Application of Modified Regression Techniques to a Quantitative Assessment for the Motor Signs of Parkinson's Disease.

Effective clinical trials for neuroprotective interventions for Parkinson's disease (PD) require a way to quantify an individual's motor symptoms and analyze the change in these symptoms over time. Clinical scales provide a global picture of function but cannot precisely measure specific aspects of motor control. We have used commercially available sensors to create a protocol called ASAP (Advanced Sensing for Assessment of Parkinson's disease) to obtain a quantitative and reliable measure of motor impairment in early to moderate PD. The ASAP protocol measures grip force as an individual tracks a sinusoidal or pseudorandom target force under three conditions of increasing cognitive load. Thirty individuals with PD have completed the ASAP protocol. The ASAP data for 26 of these individuals were summarized in terms of 36 variables, and modified regression techniques were used to predict an individual's score on the Unified Parkinson Disease Rating Scale based on ASAP data. We observed a mean prediction error of approximately 3.5 UPDRS points, and the predicted score accounted for approximately 76% of the variability of the UPDRS. These results demonstrate that the ASAP protocol can measure differences for individuals who are clinically different. This indicates that the ASAP protocol may be able to measure changes with time in the motor signs of an individual with PD.

Exercise and manual auricular acupuncture: a pilot assessor-blind randomised controlled trial. (The acupuncture and personalised exercise programme (APEP) trial).

BACKGROUND: Evidence supports the use of exercise for chronic low back pain (CLBP); however, adherence is often poor due to ongoing pain. Auricular acupuncture is a form of pain relief involving the stimulation of points on the outer ear corresponding with specific body parts. It may be a useful adjunct to exercise in managing CLBP; however, there is only limited evidence to support its use with this patient group. METHODS/DESIGN: This study was designed to test the feasibility of an assessor-blind randomised controlled trial which assess the effects on clinical outcomes and exercise adherence of adding manual auricular acupuncture to a personalised and supervised exercise programme (PEP) for CLBP. No sample size calculation has been carried out as this study aims to identify CLBP referral rates within the catchment area of the study site. The researchers aim to recruit four cohorts of n = 20 participants to facilitate a power analysis for a future randomised controlled trial. A computer generated random allocation sequence will be prepared centrally and used to allocate participants by cohort to one of the following interventions: 1) six weeks of PEP plus manual auricular acupuncture; 2) six weeks of PEP alone. Both groups will also complete a further six weeks of self-paced exercise with telephone follow-up support. In addition to a baseline and exit questionnaire at the beginning and end of the study, the following outcomes will be collected at baseline, and after 7, 13 and 25 weeks: pain frequency and bothersomeness, back-specific function, objective assessment and recall of physical activity, use of analgesia, perceived self-efficacy, fear avoidance beliefs, and beliefs about the consequences of back pain. Since this is a feasibility study, significance tests will not be presented, and treatment effects will be represented by point estimates and confidence intervals. For each outcome variable, analysis of covariance will be performed on the data, conditioning on the baseline value. DISCUSSION: The results of this study investigating the adjuvant effects of auricular acupuncture to exercise in managing CLBP will be used to inform the design of a future multi-centre randomised controlled trial. TRIAL REGISTRATION: Current Controlled Trials ISRCTN94142364.

Total contact casting in treatment of diabetic plantar ulcers. Controlled clinical trial.

