Intra-rater reliability and smallest detectable change of compression sonoelastography in quantifying the material properties of the musculoskeletal system.

Musculoskeletal conditions can change tissue elasticity. Knowledge of musculoskeletal elasticity could therefore aid clinical diagnosis and management. Sonoelastography is an ultrasound-based system that examines the material properties of tissues, and it may be useful in musculoskeletal practice. Therefore, it is important to establish its clinimetric properties. This study aimed to explore the intra-rater reliability and the smallest detectable changes of sonoelastography in examining musculoskeletal structures. A quantitative reliability design was used to examine 22 healthy participants using a compression sonoelastography system that produces color-coded images. The deltoid, biceps brachii, brachioradialis, rectus femoris, gastrocnemius medius muscles, and Achilles tendon were examined twice at 1-hr intervals to assess the intra-rater reliability. The sonoelastography images were analyzed using the strain index, strain ratio, and color pixels. The intra-rater reliability and the smallest detectable changes of each outcome variable were determined. The intra-class correlation coefficient was used to quantify the repeatability of the measurements, and the smallest detectable changes were calculated to determine clinically important differences above the error of measurement. The intra-rater reliability for the strain index, strain ratio, and color pixel analysis ranged from moderate to excellent (intra-class correlation coefficients: .734-.950, .776-.921, and .754-.990, respectively), with color pixel analysis demonstrating the highest reliability. The smallest detectable changes were determined for all structures, including the Achilles tendon (0.11 for the higher boundary of the strain index, 1.80 for the strain ratio, and 2.90% for red pixels, representing soft tissues). Color pixel analysis may be more reliable for sonoelastography interpretation compared with the strain index and strain ratio. The calculated smallest detectable changes could be used to identify clinically important differences.

Changes in Vertebral Artery Hemodynamics Associated With McKenzie Therapeutic Cervical Movements: An Exploration Using Duplex Ultrasound Imaging.

OBJECTIVE: The purpose of this study was to explore vertebral artery hemodynamic changes associated with McKenzie therapeutic cervical movements in healthy individuals. METHODS: A single-group repeated-measure design was used to examine 20 healthy participants aged 22.05 (1.69) years, mean (standard deviation). Vertebral artery volume flow, diameter, resistive index, time-averaged maximum velocity, and pulsatility index were measured using Duplex ultrasound. Vertebral artery hemodynamics were measured at cervical neutral positions then compared against vertebral artery hemodynamics measured during end-range loading and after repeated McKenzie therapeutic movements. Wilcoxon signed rank tests were used for comparisons, and standardized mean differences (SMDs) were calculated to quantify the changes in size. RESULTS: Repeated retraction with extension in a sitting position and end-range retraction with extension in supine position were significantly associated with an increase in vertebral artery volume flow, P ≤ .01, and the SMD suggests small-medium changes in size. Statistical significant vertebral artery dilation was observed in the sitting position with protraction, combined retraction with extension, and flexion, P ≤ .01, yet the SMD suggested small changes in size. End-range flexion was significantly associated with a reduction in vertebral artery pulsatility index, and the SMD suggested large changes in size. Repeated retraction with extension in supine position was significantly associated with an increase in vertebral artery time-averaged maximum velocity, yet the SMD revealed no clinically important difference. CONCLUSION: For the healthy participants in this study, McKenzie cervical movements were mostly associated with an increase in vertebral artery hemodynamics.

The impact of hypermobility spectrum disorders on musculoskeletal tissue stiffness: an exploration using strain elastography.

