

Forward reach distances on the unstable surface were significantly decreased compared to the stable condition with and without ABM (p < .001). The surface-by-contraction interaction was significant for the tibialis anterior (TA) and gastrocnemius (GS). Significant main effects were found for internal oblique, external oblique, gluteus maximus, biceps femoris, TA, and GS, where muscle activity significantly increased during the ABM trials. The interaction between surface and contraction was significant for the TA and GS muscles. TA (p = .007) and GS (p < .001) activity increased with ABM on the unstable surface. TA activity increased with ABM on the stable surface (TA: p < .001).

CONCLUSION

Reach distances decreased on the unstable surface, but ABM did not change reaching distance. Ankle muscle co-contraction occurred during ABM trials and posterior chain activity increased. These changes suggest ABM may be beneficial during forward reaching activities.

Immediate Improvements in Patellofemoral Pain Are Associated With Sagittal Plane Movement Training to Improve Use of Gluteus Maximus Muscle During Single Limb Landing

OBJECTIVE

The authors sought to examine the immediate effects of movement training aimed at improving use of gluteus maximus (GMAX) in the sagittal plane on hip internal rotation and self-reported patellofemoral pain (PFP) during single-limb landing.

METHODS

Seventeen females with PFP participated. Lower extremity kinematics and kinetics, GMAX activation, and self-reported PFP were obtained before and after a single-session movement training program aimed at increasing the use of GMAX. Dependent variables of interest included self-reported PFP, average GMAX activation, average hip extensor moment, and peak hip internal rotation. Post-training changes were evaluated using paired t tests and Wilcoxon signed rank tests.

RESULTS

Following movement training, self-reported PFP decreased significantly (mean [standard deviation]) (3.9 [1.1] vs 0.8 [1.3] on a 0-10 scale). Additionally, significant increases were observed for the average hip extensor moment (0.6 [0.3] vs 1.8 [0.4] Nm/kg) and average GMAX activation (41.0% [18.3] vs 51.6% [25.7] maximum voluntary isometric contraction), whereas peak hip internal rotation decreased significantly (8.5 degrees [5.8] vs 6.0 degrees [5.3]).

CONCLUSION

Movement training aimed at improving the use of GMAX in the sagittal plane resulted in clinically relevant changes in self-reported pain, GMAX activation, and hip kinetics and kinematics. Improving the use of GMAX during movement merits consideration when designing rehabilitation programs for females with PFP.

IMPACT

The current study highlights the clinical utility of movement training for persons with PFP and provides a biomechanical rationale for its use as a potential intervention in this population.

Clinical evaluation of thumb base osteoarthritis: A scoping review

Introduction

Thumb base osteoarthritis (OA) is a prevalent hand OA phenotype, associated with specific risk factors, treatment strategies, and requiring a distinct subset of evaluative approaches. This paper aimed at surveying our clinical evaluative methods and identifying gaps in our ability to capture the thumb's unique attributes and how they could impact our treatment recommendations.

Methods

A scoping review was conducted in accordance with the Joanna Briggs Institute methodology to gather relevant published and non-published articles regarding clinical tests currently available to assess the physical presentation of thumb base OA with special consideration of its specific multifactorial parameters namely architecture, ligaments, biomechanics, neuromuscular control, and proprioception. A full search strategy of MEDLINE, CINAHL, EMBASE, Scopus, Google Scholar, and Clinical Trials.gov from their inception through May 2020 was performed.

Results

Of 1936 citation identified, 54 met the inclusion criteria. Fifty-two clinical physical tests for the evaluation of thumb base OA were extracted, most of which well suited to address research questions regarding efficacy of clinical intervention, however providing limited information regarding the underlying impairments of ligaments, biomechanics, neuromuscular or proprioceptive components.

Conclusions

The tests and measures specific to the basal thumb OA phenotype, and capable of isolating its multifactorial contributors are scarce. Our limited physical assessment repertoire impedes our ability to describe and answer explicative research questions. Without these we cannot evaluate the effect of conservative management and provide specific treatment recommendations. Further research is needed to develop and validate distinct clinical tools for this debilitating pathology.

The Immediate Effects of Foam Rolling and Stretching on Iliotibial Band Stiffness: A Randomized Controlled Trial

BACKGROUND

Iliotibial Band Syndrome (ITBS) is a common clinical condition likely caused by abnormal compressive forces to the iliotibial band (ITB). Stretching interventions are common in ITBS treatment and may predominantly affect tensor fascia latae (TFL). Another ITBS treatment is foam rolling, which may more directly affect the ITB. Shear wave ultrasound elastography (SWUE) measures real-time soft tissue stiffness, allowing tissue changes to be measured and compared.

PURPOSE

To examine effects of foam rolling and iliotibial complex stretching on ITB stiffness at 0˚ and 10˚ of hip adduction and hip adduction passive range of motion (PROM).

STUDY DESIGN

Randomized controlled trial.