This study compared the treatment of total contact casting (TCC) with traditional dressing treatment (TDT) in the management of diabetic plantar ulcers. Forty patients with diabetes mellitus and a plantar ulcer but with no gross infection, osteomyelitis, or gangrene were randomly assigned to the TCC group (n = 21) or TDT group (n = 19). Age, sex, ratio of insulin-dependent diabetes mellitus to non-insulin-dependent diabetes mellitus, duration of diabetes mellitus, vascular status, size and duration of ulcer, and sensation were not significantly different between groups (P greater than .05). In the experimental group, TCC was applied on the initial visit, and subjects were instructed to limit ambulation to approximately 33% of their usual activity. Subjects in the control group were prescribed dressing changes and accommodative footwear and were instructed to avoid bearing weight on the involved extremity. Ulcers were considered healed if they showed complete skin closure with no drainage. Ulcers were considered not healed if they showed no decrease in size by 6 wk or if infection developed that required hospitalization. In the TCC group, 19 of 21 ulcers healed in 42 +/- 29 days; in the TDT group, 6 of 19 ulcers healed in 65 +/- 29 days. Significantly more ulcers healed (chi 2 = 12.4, P less than .05) and fewer infections developed (chi 2 = 4.1, P less than .05) in the TCC group. We conclude TCC is a successful method of treating diabetic plantar ulcers but requires careful application, close follow-up, and patient compliance with scheduled appointments to minimize complications.

Strength of the quadriceps femoris muscle and functional recovery after reconstruction of the anterior cruciate ligament. A prospective, randomized clinical trial of electrical stimulation.

Immediately after reconstruction of the anterior cruciate ligament, 110 patients were randomly assigned to treatment with high-intensity neuromuscular electrical stimulation (thirty-one patients), high-level volitional exercise (thirty-four patients), low-intensity neuromuscular electrical stimulation (twenty-five patients), or combined high and low-intensity neuromuscular electrical stimulation (twenty patients). All treatment was performed isometrically with the knee in 65 degrees of flexion. All of the patients participated in an intensive program of closed-kinetic-chain exercise. After four weeks of treatment, the strength of the quadriceps femoris muscle and the kinematics of the knee during stance phase were measured. Quadriceps strength averaged 70 per cent or more of the strength on the uninvolved side in the two groups that were treated with high-intensity electrical stimulation (either alone or combined with low-intensity electrical stimulation), 57 per cent in the group that was treated with high-level volitional exercise, and 51 per cent in the group that was treated with low-intensity electrical stimulation. The kinematics of the knee joint were directly and significantly (p < 0.05) correlated with the strength of the quadriceps. There was a clinically and statistically significant (p < 0.05) difference in the recovery of the quadriceps and the gait parameters according to the type of operation that had been performed: the patients who had had reconstruction of the anterior cruciate ligament with use of an autologous patellar-ligament graft did poorly compared with the other patients.

Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain.

STUDY DESIGN: A cross-sectional study was used to determine whether limited range of motion in the hip was present in 100 patients--one group with unspecified low back pain and another group with signs suggesting sacroiliac joint dysfunction. OBJECTIVES: To determine whether a characteristic pattern of range of motion in the hip is related to low back pain in patients and to determine whether such a pattern is associated with and without signs of sacroiliac joint dysfunction. SUMMARY OF BACKGROUND DATA: The sacroiliac joint is often considered a potential site of low back pain. Problems with the sacroiliac joint, as well as with the low back, have often been related to reduced or asymmetric range of motion in the hip. The correlation between sacroiliac joint dysfunction and hip range of motion, however, has not been thoroughly evaluated with reliable tests in a population of patients with low back pain. METHODS: Passive hip internal and external rotation goniometric measurements were taken by a blinded examiner, while a separate examiner evaluated the patient for signs of sacroiliac joint dysfunction. Patients with sacroiliac joint dysfunction were further classified as having a left or a right posteriorly tilted innominate. RESULTS: The patients with low back pain but without evidence of sacroiliac joint dysfunction had significantly greater external hip rotation than internal rotation bilaterally, whereas those with evidence of sacroiliac joint dysfunction had significantly more external hip rotation than internal rotation unilaterally, specifically on the side of the posterior innominate. CONCLUSIONS: Clinicians should consider evaluating for unilateral asymmetry in range of motion in the hip in patients with low back pain. The presence of such asymmetry in patients with low back pain may help identify those with sacroiliac joint dysfunction.

Reliability of isokinetic measurements of trunk muscle performance.