Hypermobility spectrum disorders (HSDs) are conditions associated with chronic joint pain and laxity. HSD's diagnostic approach is highly subjective, its validity is not well studied, and it does not consider many of the most commonly affected joints. Strain elastography (SEL) reflects musculoskeletal elasticity with sonographic images. The study explored the impact of HSD on musculoskeletal elasticity using SEL. A cross-sectional design compared 21 participants with HSD against 22 controls. SEL was used to assess the elasticity of the deltoid, biceps brachii, brachioradialis, rectus femoris, and gastrocnemius muscles, and the patellar and Achilles tendon. SEL images were analyzed using strain index, strain ratio, and color pixels. Mean strain index (standard deviation) was significantly reduced in the HSD group compared to the control group in the brachioradialis muscle 0.43 (0.10) vs. 0.59 (0.24), patellar 0.30 (0.10) vs. 0.44 (0.11), and Achilles tendons 0.24 (0.06) vs. 0.49 (0.13). Brachioradialis muscle and patellar tendon's strain ratios were significantly lower in the HSD group compared to the control group, 6.02 (2.11) vs. 8.68 (2.67) and 5.18 (1.67) vs. 7.62 (1.88), respectively. The percentages (%) of red color (soft tissues) in the SEL images were significantly increased in the HSD group compared to the control group in the biceps brachii muscle, 34.72 (7.82) vs. 26.69 (3.89), and Achilles tendon, 18.14 (13.21) vs. 5.59 (8.23) (p ≤ 0.01). The elasticity of the musculoskeletal system seems to be lower in people with HSD. SEL could be a supplementary tool for diagnosing and monitoring HSD.

Importance Attributed to Cardiovascular and Pulmonary Competencies by Public Sector Physical Therapists in Kuwait: A Population-based Exploratory Study.

BACKGROUND AND PURPOSE: Indications for cardiovascular and pulmonary (CVP) physical therapy competencies are changing with the epidemic of non-communicable diseases in Kuwait, particularly lifestyle-related conditions. The degree to which the country's physical therapists (PTs) perceive the importance of CVP competencies (assessment/evaluation and clinical and laboratory investigation interpretation) in professional practice is relevant. Our study objectives were to (1) explore the importance attributed to specific CVP competencies by PTs to professional practice in Kuwait and (2) establish whether these are related to practitioner traits, for example, age, sex, practice setting and specialty. METHOD: The study design was exploratory with a stratified random sample. Questionnaires (n = 221) were distributed to PTs practicing in the facilities of the Ministry of Health, the primary employer of PTs in Kuwait. Questions included participants' demographics and perceived importance of specific CVP competencies (Likert rating scale 1-not important to 5-highly important). RESULTS: Response rate was 87% (n = 193). Participant mean age was 36(±9) years, 63% were women and 48% were Kuwaiti. Ratings of moderately important or higher were 84% for cardiac assessment/intervention skills, 78.8% for cardiac clinical/laboratory investigations interpretation, 77.2% for pulmonary assessment/intervention skills and 73.6% for pulmonary clinical/laboratory investigations interpretation. PTs in the musculoskeletal area attributed less importance to the competencies than those in other specialties. CONCLUSIONS: Participants perceived CVP competencies as generally relevant to practice. However, greater importance was attributed to these competencies in relation to management of CVP conditions (e.g. those that address lifestyle-related conditions) rather than across practice areas. Research is needed to elucidate whether this finding reflects the profession's commitment to holistic care, the prevalence of lifestyle-related risk factors and conditions irrespective of a patient's primary complaint presenting to the PT, best evidence-based, non-pharmacologic practice to address these or some combination. Copyright © 2015 John Wiley & Sons, Ltd.

Immune responses following McKenzie lumbar spine exercise in individuals with acute low back pain: a preliminary study.

OBJECTIVE: This study explores the immune responses following 4 weeks of McKenzie lumbar spine exercise in individuals with acute low back pain (ALBP). PATIENTS AND METHODS: Fifteen patients with ALBP and 15 healthy individuals volunteered in this study. Ten ml of peripheral blood were obtained from each patient before and after exercise sessions, and from healthy individuals at the beginning of the study. Flow cytometric analysis was used to evaluate the frequencies of CD4+ T lymphocyte sub-populations and the intracellular cytokine expression within this cell population. Pain perceptions were obtained at baseline and following each week of exercise sessions. RESULTS: In comparison with healthy subjects there was an elevated frequency of memory (CD4+CD45RO+) T cells, helper inducer (CD4+CD29+) T cells, CD3+CD16+CD56+ T cells and a lower frequency of naïve/suppressor (CD4+CD45RA+) T cells at base line in back pain patients (p<0.05). After 4 weeks of McKenzie exercise sessions, pain intensity significantly decreased (p<0.05); however, there was no significant difference in the frequency of memory (CD4+CD45RO+) T cells, helper inducer (CD4+CD29+) T cells, CD3+CD16+CD56+ T cells and naïve/ suppressor (CD4+CD45RA+) T cells at base line relative to these cell populations after exercise sessions. The percentage of Pan (CD3+) T cells expressing IL-8 and TNF-α and the CD3+ T cells expressing the anti-inflammatory cytokine IL-4 increased significantly (p<0.05) following exercise sessions in comparison with baseline and healthy references. The reduction in pain scores did not correlate with elevated anti-inflammatory cytokines. CONCLUSION: McKenzie exercise sessions induced an immune activation state and simultaneously up regulated anti-inflammatory IL-4 cytokines that boost pain relief.

