Real time ultrasound imaging shows changes in deep neck flexor activation during exercise in individuals with mechanical neck pain.

BACKGROUND: Deep neck flexor muscle atrophy and increased superficial neck muscle activation are associated with disability and pain intensity in individuals with neck pain. There is a lack of evidence to support direct assessment of deep neck flexor muscles in a non-invasive way during exercise performance to help determine the effectiveness of different neck strengthening exercises. OBJECTIVE: Compare longus colli (LC) and sternocleidomastoid (SCM) activation between individuals with and without neck pain using real time ultrasound (RTUS) during a series of craniocervical exercises. METHODS: This cross-sectional cohort study recruited 10 control and 10 neck pain participants to complete four deep neck flexor activation activities involving varying levels of craniocervical flexion. Dimensions of the LC and SCM were measured using RTUS at rest and during exercise. Independent t-tests assessed baseline differences and analysis of variance examined activation changes. RESULTS: At rest, the neck pain group had significantly smaller cross-sectional area and thickness of the LC compared to the control group (p< 0.05). During exercise, the neck pain group showed significantly larger increases in LC thickness and cross-sectional area across exercise compared to the control group, with no differences in SCM activation between groups. CONCLUSIONS: Despite atrophy, individuals with neck pain can activate their deep neck flexor muscles appropriately without activating their superficial neck flexor muscles in a supine series of craniocervical flexion exercise as measured by non-invasive ultrasound imaging.

Effect of Starting Posture on Three-Dimensional Jaw and Head Movement.

Objectives: The effect of body posture on movement of the jaw and head has not yet been clearly established. The relationship between jaw and head movement has implications for conditions such as temporomandibular joint disorders which can be associated with neck pain. The purpose of this quasi-experimental study was to examine the effect of starting posture on three-dimensional movement of the jaw and head, and to examine the relationship between head and jaw movement during mouth opening. Material and Methods: Fourteen healthy participants performed jaw opening to comfortable and maximal amounts from three starting body postures (neutral, slumped, upright) while three-dimensional movement of the head, jaw, and trunk was tracked. Separate repeated measures analyses of variance analyses examined the effect of posture on jaw and head rotation and translation, and Pearson product moment correlations examined the relationship between jaw opening and head rotation. Results: Body posture significantly influenced maximal opening but not comfortable opening (P < 0.0033). There was a positive relationship between head extension and maximum opening in an upright posture (r = 0.74, P = 0.006), and head extension and comfortable opening in neutral and upright postures (r = 0.75 to 0.93, P < 0.0033), although there was no relationship between head extension and jaw opening in a slumped posture when opening comfortably. Conclusions: Posture can affect three-dimensional movement of the jaw when opening. Negating the normal head extension that occurs with mouth opening when in a slumped posture has implications for the development of temporomandibular and neck problems in some individuals.

Predicting the number of physical therapy visits and patient satisfaction in individuals with temporomandibular disorder: A cohort study.

BACKGROUND: Temporomandibular disorders (TMD) can be challenging to manage for clinicians and patients alike. It is unclear which factors are associated with prolonging conservative care and patient dissatisfaction with treatment outcomes. OBJECTIVES: To examine factors collected during a physical therapy (PT) evaluation in a cohort of individuals with TMD to determine factors associated with an increased number of PT visits and reduced patient satisfaction. METHODS: Records of 511 patients referred to PT over 18 months were reviewed to extract 27 variables to develop a predictive model. Outcomes were patient satisfaction following PT and number of PT visits. Linear and zero inflated negative binomial regressions were used, and a multivariate regression model was built for both outcomes. RESULTS: Two factors were associated with both lower patient satisfaction and an increased number of PT visits: higher patient rated functional neck disability and a greater number of healthcare professionals seen. Other factors associated with patient satisfaction were duration of symptoms, subluxation, and referral from an oral surgeon. Only patient rated functional neck disability score was a significant predictive factor in the multivariate model. Factors associated with number of PT visits were gender, educational level, time between initial visit and discharge, number of pain areas, bruxism, biopsychosocial factors, dizziness, pain rating, and presence of neck pain. In the multivariate model, gender, number of healthcare professionals seen, and resting pain rating were significant predictors of number of PT visits. CONCLUSION: Considering key factors on initial evaluation, specifically functional neck disability and the number of prior healthcare professionals seen before starting PT, can help to predict a higher number of PT visits and reduced patient satisfaction with outcomes.