The purpose of this investigation was to assess the reliability of isokinetic trunk muscle performance. Sixty-one volunteers participated (29 men, 32 women; age range, 20-60 years). All subjects were without low-back symptoms at the time of testing. All testing was performed with the subject initially standing, using speeds of 60, 120, and 180 degrees per second. Ten repetitions of flexion and extension were performed reciprocally at each speed, with a 3-minute rest period between speeds. Test-retest intervals were 1 and 3 weeks from the initial test. Peak torque-to-body-weight ratios, extension-to-flexion ratios, and average work per repetition were calculated for each speed for flexion and extension. Data were analyzed with analysis of variance, intraclass correlation coefficients, and Pearson correlation coefficients. Intraclass correlation coefficient values ranged from .74 to .88 for measurements derived from peak torque, and from .88-.93 for measurements derived from work (with the exception of .69 for men at 180 degrees/sec). Standard error of measurements ranged from 8 to 32 ft-lb, with a tendency to increase with increasing speeds. It was concluded that, when using this protocol, isokinetic measurements of muscle function offer the clinician sensitive and reliable measurements of trunk muscle performance and that incorporating increased practice with women and longer rest periods with men may further decrease error associated with these isokinetic trunk strength measurements.

Body motion patterns during a novel repetitive wheel-rotation task. A comparative study of healthy subjects and patients with low back pain.

STUDY DESIGN: This study evaluated performance differences between patients with chronic low back pain and a control group during their performance of a novel functional capacity task. OBJECTIVE: To 1) evaluated strength and endurance differences between patients and control subjects, 2) test for movement pattern differences between these groups, and 3) evaluate how these patterns changed with repetitive performance of the wheel-turning task. SUMMARY OF BACKGROUND DATA: Despite increased emphasis on quantifying functional capacities, few well-controlled studies comparing the performances of patients with low back pain with those of control subjects have appeared in the literature, particularly for movement patterns. METHODS: Forty patients with low back pain and 40 control subjects performed a sustained isodynamic wheel turning task. This task was selected because it simultaneously combined several common pain-related movements. A set of kinematic measures to characterize the basic movement patterns during this task were developed. RESULTS: Control subjects produced significantly higher levels of static torque and completed significantly more wheel-turning repetitions. Patients with low back pain exhibited significantly less upper torso and pelvic motion, upper torso rotation, and lateral trunk flexion than those in the control group. CONCLUSION: The dissimilar movement strategies found between the patient and control groups suggests that factors beyond more global physical explanations (e.g., deconditioning) may be important in accounting for the large discrepancy between these groups regarding the amount of work performed. These findings, along with the basic kinematic patterns developed in this study, may have important implications for determining the efficacy of instruction in body mechanics and treatment outcome for patients with chronic low back pain.

Subjective measures and clinical decision making.

I have attempted to use Feinstein's model of clinimetric indexes and his criteria as a focus for further development of measures that in physical therapy are currently considered "soft" or "subjective". I feel this development will enhance the body of knowledge by objectifying a portion of clinical assessment (eg, the patient's complaints, "subjective" portion of the POMR's SOAP format) that is in tremendous need of quantification. By making these "soft" data "hard," I feel we will enhance the decision-making power of clinicians.

Are measures of function and disability important in low back care?

Currently, disablement due to low back syndrome (LBS) inflicts an extremely high cost to society, with yearly direct and indirect costs estimated in the billions of dollars. Patients with LBS often present a challenge for physical therapists trained in the evaluation of the physical nature of LBS. The psychosocial nature of a patient's complaint and the use of measures obtained from evaluation to guide patient management sometimes require interaction in a multidisciplinary environment. In this article, LBS will be discussed within the frameworks of Nagi's disablement pathway and an illness model described by Waddell. Both models suggest that to adequately treat LBS requires evaluation of the impairment, functional limitations, and disability using tools with adequate measurement characteristics. This article will focus on impairments and patient self-reports of quality of life and will discuss the relationship between impairments, functional limitations, and disability in LBS. Standardized quality of life measures are easily administered in everyday clinical settings and capture the patient's perceptions of the functional limitations and disability seen with LBS. Common self-reports are reviewed, and potential barriers to their use are discussed. Lacking an identifiable disease process in the majority of cases of LBS leaves most clinicians to deal with the impairments, functional limitations, and resultant disability. Physical therapists should, therefore, measure and gauge changes in all of these dimensions. To accomplish this, physical therapists must be willing to evaluate the dimensions of functional limitations and disabilities using tools that allow adherence to the same measurement standards (eg, reliability and validity) as those used to evaluate physical impairments.