Religious faith and psychosocial adaptation among stroke patients in Kuwait: a mixed method study.

Religious faith is central to life for Muslim patients in Kuwait, so it may influence adaptation and rehabilitation. This study explored quantitative associations among religious faith, self-efficacy, and life satisfaction in 40 female stroke patients and explored the influence of religion within stroke rehabilitation through qualitative interviews with 12 health professionals. The quantitative measure of religious faith did not relate to life satisfaction or self-efficacy in stroke patients. However, the health professionals described religious coping as influencing adaptation post-stroke. Fatalistic beliefs were thought to have mixed influences on rehabilitation. Measuring religious faith among Muslims through a standardized scale is debated. The qualitative accounts suggest that religious beliefs need to be acknowledged in stroke rehabilitation in Kuwait.

Smoking impact on grip strength and fatigue resistance: implications for exercise and hand therapy practice.

BACKGROUND: Grip strength assessment reflects on overall health of the musculoskeletal system and is a predictor of functional prognosis and mortality. The purpose of this study was: examine whether grip-strength and fatigue resistance are impaired in smokers, determine if smoking-related impairments (fatigue-index) can be predicted by demographic data, duration of smoking, packets smoked-per-day, and physical activity. METHODS: Maximum isometric grip strength (MIGS) of male smokers (n = 111) and nonsmokers (n = 66) was measured before/after induced fatigue using Jamar dynamometer at 5-handle positions. Fatigue index was calculated based on percentage change in MIGS initially and after induced fatigue. RESULTS: Number of repetitions to squeeze the soft rubber ball to induce fatigue was significantly lower in smokers compared with nonsmokers (t = 10.6, P < .001 dominant hand; t = 13.9, P < .001 nondominant), demonstrating a significantly higher fatigue-index for smokers than nonsmokers (t = -8.7, P < .001 dominant hand; t = -6.0, P < .001 nondominant). The effect of smoking status on MIGS scores was significantly different between smokers and nonsmokers after induced fatigue (ß = -3.98, standard error = 0.59, P < .001) where smokers experienced on average a reduction of nearly 4 MIGS less than nonsmokers before fatigue. Smoking status was the strongest significant independent predictor of the fatigue-index. CONCLUSIONS: Smokers demonstrated reduced grip strength and fast fatigability in comparison with nonsmokers.

To establish whether McKenzie lumbar flexion and extension mobility exercises performed in lying affect central as well as systemic hemodynamics: a crossover experimental study.

OBJECTIVE: Examine systemic and central hemodynamic responses following McKenzie lumbar flexion and extension mobility exercises performed in lying (FIL and EIL). DESIGN: Crossover experimental study. SETTING: Clinical laboratory. PARTICIPANTS: Healthy male volunteers (n=25) (mean(SD) age: 28(3)years; range 21 to 34). INTERVENTIONS: Based on alternating assignment of either FIL or EIL to participants, three sets of the first exercise (10, 15, 20 repetitions) were performed with 5-minute rest between sets; after 15-minute rest, the protocol was repeated for the other exercise. MAIN OUTCOME MEASURES: Systemic hemodynamic parameters included heart rate (HR), and systolic and diastolic blood pressures (SBP, DBP). Central hemodynamic parameters included abdominal aortic diameter (AD), peak systolic velocity (PSV/AD), end diastolic velocity (EDV/AD) and resistive index (RI). Measures recorded after each exercise set. RESULTS: FIL RPP at baseline was 9.1 (1.4), after 20 repetitions 18.3 (2.5), mean difference 8.9 (95% confidence interval (CI) 7.9 to 9.8) compared to EIL at baseline 9.1 (1.5), after 20 repetitions 13.0 (3.1), mean difference 4.1 (95% CI 3.3 to 5.0). FIL RI at baseline was 0.78 (0.03), after 20 repetitions 0.87 (0.03), mean difference 0.08 (95% CI 0.06 to 0.10) compared to EIL at baseline 0.78 (0.03), after 20 repetitions 0.83 (0.03), mean difference 0.05 (95% CI 0.04 to 0.07). CONCLUSIONS: Although 10 repetitions of FIL and EIL may be regarded as safe, our findings support screening patients with lifestyle risk factors, and cautioning about adhering to recommended repetition number given associated increased work of the heart. The extent of AD mechanical perturbation remains unclear.