Temporomandibular disorder content in the curricula of physical therapist professional programs in the United States.

Objective: To describe the status of entry-level physical therapist (PT) education related to the diagnosis and management of temporomandibular disorders (TMD) in accredited, entry-level United States PT programs. Methods: An electronic survey explored specific TMD diagnostic and management curricular content, including the use of evidence-based diagnostic criteria, opportunities for students to interact with individuals with TMD, and faculty qualifications. Results: Eighty-four programs completed the survey. TMD content is covered in the entry-level PT curriculum of almost all (98.8%) responding programs. Content specifically related to TMD averaged 12 h across program respondents (range 1.5-50 h). The majority (68%) of respondents utilized established evidence-based diagnostic criteria. Discussion: Consistent entry-level education guidelines related to TMD and additional post-professional education opportunities are necessary to ensure that patients with TMD are not underserved by the profession of PT by newly graduated PTs.

Effect of Injury Prevention Programs on Lower Extremity Performance in Youth Athletes: A Systematic Review.

BACKGROUND: Understanding how existing youth injury prevention programs affect specific modifiable injury risk factors will inform future program development for youth athletes. OBJECTIVE: To comprehensively evaluate the effects of injury prevention programs on the modifiable intrinsic risk factors associated with lower extremity performance in youth athletes. DATA SOURCES: This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A systematic search of the literature was performed using multiple databases (PubMed, EBSCOhost [including CINAHL, Medline, and SPORTDiscus], and PEDro). Secondary references were appraised for relevant articles. Article types included randomized or cluster randomized controlled trials and randomized cohort designs with youth athletes engaged in organized sports, along with outcomes that included at least 1 physical performance outcome measure. STUDY SELECTION: Eight studies met inclusion and exclusion criteria and were reviewed by 2 independent reviewers, with a third consulted in the case of disagreement, which was not needed. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 3. DATA EXTRACTION: Included studies underwent review of methodological quality using the Physiotherapy Evidence Database scale. RESULTS: Studies included mixed-sex samples of youth athletes who predominantly participated in soccer at different skill levels. The FIFA 11+ series was the most commonly used injury prevention program. Among studies, the mean percentage of improvement identified was 11.3% for force generation, 5.7% for coordination, 5.2% for posture, and 5.2% for balance. The lowest mean percentage improvement was in speed (2.2%). Endurance was not significantly affected by any of the programs. CONCLUSION: This systematic review shows that injury prevention programs improve several modifiable intrinsic risk factors of lower extremity performance among youth athletes, particularly force generation. However, several intrinsic risk factors were either not significantly affected or specifically addressed by existing programs.

Outcomes and patient satisfaction following individualized physical therapy treatment for patients diagnosed with temporomandibular disc displacement without reduction with limited opening: A cross-sectional study.

OBJECTIVE: To investigate physical therapy treatment outcomes and patient satisfaction in patients with a diagnosis of disc displacement without reduction with limited opening (DDWoR wLO). METHODS: Records of 97 patients with DDWoR wLO who received physical therapy in one outpatient clinic were used in this cross-sectional study. Outcomes included number of visits, maximum active interincisal opening, self-reported pain, and patient satisfaction. RESULTS: The average number of physical therapy visits per patient was 5.5, and there were significant improvements in pain rating and interincisal opening following physical therapy. Effect sizes for these comparisons were large (>1.0). Mean patient satisfaction responses across all symptom areas was consistent with patients being more than less satisfied following treatment. DISCUSSION: Individualized physical therapy treatment is an effective conservative intervention to improve mouth opening, reduce pain, and provide patient satisfaction in patients with one specific sub-type of temporomandibular disorder (TMD), DDWoR wLO.