The diagnostic process: examples in orthopedic physical therapy.

Diagnosis by the physical therapist has received increased attention in the physical therapy literature. The contributions thus far are in agreement that although physical therapists do not identify disease in the sense of pathology, they certainly can identify clusters of signs, symptoms, symptom-related behavior, and other data from patient history and other testing. These clusters can be labeled as classifications or diagnoses by physical therapists and can guide management of the patient. The purpose of this article is to discuss what has yet to be included in articles about diagnosis: the diagnostic process. We first acknowledge the complexity of the diagnostic process, reviewing the study of clinical diagnosis mostly from the field of medicine, including statistical as well as process-tracing approaches. We next discuss steps we believe are important to consider in order to interface the diagnostic process into entry-level training curricula, urging teachers and mentors of future physical therapists to rethink our emphasis on the problem-oriented medical record's "SOAP" type of approach as a clinical decision-making format. We next discuss error and clinical judgment and strategies to constructively deal with error in the clinical environment. We urge physical therapists to strive to reach a point at which we can (1) identify and classify patients in such a manner that allows for more efficient treatment management and (2) demonstrate such abilities in peer-reviewed publication form.

Two theories of muscle strength augmentation using percutaneous electrical stimulation.

Electrical stimulation of muscle is a commonly used, well-substantiated strategy that physical therapists use to augment strength in patients with muscle weakness. Two distinctly different theories of strength augmentation using percutaneous muscle stimulation are presented. The first theory proposes that augmentation of muscle strength with electrically elicited muscle contractions occurs in a similar manner to augmentation of muscle strength with voluntary exercise. Electrically elicited muscle contractions of relatively high intensity with low numbers of repetitions strengthen muscle proportionally to the external load on the muscle in a manner that is equivalent to voluntary contraction. The second theory proposes that augmentation of muscle strength using percutaneous stimulation is fundamentally different from augmentation of strength with voluntary exercise. This theory uses the physiological differences between electrically elicited and voluntary contractions, such as the reversal of motor unit recruitment order, as a basis for argument. Both theories are partially substantiated using published literature. Strategies for testing both theories are also presented.

Considerations for planning and conducting clinic-based research in physical therapy.

There is growing demand to increase the volume of clinic-based research in physical therapy. Special considerations, unique to the planning and conduct of clinic-based research, need to be addressed to increase the likelihood that these studies will be completed successfully. The purposes of this perspective are to discuss factors affecting clinic-based research and to offer suggestions for addressing these problems when designing and conducting research studies in a clinical setting. This perspective discusses issues such as patient management, determining the availability of target patient populations, acquiring support from physical therapists and physicians, reporting and managing research-related injury or illness, and modifying or terminating projects. Some of the points made in this perspective are illustrated using examples from the authors' experiences in conducting clinical research.

Physical therapy treatment choices for musculoskeletal impairments.

BACKGROUND AND PURPOSE: The primary goal of this investigation was to describe outpatient physical therapy treatments provided to patients with lumbar, cervical, or knee impairments. SUBJECTS: Patients in this analysis received outpatient physical therapy for a primary orthopedic complaint during July 1993 through June 1994 from one of 68 practices participating in the Focus on Therapeutic Outcomes database. Data were available on 2,598 completed physical therapy episodes of care provided by 141 therapists. METHODS: At each patient's discharge, the primary physical therapist gave information on the treatments provided to each patient during the initial, middle, and final thirds of the episode of therapy as well as information on primary source of reimbursement. Patients provided information on the date of onset of their symptoms or surgery. RESULTS: These outpatient physical therapy episodes of care were characterized by a diverse array of modalities, exercises, and manual therapy treatments. Treatment choices varied by type of impairment and across thirds of the episode. Fee-for-service versus managed care payment arrangements were associated with increased use of devices, therapeutic massage, strengthening, and endurance exercises. CONCLUSION AND DISCUSSION: The study's findings revealed that although physical agents were frequently used in physical therapy episodes of care, they were applied along with exercise and manual therapy interventions. Future research should relate specific treatments to variation in patient outcomes following physical therapy.