The reliability of prayer-based self-efficacy scale to assess self-confidence of Muslims with low back pain.

BACKGROUND: Low back pain (LBP) may challenge an individual's self-confidence to perform usual daily activities such as Islamic daily prayer. Existing self-efficacy scales may not be appropriate to assess individual's self-confidence to perform Islamic prayers. OBJECTIVE: This study aimed to develop a scale to assess self-confidence to prepare and perform Islamic prayer in the presence of LBP, the Islamic Prayer-based Self-efficacy Scale (IpbSeS), and to determine its consistency. METHODS: The IpbSeS consists of three parts: pre-prayer preparation, getting to and from the mosque, and positions and movements during prayer. On a scale of 0 to 6, 0 indicates 'not at all confident' and 6 'fully confident'. Sixty individuals with LBP gave their responses on two different visits. Pain intensity was assessed by the Visual Analogue Scale (VAS), and the pain intensity changes were assessed using a seven-point global patient rating scale. DATA ANALYSIS: Descriptive statistics, Pearson's correlation coefficient, Wilcoxon test and t-test were used in the analysis (alpha set at 0.05). RESULTS: VAS scores did not differ significantly between visits. No association was found between VAS and age (r = 0.039, p = 0.77) and between VAS and body mass index (BMI; r = 0.06, p = 0. 67). All 28 questions have consistent responses on two visits (0.75 ≤ r ≤ 0.99, p < 0.001 for all) indicating a very high reliability. CONCLUSION: IpbSeS appears to be a reliable instrument to assess the self-confidence of Muslims in the presence of LBP to pray.

Evaluation of the McKenzie intervention for chronic low back pain by using selected physical and bio-behavioral outcome measures.

OBJECTIVES: To assess the bio-behavioral and physical performance characteristics of individuals with chronic low back pain who demonstrated the pain centralization phenomenon and received the McKenzie intervention using selected bio-behavioral and physical performance measures at intake and at 5 weeks and 10 weeks after treatment. DESIGN: A prospective cohort study with assessment at baseline and 2 follow-ups after completion of the McKenzie intervention. SETTING: Outpatient orthopedic physical therapy clinics. PARTICIPANTS: Sixty-two volunteers with chronic low back pain (28 men, 34 women; average ages 41.9 and 37.1 years, respectively). METHODS: The subjects completed pain and related fear and disability questionnaires, underwent McKenzie mechanical assessment, and executed selected physical performances. They then received the McKenzie intervention. MAIN OUTCOME MEASUREMENTS: Outcomes measurements were repeated at the end of the 5th and 10th weeks after treatment completion. Pain-related disability and fear beliefs were assessed by using the Disability Belief Questionnaire and Fear Avoidance Belief Questionnaires, respectively. The time for repeated sit to stand, trunk forward bending, and customary and fast walking were measured by stopwatch. Pain (anticipated versus actual reported) was measured before and immediately after a given physical performance. Descriptive statistics, paired t-tests, and repeated measures analysis of variance were used. RESULTS: Significant improvements peaked at the end of the 5th week for all outcome measures (P < .001), with slight increase in bio-behavioral variables at the end of the 10th week. CONCLUSIONS: McKenzie intervention reduced pain and related fear and disability beliefs and improved physical performances in individuals with chronic low back pain. Improvements in physical performances remained stable 10 weeks after treatment, regardless of the elevation in bio-behavioral factors.

The First Physical Therapy Summit on Global Health: implications and recommendations for the 21st century.