Disc displacement without reduction with limited opening: A clinical diagnostic accuracy study.

PURPOSE: The purpose of this study is to explore the diagnostic accuracy and clinical utility of an examination by a physical therapist using a clinical patient population for diagnosing a specific sub-type of disc displacement (DDWoR wLO) compared to the imaged disc position. METHODS: Data from 46 patients with a clinical diagnosis of DDWoR wLO (92 clinical examinations and MRI records) were collected. Clinical diagnosis was made based on predefined diagnostic criteria, and the MRI diagnosis was made based on the MRI radiology report obtained from the dental provider. A McNemar test was used to determine whether the outcomes of the clinical and MRI diagnoses differed significantly, and sensitivity, specificity, likelihood ratios, predicative values, 95% confidence intervals, and the overall diagnostic accuracy were computed. RESULTS: There was high sensitivity (85%), moderate but unacceptable specificity (73%), and acceptable overall diagnostic accuracy (80%) for using predefined criteria in the diagnosis of DDWoR wLO. The likelihood ratios and predictive values supported the clinical utility of the criteria used for diagnosing DDWoR wLO. CONCLUSION: This is the first study to characterize diagnostic accuracy by a physical therapist of a specific sub-type of TMD in a clinical patient population rather than a research based population. The results suggest that while sensitivity and the overall diagnostic accuracy were acceptable, specificity was lower than acceptable and these findings are discussed in relation to clinical utility of using diagnostic criteria in a clinical setting against a gold standard of MRI.

Effects of 2 Years of Exercise on Gait Impairment in People With Parkinson Disease: The PRET-PD Randomized Trial.

BACKGROUND AND PURPOSE: This study presents a secondary analysis from the Progressive Resistance Exercise Training in Parkinson Disease (PRET-PD) trial investigating the effects of progressive resistance exercise (PRE) and a Parkinson disease (PD)-specific multimodal exercise program, modified Fitness Counts (mFC), on spatial, temporal, and stability-related gait impairments in people with PD. METHODS: Forty-eight people with PD were randomized to participate in PRE or mFC 2 times a week for 24 months; 38 completed the study. Gait velocity, stride length, cadence, and double-support time were measured under 4 walking conditions (off-/on-medication, comfortable/fast speed). Ankle strength was also measured off- and on-medication. Twenty-four healthy controls provided comparison data at one time point. RESULTS: At 24 months, there were no significant differences between exercise groups. Both groups improved fast gait velocity off-medication, cadence in all conditions, and plantarflexion strength off-/on-medication. Both groups with PD had more gait measures that approximated the healthy controls at 24 months than at baseline. Plantarflexion strength was significantly associated with gait velocity and stride length in people with PD at baseline and 24 months, but changes in strength were not associated with changes in gait. DISCUSSION AND CONCLUSIONS: Twenty-four months of PRE and mFC were associated with improved off-medication fast gait velocity and improved cadence in all conditions, which is important because temporal gait measures can be resistant to medications. Spatial and stability-related measures were resistant to long-term improvements, but did not decline over 24 months. Strength gains did not appear to transfer to gait.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A161).

Distinct functional and macrostructural brain changes in Parkinson's disease and multiple system atrophy.