Selective criteria for successful long-term prosthetic use.

The purpose of this study was to identify criteria contributing to successful long-term prosthetic use in patients with an amputation secondary to vascular disease. All elderly patients with a unilateral below-knee amputation or an above-knee amputation, secondary to vascular disease, seen in our clinic between 1977 and 1982 were included in this telephone survey. Of those contacted, 37 of 38 below-knee amputees (BKAs) and 7 of 18 above-knee amputees (AKAs) still wore their prostheses at least part of every day (success). We used a two-tailed chi-square to compare the success of the BKAs with the success of the AKAs. The BKAs were successful more often (X2 = 24.81, df = 1, p less than .001). All AKAs also were characterized according to age, time from prescription, obesity, ambulatory status, strength, range of motion, sex, general compliance, and medical problems after prosthetic prescription. Of these criteria, only compliance and medical problems after prescription showed a significant difference between successful and nonsuccessful long-term AKA prosthetic users (X2 = 5.76, df = 1, p less than .05 for each criterion). As the demands of quality assurance and diagnostic related groupings increase, these results can assist the physical therapy clinician in setting realistic goals for the geriatric amputee and help predict if the patient will be a successful prosthetic user.

Comparative comfort of three waveforms used in electrically eliciting quadriceps femoris muscle contractions.

The purpose of this study was to compare the relative comfort levels of electrical stimulation having different waveforms, but otherwise identical current characteristics, delivered percutaneously to normal quadriceps femoris muscles contracting at the same intensity level. The quadriceps femoris muscles of 20 healthy subjects were stimulated to a torque level 60% of that obtained in a maximal voluntary isometric contraction, using pulsed current with a carrier frequency of 2,500 Hz, at 50 pulses per second of 10-msec pulse duration. Three different waveforms were used: sinusoidal, sawtooth (triangular), and square. The relative comfort level of each electrically elicited contraction for each waveform was determined for each subject using a 20-cm-long visual analog scale. The results showed that no one waveform was most comfortable (least uncomfortable) and the difference was significant in what the subjects perceived to be the most comfortable contraction, regardless of waveform (p less than .01). These results indicate that a subject's perception of discomfort changes as the waveform of stimulation varies and that individual preferences exist for different waveforms. Selection of the most comfortable waveform could prove beneficial when the intensity of muscle stimulation is increased.

Lumbar spinal stenosis.

Symptoms for spinal stenosis apparently result from an incongruity between the capacity and contents of the spinal nerve passages. These symptoms are most frequently seen in men in their fifth or sixth decade of life. Spinal extension generally exacerbates the claudication-type symptoms (lower-extremity pain and paresthesia), whereas spinal flexion diminishes these symptoms. Differential diagnosis is needed to rule out vascular claudication due to atherosclerosis. Decisions regarding surgery should be made based not only on diagnostic imaging but also on a thorough history and clinical examination.

Outcomes of patients with pelvic-ring fractures managed by open reduction internal fixation.

The purpose of this multiple-subject case report is to describe the physical impairments, disabilities, and handicaps of patients with multiple traumas and pelvic-ring fractures after management with open reduction internal fixation. Nineteen men and 12 women, with a mean age of 38+/-16 years (chi+/-SD), were interviewed and examined at least 1 year (chi+/-14.5 months) after sustaining multiple traumas, including an unstable pelvic-ring fracture that was repaired by open reduction internal fixation. Disabilities and handicaps were assessed using the Oswestry Low Back Pain Questionnaire and the Sickness Impact Profile (SIP). Assessments of physical performance consisted of lift capacity, the amount of forward bending, and gait. A descriptive analysis by age and pelvic fracture classification is reported. The < or = 50-year-old group had the best physical testing scores, except for the lifting test. The > 50-year-old group had the lowest scores. Subjects with B1-class "open-book" pelvic fractures had a tendency to score higher in individual SIP categories. The average SIP scores of 9.34+/-7.47 for the total SIP score, 7.79+/-6.93 for the physical dimension, and 8.24+/-9.61 for the psychosocial dimension represent mild disability. The mean Oswestry score of 13.26%+/-15.41% also represents mild disability. Some subjects demonstrated impairments, disabilities, and handicaps 1 year postoperatively, but for the most part the subjects recovered almost all lost function. The data and clinical management information can be used as a basis of comparison for treatment and research with these types of patients.