METHODS

Data from 11 males (age = 30.5 ± 9.0 years, Body Mass Index (BMI) = 27.8 ± 4.0) and 19 females (age = 23.5 ± 4.9, BMI = 23.2 ± 2.1) were analyzed for this study. Subjects were randomly assigned to one of three groups: control, stretching, and foam rolling. Shear wave ultrasound elastography measurements included ITB Young's modulus at the mid-thigh, the distal femur and the TFL muscle belly. ITB-to-femur depth was measured at mid-thigh level. Hip adduction PROM was measured from digital images taken during the movement.

RESULTS

No significant interactions or main effects were found for group or time differences in ITB Young's modulus at the three measured locations. The ITB stiffness at the mid-thigh and distal femur increased with 10° adduction, but TFL stiffness did not increase. A main effect for adduction PROM was observed, where PROM increased 0.8˚ post-treatment (p = 0.02).

CONCLUSION

A single episode of stretching and foam rolling does not affect short-term ITB stiffness. The lack of ITB stiffness changes may be from an inadequate intervention stimulus or indicate that the interventions have no impact on ITB stiffness.

LEVELS OF EVIDENCE

1b.

Manual Therapy in Preadolescent Children: A Delphi Investigation of Physical Therapists in the United States

OBJECTIVE

Limited research has investigated the use of manual therapy to treat the preadolescent (0-12 years of age) population with musculoskeletal and neurological impairments. The purpose of this study was to identify the following among physical therapists holding advanced credentials in pediatrics, neurodevelopmental treatment, or manual therapy: (1) consensus regarding effective techniques in the preadolescent population, (2) differences in opinion, and (3) perceived decision-making barriers and factors regarding use of manual therapy techniques.

METHODS

Credentialed physical therapists in the United States were recruited for a 3-round Delphi investigation. An electronic survey in Round 1 identified musculoskeletal and neurological impairments and the manual techniques considered effective to treat such conditions, in addition to factors and barriers. Responses were used to create the second round, during which a 4-point Likert scale was used to score each survey item. A third round of scoring established consensus. Descriptive statistics and composite scores were calculated for each manual technique by impairment. Between-group differences were calculated using the Mann-Whitney U test with Bonferroni correction.

RESULTS

Consensus was determined for several concepts. First, neuromuscular techniques were considered effective across all impairments, and joint mobilizations (grades I-IV) were believed to be effective to treat joint and muscle and myofascial impairments. Second, visceral manipulation and craniosacral therapy were considered ineffective in treating most impairments. There was lack of consensus and clear differences of opinion regarding the use of grade V mobilizations and dry needling. Significant barriers to use of manual therapy were: lack of knowledge, lack of evidence, and fear of litigation and harming patients.

CONCLUSION

This study is an initial step for developing manual therapy guidelines, research, and educational opportunities regarding manual therapy in pediatric physical therapy.

Upper limb neurodynamic testing with radial and ulnar nerve biases: An analysis of cervical spinal nerve mechanics

BACKGROUND

Clinical research supports a combination of upper limb neurodynamic testing (ULNT) strategies to rule out upper limb and cervical neurogenic pathology; however, knowledge of the biomechanical response of spinal nerves during ULNT is lacking for radial and ulnar nerve biases.

OBJECTIVE

To assess whether radial and ulnar nerve biased strategies of ULNT elicit significant displacement and strain of cervical spinal nerves.

STUDY DESIGN

Cross-sectional.

METHODS

Radiolucent markers were implanted into spinal nerves C5-C8 proximal and distal to the intervertebral foramen in nine unembalmed cadavers (six male; three female) age 80.1 ± 13.2 years. Fluoroscopic images were captured during ULNT with radial and ulnar nerve biases. Images at rest and maximum tension were digitized and displacement and strain were measured. All data were analyzed using one sample t-tests and a generalized linear mixed models approach.

RESULTS

Upper limb neurodynamic testing with radial nerve bias resulted in displacement (2.44-3.04 mm) and strain (7.99-11.98%) and ULNT with ulnar nerve bias resulted in displacement (2.16-4.41 mm) and strain (7.12 and 12.95%). Significant extraforaminal displacement occurred during radial and ulnar nerve biases for all spinal nerves (all P < 0.05) whereas significant strain occurred during ulnar nerve biases for all spinal nerves but only in C6-C8 during radial nerve bias.

CONCLUSION

Upper limb neurodynamic testing using both radial and ulnar nerve biases resulted in cervical spinal nerve displacement and strain. Such techniques could be used to tension load or mobilize or cervical spinal nerves to evaluate for pathology.