Parkinson's disease (PD) and the parkinsonian variant of multiple system atrophy (MSAp) are neurodegenerative disorders that can be difficult to differentiate clinically. This study provides the first characterization of the patterns of task-related functional magnetic resonance imaging (fMRI) changes across the whole brain in MSAp. We used fMRI during a precision grip force task and also performed voxel-based morphometry (VBM) on T1 -weighted images in MSAp patients, PD patients, and healthy controls. All groups were matched on age, and the patient groups had comparable motor symptom durations and severities. There were three main findings. First, MSAp and PD had reduced fMRI activation in motor control areas, including the basal ganglia, thalamus, insula, primary sensorimotor and prefrontal cortices, and cerebellum compared with controls. Second, there were no activation differences among the disease groups in the basal ganglia, thalamus, insula, or primary sensorimotor cortices, but PD had more extensive activation deficits throughout the cerebrum compared with MSAp and controls. Third, VBM revealed reduced volume in the basal ganglia, middle and inferior cerebellar peduncles, pons, and throughout the cerebrum in MSAp compared with controls and PD, and additionally throughout the cerebellar cortex and vermis in MSAp compared with controls. Collectively, these results provide the first evidence that fMRI activation is abnormal in the basal ganglia, cerebellum, and cerebrum in MSAp, and that a key distinguishing feature between MSAp and PD is the extensive and widespread volume loss throughout the brain in MSAp.

Effects of endurance exercise training on the motor and non-motor features of Parkinson's disease: a review.

BACKGROUND: Despite the benefits of medications and surgical interventions for Parkinson's disease (PD), these treatments are not without complications and neuroprotective strategies are still lacking. Therefore, there is a need for effective alternative approaches to treat motor and non-motor symptoms in PD. During the last decade, several studies have investigated endurance exercise training as a potential treatment for individuals with PD. OBJECTIVE: This paper reviews the therapeutically beneficial effects of endurance exercise training on motor and non-motor symptoms in PD. METHODS: First, we performed a systematic review of the literature on the effects of endurance exercise training on motor and non-motor signs of parkinsonism, functional outcomes including gait, balance and mobility, depression and fatigue, quality of life and perceived patient improvement, cardiorespiratory function, neurophysiological measures, and motor control measures in PD. Second we performed a meta-analysis on the motor section of the UPDRS. Then, we focused on several important factors to consider when prescribing endurance exercise training in PD such as intensity, duration, frequency, specificity and type of exercise. In addition, we identified current knowledge gaps regarding endurance exercise training in PD and made suggestions for future research. RESULTS: A total of eight randomized controlled trials met the inclusion criteria and were reviewed. This systematic review synthesizes evidence that endurance exercise training at a sufficiently high level enhances cardiorespiratory capacity and endurance by improving VO2 max and gait in moderately to mildly affected individuals with PD. However, there is not yet a proven effect of endurance exercise training on specific features of PD such as motor signs of parkinsonism. CONCLUSION: Endurance exercise training improves physical conditioning in PD patients; however, to date, there is insufficient evidence to include endurance exercise training as a specific treatment for PD. There is a need for well-designed large-scale randomized controlled trials to confirm benefits and safety of endurance exercise training in PD and to explore potential benefits on the motor and non-motor signs of PD.

Two-year exercise program improves physical function in Parkinson's disease: the PRET-PD randomized clinical trial.

Background. The progressive resistance exercise (PRE) in Parkinson's disease trial (PRET-PD) showed that PRE improved the motor signs of PD compared to a modified Fitness Counts (mFC) program. It is unclear how long-term exercise affects physical function in these individuals. Objective. To examine the effects of long-term PRE and mFC on physical function outcome measures in individuals with PD. Methods. A preplanned secondary analysis was conducted using data from the 38 patients with idiopathic PD who completed the PRET-PD trial. Participants were randomized into PRE or mFC groups and exercised 2 days/week up to 24 months. Blinded assessors obtained functional outcomes on and off medication at baseline, 6 and 24 months with the Modified Physical Performance Test, 5 times sit to stand test, Functional Reach Test, Timed Up and Go, Berg Balance Scale, 6 minute walk test (6MWT), and 50-ft walking speed (walk speed). Results. The groups did not differ on any physical function measure at 6 or 24 months (Ps > .1). Across time, all physical function measures improved from baseline to 24 months when tested on medication (Ps < .0001), except for 6MWT (P = .068). Off medication results were similar except that the 6MWT was now significant. Conclusions. Twenty-four months of supervised and structured exercise (either PRE or mFC) is effective at improving functional performance outcomes in individuals with moderate PD. Clinicians should strive to include structured and supervised exercise in the long-term plan of care for individuals with PD.