Peak torque-to-body weight ratios in the trunk: a critical analysis.

The purpose of this study was to document the relationships between body weight and isokinetic extension and flexion peak torque produced by the trunk musculature. Using a dynamometer, we collected isokinetic measurements during trunk flexion and extension at speeds of 60 degrees and 120 degrees/sec on 61 healthy subjects (29 men, 32 women; 20-60 years old) while standing. Extension and flexion peak torque measurements were calculated for each subject at each speed. Male and female subjects' data were analyzed separately. Each subject's body weight was paired with peak torque at each speed, and Pearson product-moment correlation coefficients (r) were calculated. The correlation coefficients ranged from .27 to .39 for extension and from .66 to .70 for flexion, establishing a positive linear relationship between body weight and each of the isokinetic measurements. Body weight accounted for very small proportions of the variance (as low as 7%-15% in extension isokinetic measurements). In attempting to use a client's body weight to predict isokinetic peak torque measurements, the clinician should be aware that a great deal of unaccounted for variance exists. We recommend that clinicians use other variables (eg, activity level, age) in addition to body weight to control for individual differences among healthy subjects when measuring isokinetic trunk extension muscle performance.

Association between direction of lateral lumbar shift, movement tests, and side of symptoms in patients with low back pain syndrome.

The purpose of this study was to determine the relationship between direction of lateral lumbar shift (LLS) and 1) the occurrence of symptoms during the side-bending movement test and 2) the location of symptoms in patients with low back pain syndrome (LBS). Twenty-four patients with LBS (17 male, 7 female) with an observable LLS were studied. Side-bending movement tests were performed bilaterally, and the results were recorded as positive if symptoms occurred during the movement. The location of symptoms (right side or left side) was obtained from the patient history. Use of the chi-square statistic revealed a statistically significant relationship between the direction of the LLS and the direction of the positive side-bending movement test. Seventeen tests (71%) were positive to the contralateral side of the LLS, and 5 (21%) were positive to the ipsilateral side. Two tests (8%) were negative in both directions. There was no significant relationship between the side of symptoms and the direction of the LLS. The determination of presence and direction of an LLS is necessary in certain physical therapy management approaches. Pain or restricted side-bending movement has been used to confirm the presence of an LLS. This study confirms the clinical usefulness of the side-bending movement test for determining the presence and direction of an LLS.

A treatment-based classification approach to low back syndrome: identifying and staging patients for conservative treatment.

We present a treatment-based classification approach to the conservative management of low back syndrome. The approach has three levels of classification based on historical information, behavior of symptoms, and clinical signs. We first distinguish patients whose conservative care can be managed predominantly and independently by physical therapists versus patients who require consultation with other services (eg, psychology) or who require referral because of possible serious nonmusculoskeletal pathology. Once patients who can be managed by physical therapists are identified, the next level of classification is to stage their condition with regard to severity. We propose three stages: stage I for patients in the acute phase where the therapeutic goal is symptom relief, stage II for patients in a subacute phase where symptom relief and quick return to normal function are encouraged, and stage III for selected patients who must return to activities requiring high physical demands and who demonstrate a lack of physical conditioning necessary to perform the desired activities safely. The remainder of the article focuses on a third level of classification for stage I only in which patients are classified into distinct categories that are treatment-based and that specifically guide conservative management. The entire approach is diagnosis based, with specific algorithms and decision rules as well as examples presented.