The First Physical Therapy Summit on Global Health was convened at the 2007 World Confederation for Physical Therapy (WCPT) Congress to vision practice in the 21st century and, in turn, entry-level education and research, as informed by epidemiological indicators, and consistent with evidence-based noninvasive interventions, the hallmark of physical therapy. The Summit and its findings were informed by WHO data and validated through national databases of the countries of the five WCPT regions. The health priorities based on mortality were examined in relation to proportions of physical therapists practicing in the areas of regional priorities and of the curricula in entry-level programs. As a validation check and to contextualize the findings, input from members of the 800 Summit participants was integrated and international consultants refined the recommendations. Lifestyle-related conditions (ischemic heart disease, smoking-related conditions, hypertension, stroke, cancer, and diabetes) were leading causes of premature death across regions. Contemporary definitions of physical therapy support that the profession has a leading role in preventing, reversing, as well as managing lifestyle-related conditions. The proportions of practitioners practicing primarily in these priority areas and of the entry-level curricula based on these priorities were low. The proportions of practitioners in priority areas and entry-level curricula devoted to lifestyle-related conditions warrant being better aligned with the prevalence of these conditions across regions in the 21st century. A focus on clinical competencies associated with effective health education and health behavior change formulates the basis for The Second Physical Therapy Summit on Global Health.

Outcome measures and psychomotor skills related to shoulder conditions for clinical orthopedic training.

OBJECTIVE: This study was designed to assess the ability of physical therapy (PT) students to utilize selected outcome measures such as range of motion (ROM), pain and a number of psychomotor skills and to determine the efficacy of treatment they carried out during orthopedic clinical training. MATERIALS AND METHODS: The clinical education booklets in orthopedics of all PT students over a 6-year period were reviewed. Students' application of psychomotor skills such as peripheral joint mobilizations (PJM), proprioceptive neuromuscular facilitation (PNF) techniques, therapeutic exercise techniques as well as utilization of basic outcome measures such as ROM and pain were analyzed with descriptive statistics and paired t test. RESULTS: A majority of students used PJM techniques (78.6%) and PNF techniques (58.6%). The paired t test indicated that treatment interventions used by the students were associated with improved shoulder joint ROM and decreased pain levels (p < 0.001). At the same time, therapeutic exercises were employed by the students after PJM and PNF. The most common 'comparable joint sign' was limitation in shoulder abduction ROM, which occurred in 44% of patients seen by the students. CONCLUSION: PT students' application of PJM, PNF, and therapeutic exercise improved ROM and decreased pain in patients with shoulder pathologies.

The relationship of anticipated pain and fear avoidance beliefs to outcome in patients with chronic low back pain who are not receiving workers' compensation.

STUDY DESIGN: A prospective, interventional case series design. OBJECTIVES: To determine the degree to which preintervention measures of anticipated pain and fear avoidance beliefs predict outcome after intervention for patients with delayed recovery from low back pain (LBP) for which they are not receiving workers' compensation. SUMMARY OF BACKGROUND DATA: Anticipated pain and fear avoidance beliefs have been suggested as important factors for the classification and treatment of patients with LBP. However, the degree to which they are associated with outcome after intervention is uncertain. METHODS: There were 42 subjects with activity limiting LBP for more than 2 months enrolled in an exercise based, physical therapy program. A multidimensional test battery was completed before and after a 10-week program of lumbar extensor muscle strengthening. Correlational analyses, independent t tests, and validity indexes were used to determine relationships of preintervention measures of anticipated pain and the fear avoidance beliefs to clinically meaningful improvements in the Roland-Morris score. Intention-to-treat strategies were used to account for study dropouts. RESULTS: A total of 36 subjects completed the 10-week intervention. The lack of clinically meaningful outcome, as determined by a failure-to-report a minimum of 16% decrease in the Roland-Morris score, was associated with high preintervention scores on the physical activity subscale of the Fear Avoidance Beliefs Questionnaire (FABQP). Subjects with a preintervention score > or =29 on the FABQP had a likelihood ratio of 3.78 (95% confidence interval [CI] 2.4-5.16) for an increased probability of negative outcome after initial testing when compared to those subjects with low (<20) scores. The sensitivity and specificity of low scores to predict clinically meaningful outcomes compared to those with high scores were moderate (sensitivity = 0.87 and specificity 0.77); however, the likelihood ratio was inconclusive. Anticipated pain was significantly correlated with but was higher than the reported pain during activity both before and after intervention but not predictive of outcome. CONCLUSIONS: In a sample of people from a Middle Eastern culture undergoing exercise intervention for LBP for which they are not receiving workers' compensation, the preintervention physical activity subscale of the FABQ is predictive of negative outcome when the observed scores are > or =29. Despite significant improvements in all variables after intervention, anticipated pain remained significantly higher than reported pain during physical performance testing but did not predict outcome.