Resting state functional magnetic resonance imaging in Parkinson's disease.

Neuroimaging advances over the past several decades have provided increased understanding of the structural and functional brain changes that occur with Parkinson's disease (PD). Examination of resting state functional magnetic resonance imaging (rs-fMRI) provides a noninvasive method that focuses on low-frequency spontaneous fluctuations in the blood-oxygenation-level-dependent signal that occurs when an individual is at rest. Several analysis methods have been developed and used to explore how PD affects resting state activity and functional connectivity, and the purpose of this review is to highlight the critical advances made thus far. Some discrepancies in the rs-fMRI and PD literature exist, and we make recommendations for consideration in future studies. The rs-fMRI technique holds promise for investigating brain changes associated with the motor and nonmotor symptoms of PD, and for revealing important variations across large-scale networks of the brain in PD.

Diffusion tensor imaging of Parkinson's disease, atypical parkinsonism, and essential tremor.

Diffusion tensor imaging could be useful in characterizing movement disorders because it noninvasively examines multiple brain regions simultaneously. We report a multitarget imaging approach focused on the basal ganglia and cerebellum in Parkinson's disease, parkinsonian variant of multiple system atrophy, progressive supranuclear palsy, and essential tremor and in healthy controls. Seventy-two subjects were studied with a diffusion tensor imaging protocol at 3 Tesla. Receiver operating characteristic analysis was performed to directly compare groups. Sensitivity and specificity values were quantified for control versus movement disorder (92% sensitivity, 88% specificity), control versus parkinsonism (93% sensitivity, 91% specificity), Parkinson's disease versus atypical parkinsonism (90% sensitivity, 100% specificity), Parkinson's disease versus multiple system atrophy (94% sensitivity, 100% specificity), Parkinson's disease versus progressive supranuclear palsy (87% sensitivity, 100% specificity), multiple system atrophy versus progressive supranuclear palsy (90% sensitivity, 100% specificity), and Parkinson's disease versus essential tremor (92% sensitivity, 87% specificity). The brain targets varied for each comparison, but the substantia nigra, putamen, caudate, and middle cerebellar peduncle were the most frequently selected brain regions across classifications. These results indicate that using diffusion tensor imaging of the basal ganglia and cerebellum accurately classifies subjects diagnosed with Parkinson's disease, atypical parkinsonism, and essential tremor and clearly distinguishes them from control subjects.

Force control deficits in individuals with Parkinson's disease, multiple systems atrophy, and progressive supranuclear palsy.

OBJECTIVE: This study examined grip force and cognition in Parkinson's disease (PD), Parkinsonian variant of multiple system atrophy (MSAp), progressive supranuclear palsy (PSP), and healthy controls. PD is characterized by a slower rate of force increase and decrease and the production of abnormally large grip forces. Early-stage PD has difficulty with the rapid contraction and relaxation of hand muscles required for precision gripping. The first goal was to determine which features of grip force are abnormal in MSAp and PSP. The second goal was to determine whether a single variable or a combination of motor and cognitive measures would distinguish patient groups. Since PSP is more cognitively impaired relative to PD and MSAp, we expected that combining motor and cognitive measures would further distinguish PSP from PD and MSAp. METHODS: We studied 44 participants: 12 PD, 12 MSAp, 8 PSP, and 12 controls. Patients were diagnosed by a movement disorders neurologist and were tested off anti-Parkinsonian medication. Participants completed a visually guided grip force task wherein force pulses were produced for 2 s, followed by 1 s of rest. We also conducted four cognitive tests. RESULTS: PD, MSAp, and PSP were slower at contracting and relaxing force and produced longer pulse durations compared to controls. PSP produced additional force pulses during the task and were more cognitively impaired relative to other groups. A receiver operator characteristic analysis revealed that the combination of number of pulses and Brief Test of Attention (BTA) discriminated PSP from PD, MSAp, and controls with a high degree of sensitivity and specificity. CONCLUSIONS: Slowness in contracting and relaxing force represent general features of PD, MSAp, and PSP, whereas producing additional force pulses was specific to PSP. Combining motor and cognitive measures provides a robust method for characterizing behavioral features of PSP compared to MSAp and PD.