Influence of clinical experience on accuracy and safety of obliquus capitus inferior dry needling in unembalmed cadavers

Background: Suboccipital myofascial trigger points are common in tension-type headaches.Objectives: Compare the influence of clinical experience on the accuracy and safety of dry needle placement on the C2 laminar arch using a cranial-medial and caudal-medial technique to target obliquus capitus inferior in unembalmed cadavers.Methods: Three physical therapists inserted three 50 mm dry needles, per technique, individually toward the C2 laminar arch targeting the obliquus capitus inferior. Ultrasound video of each trial was recorded, and an investigator trained in ultrasound interpretation and blinded to experience level recorded needling accuracy.Results: The novice, experienced and expert clinicians were accurate on 73.8%, 59.5% and 71.4% of caudal-medial trials, and 14.3%, 16.7% and 66.7% of cranial-medial trials, respectively, with each clinician striking the spinal cord at least once. The expert clinician was 10 times more likely to accurately reach the C2 laminar arch using the cranial-medial direction than the experienced and novice clinicians.Conclusion: Increased clinical experience improved accuracy reaching the C2 laminar arch, with all investigators being more accurate with the caudal-medial technique. Greater experience did not eliminate risk as all investigators recorded at least one incident of striking the spinal cord. Fewer spinal cord strikes occurred with the cranial-medial than the caudal-medial technique.

Should low-quality evidence dominate high-level evidence? A systematic review and meta-analysis of systematic reviews of musculoskeletal physical therapy interventions

OBJECTIVES

To determine the: 1) quality of articles cited in systematic reviews (SRs); 2) methodological quality of the SRs; and 3) impact of quality on level 1A evidence.

METHODS

SRs related to musculoskeletal physical therapy interventions were identified. The methodological quality of the SRs and articles cited by the SRs were assessed by two blinded reviewers. Data analysis was performed by a third blinded researcher. Additional comparisons were made based on the Journal Impact Factor, spin, financial bias, and conflict of interest.

RESULTS

Twenty-four SRs were identified; 21/24 SRs had 'critically low' quality on the AMSTAR 2. Thirty-four percent of included studies were 'low quality,' and 58% of SRs included studies that had unreported external validity. One-half of the SRs represented 'spin,' and one-third of the SRs generated conclusions based on low-quality clinical trials.

DISCUSSION

The 'critically low' SRs methodological quality was exacerbated by low-quality research inclusion. Most SRs failed to follow best practices, including prospective registration and integration of professional librarians in the search process. Based on the high proportion of SRs that include low-quality trials and overall low methodological quality, further discussion regarding practice recommendations on level vs. quality of evidence is warranted.

LEVEL OF EVIDENCE

1a.

The relationship between measures of foot mobility and subtalar joint stiffness using vibration energy with color Doppler imaging-A clinical proof-of-concept validation study

INTRODUCTION

Subtalar joint (STJ) dysfunction can contribute to movement disturbances. Vibration energy with color Doppler imaging (VECDI) may be useful for detecting STJ stiffness changes.

OBJECTIVES

(1) Support proof-of-concept that VECDI could detect STJ stiffness differences; (2) Establish STJ stiffness range in asymptomatic volunteers; (3) Examine relationships between STJ stiffness and foot mobility; and (4) Assess VECDI precision and reliability for examining STJ stiffness.

METHODS

After establishing cadaveric testing model proof-of-concept, STJ stiffness (threshold units, ΔTU), ankle complex passive range-of-motion (PROM) and midfoot-width-difference (MFWDiff) data were collected in 28 asymptomatic subjects in vivo. Three reliability measurements were collected per variable; Rater-1 collected on all subjects and rater-2 on the first ten subjects. Subjects were classified into three STJ stiffness groups.

RESULTS

Cadaveric VECDI measurement intra-rater reliability was 0.80. A significantly lower STJ ΔTU (p = .002) and ankle complex PROM (p < .001) was observed during the screw fixation versus normal condition. A fair correlation (r = 0.660) was observed between cadaveric ΔTU and ankle complex PROM. In vivo VECDI measurements demonstrated good intra-rater (0.76-0.84) versus poor inter-rater (-3.11) reliability. Significant positive correlations were found between STJ stiffness and both dorsum (r = .440) and posterior (r = .390) PROM. MFWDiff exhibited poor relationships with stiffness (r = .103) and either dorsum (r = .256) or posterior (r = .301) PROM. STJ stiffness ranged from 2.33 to 7.50 ΔTUs, categorizing subjects' STJ stiffness as increased (n = 6), normal (n = 15), or decreased (n = 7). Significant ANOVA main effects for classification were found based on ΔTU (p< .001), dorsum PROM (p = .017), and posterior PROM (p = .036). Post-hoc tests revealed significant: (1) ΔTU differences between all stiffness groups (p < .001); (2) dorsum PROM differences between the increased versus normal (p = .044) and decreased (p = .017) stiffness groups; and (3) posterior PROM differences between the increased versus decreased stiffness groups (p = .044). A good relationship was found between STJ stiffness and dorsum PROM in the increased stiffness group (r = .853) versus poor, nonsignificant relationships in the normal (r = -.042) or decreased stiffness (r = -.014) groups.

CONCLUSION

PROM may not clinically explain all aspects of joint mobility. Joint VECDI stiffness assessment should be considered as a complimentary measurement technique.