Differences in back extensor strength between smokers and nonsmokers with and without low back pain.

STUDY DESIGN: Cross-sectional study comparing isometric lumbar extensor strength (ILES) in individuals who smoke and nonsmokers with and without low back pain (LBP). OBJECTIVES: To examine the differences in ILES between individuals who smoke and nonsmokers with and without LBP. BACKGROUND: Given the evidence for general muscle weakness in individuals who smoke and in individuals with LBP, we were interested in examining the interrelationships between back strength, in particular ILES, and LBP in individuals who smoke and nonsmokers. METHODS AND MEASURES: The study involved 76 men (age range, 30-50 years) in 4 groups, namely, nonsmokers with LBP (NS-LBP), a control group of nonsmokers without LBP (NS-C), smokers with LBP (S-LBP), and a control group of smokers without LBP (S-C). ILES was measured at 7 angles of lumbar flexion, specifically 72 degrees, 60 degrees, 48 degrees, 36 degrees, 24 degrees, 12 degrees, and 0 degrees. ANOVA and Scheffe post hoc comparison tests were used to analyze the data. RESULTS: Nonsmokers with LBP had less muscle strength than those without LBP (P<.01). However, the strength of smokers with and without LBP was comparable (P>.05). Both groups of individuals who did not smoke were stronger than the 2 groups comprised of smokers. CONCLUSIONS: Individuals who smoke were weaker than those who did not smoke, but no difference in strength was noted between smokers with and without LBP. Although smoking appears to be an important cofactor in the etiology of LBP, the degree to which smoking is a primary, secondary, or a component of a combined etiology warrants further study.

The influence of pain and pain-related fear and disability beliefs on walking velocity in chronic low back pain.

The purpose of this study was to examine the influence of anticipation of pain, sensory perception of pain and pain-related fear and disability beliefs on the gait characteristics of patients with chronic low back pain (CLBP). Thirty-one individuals with CLBP (16 men and 15 women) and 24 healthy individuals (11 men and 13 women) between 20 to 56 years of age participated in this study. Anticipated pain and the pain actually felt were measured with two separate visual analogue scales before and after preferred and fast walking performances. Pain-related fear and disability beliefs were measured with the Fear-Avoidance Belief Questionnaire (FABQ) and the Disability Belief Questionnaire (DBQ). Spatial and temporal walking parameters were measured at preferred and fast walking performances using a computerized gait mat. Analysis of variance demonstrated significant differences between patients and healthy individuals in step length, single support time and walking velocity (P<0.05). Within the CLBP group, stepwise regression analysis showed that FABQ (physical activity) and anticipated pain were the strongest predictors of velocity deficits in preferred and fast walking respectively. Anticipation and fear of pain accounted significantly for the velocity deficits in walking. Standard clinical gait assessments must incorporate psychological measures of pain experience.

Basic gait parameters: a comparison of reference data for normal subjects 20 to 29 years of age from Kuwait and Scandinavia.

This study obtained measurements of the spatiotemporal gait parameters of healthy young adult Kuwaiti subjects from both genders and compared the data to those collected in a similar study performed in Sweden. Thirty healthy subjects volunteered to participate in the study (which included being asked to walk at their "free," "slow," and "fast" self-selected speeds). We collected the spatiotemporal gait data using an automated system. Descriptive statistics were calculated for each variable measured at each walking condition. The data were then compared to those from the Swedish study. The results indicate several significant differences between Kuwaiti and Swedish subjects in their manner of walking. These results suggest a need to include data from subjects with diverse cultural backgrounds when a database on normal gait is developed or a need to limit the results of the database to a specified ethnic population.