Differences in brain activation between tremor- and nontremor-dominant Parkinson disease.

OBJECTIVE To compare differences in functional brain activity between tremor- and nontremor-dominant subtypes of Parkinson disease (PD) using functional magnetic resonance imaging. DESIGN In our study, patients with tremor-dominant PD and those with nontremor-dominant PD performed a grip task, and the results obtained were compared using voxelwise analysis. Areas of the brain that were significantly different were then examined using a region-of-interest analysis to compare these patients with healthy controls. Voxel-based morphometry was used to determine macroscopic differences in gray and white matter volume between patient groups. SETTING University-affiliated research institution. PARTICIPANTS A total of 20 drug-naive patients with PD (10 with tremor-dominant PD and 10 with nontremor-dominant PD) and a total of 20 healthy controls. MAIN OUTCOME MEASURES Blood oxygenation level-dependent activation and percent signal change. RESULTS Robust findings across both voxelwise and region-of-interest analyses showed that, compared with patients with tremor-dominant PD, patients with nontremor-dominant PD had reduced activation in the ipsilateral dorsolateral prefrontal cortex, the globus pallidus interna, and the globus pallidus externa. Region-of-interest analyses confirmed that patients with nontremor-dominant PD had reduced activity in the ipsilateral dorsolateral prefrontal cortex, the globus pallidus interna, and the globus pallidus externa compared with patients with tremor-dominant PD and healthy controls. Patients with tremor-dominant PD had increased activity in the contralateral dorsolateral prefrontal cortex compared with patients with nontremor-dominant PD and healthy controls. These results could not be explained by differences in gray or white matter volume. CONCLUSIONS Reduced brain activity occurs in the prefrontal cortex and globus pallidus of patients with nontremor-dominant PD compared with both patients with tremor-dominant PD and healthy controls, which suggests that functional magnetic resonance imaging is a promising technique to understand differences in brain activation between subtypes of PD.

Effects of aging on the ventral and dorsal substantia nigra using diffusion tensor imaging.

Dopaminergic neurons in the substantia nigra produce dopamine for the nigrostriatal pathway that facilitates motor function. Postmortem examinations demonstrate an age-related loss of cells in the substantia nigra, with most of the cell loss focused on the dorsal substantia nigra compared with the ventral substantia nigra. The current study used diffusion tensor imaging (DTI) to provide the first in vivo assessment of age-related degeneration in specific segments of the substantia nigra of humans. Measures extracted from DTI of 16 young adults (19-27 years) and 15 older adults (55-71 years) showed that in the dorsal substantia nigra, fractional anisotropy was reduced and radial diffusivity was increased with age. In the ventral substantia nigra and red nucleus, there were no differences across age for the DTI measures. DTI provides a noninvasive technique that accurately reflects the established pattern of age-related cell loss in the dorsal and ventral substantia nigra, further suggesting the robust potential for using DTI to characterize degeneration in the nigrostriatal pathway in both health and disease.

Progressive resistance exercise and Parkinson's disease: a review of potential mechanisms.

This paper reviews the therapeutically beneficial effects of progressive resistance exercise (PRE) on Parkinson's disease (PD). First, this paper discusses the rationale for PRE in PD. Within the first section, the review discusses the central mechanisms that underlie bradykinesia and muscle weakness, highlights findings related to the central changes that accompany PRE in healthy individuals, and extends these findings to individuals with PD. It then illustrates the hypothesized positive effects of PRE on nigro-striatal-thalamo-cortical activation and connectivity. Second, it reviews recent findings of the use of PRE in individuals with PD. Finally, knowledge gaps of using PRE on individuals with PD are discussed along with suggestions for future research.