Investigating force-time characteristics of prone thoracic SMT and self-reported patient outcome measures: a feasibility study.

BACKGROUND: Spinal manipulative therapy (SMT) is commonly used to treat musculoskeletal conditions, including thoracic spine pain. Applying patient-specific force-time characteristics are believed to be important to improve SMT's effectiveness. Investigating SMT as part of a multimodal approach is fundamental to account for the complexity of chiropractic clinical practice. Therefore, pragmatic investigations balancing minimal disruptions to the clinical encounter at the same time as ensuring a robust data quality with rigorous protocols are needed. Consequently, preliminary studies are required to assess the study protocol, quality of data recorded and the sustainability of such investigation. Therefore, this study examined the feasibility of investigating SMT force-time characteristics and clinical outcome measures in a clinical setting. METHODS: In this mixed-methods study, providers recorded thoracic SMT force-time characteristics delivered to patients with thoracic spinal pain during regular clinical encounters. Self-reported clinical outcomes of pain, stiffness, comfort during the SMT (using an electronic visual analogue scale), and global rating of change scale were measured before and after each SMT application. Feasibility was quantitatively assessed for participant recruitment, data collection and data quality. Qualitative data assessed participants' perceptions on the impact of data collection on patient management and clinical flow. RESULTS: Twelve providers (58% female, 27.3 ± 5.0 years old) and twelve patients (58% female, 37.2 ± 14.0 years old) participated in the study. Enrolment rate was greater than 40%, data collection rate was 49% and erroneous data was less than 5%. Participant acceptance was good with both providers and patients reporting positive experience with the study. CONCLUSIONS: Recording SMT force-time characteristics and self-reported clinical outcome measures during a clinical encounter may be feasible with specific modification to the current protocol. The study protocol did not negatively impact patient management. Specific strategies to optimize the data collection protocol for the development of a large clinical database are being developed.

Effects of Distinct Force Magnitude of Spinal Manipulative Therapy on Blood Biomarkers of Inflammation: A Proof of Principle Study in Healthy Young Adults.

OBJECTIVES: The purpose of this preliminary study was to determine the influence of thoracic spinal manipulation therapy (SMT) of different force magnitudes on blood biomarkers of inflammation in healthy adults. METHODS: Nineteen healthy young adults (10 female, age: 25.6 ± 1.2 years) were randomized into the following 3 groups: (1) control (preload only), (2) single thoracic SMT with a total peak force of 400N, and (3) single thoracic SMT with a total peak force of 800N. SMT was performed by an experienced chiropractor, and a force-plate embedded treatment table (Force Sensing Table Technology) was used to determine the SMT force magnitudes applied. Blood samples were collected at pre intervention (baseline), immediately post intervention, and 20 minutes post intervention. A laboratory panel of 14 different inflammatory biomarkers (pro, anti, dual role, chemokine, and growth factor) was assessed by multiplex array. Change scores from baseline of each biomarker was used for statistical analysis. Two-way repeated-measures analysis of variance was used to investigate the interaction and main effects of intervention and time on cytokines, followed by Tukey's multiple comparison test (P ≤ .05). RESULTS: A between-group (800N vs 400N) difference was observed on interferon-gamma, interleukin (IL)-5, and IL-6, while a within-group difference (800N: immediately vs 20 minutes post-intervention) was observed on IL-6 only. CONCLUSION: In this study, we measured short-term changes in plasma cytokines in healthy young adults and found that select plasma pro-inflammatory and dual-role cytokines were elevated by higher compared to lower SMT force. Our findings aid to advance our understanding of the potential relationship between SMT force magnitude and blood cytokines and provide a healthy baseline group with which to compare similar studies in clinical populations in the future.

Progressive Resistance Training Program Characteristics in Rehabilitation Programs Following Hip Fracture: A Meta-Analysis and Meta-Regression.

Introduction: Older adults often experience incomplete recovery after a hip fracture. Rehabilitation programs with progressive resistance training are associated with improved functional recovery. This systematic review and meta-analysis with meta-regression a) evaluated resistance training characteristics reported in hip fracture rehabilitation programs, b) performed meta-analysis of resistance training impact on strength (primary outcome), gait and physical activity (secondary outcomes), and c) explored resistance training program characteristics associated with improved outcomes using meta-regression. Materials and Methods: Medline, EMBASE, CINAHLPLUS, and Web of Science Core Collection databases were searched (January2000-February2021). Randomized controlled trials including progressive resistance training rehabilitation programs after hip fracture surgery in adults ≥50 years old were included. Meta-analyses and exploratory meta-regression were performed. Results: Meta-analysis showed significant increases in strength (10 trials-728 participants; Standardized Mean Difference (SMD) [95%CI]; .40 [.02, .78]) immediately following program completion in intervention relative to control participants. Meta-analysis on 5 trials (n = 384) with extended follow up found no significant group differences (SMD = .47 [-.28, 1.23]) in strength. Center-based relative to home-based programs were associated with significantly greater improvements in strength (P < .05) as were programs where resistance training intensity was prescribed using one-repetition maximum relative to other exercise prescription methods (P < .05). In gait meta-analysis (n = 10 trials-704 participants), gait speed in intervention participants immediately after the program was significantly higher than control (SMD = .42 [.08, .76]) but this finding was not maintained in extended follow-up (n = 5 trials-240 participants; SMD = .6 [-.26, .38]). Higher resistance training intensity was associated with significant improvements in gait speed (P < .05). No meta-analysis was performed for the 3 heterogeneous studies reporting physical activity. Discussion: Progressive resistance training improved muscle strength and gait speed after hip fracture surgery in adults ≥50years old immediately after the program ended, but the longer-term impact may be more limited. Conclusions: Higher resistance training intensity and center-based programs may be associated with more improvement, but require further research.

Prevalence, Incidence, and Factors Associated With Non-Specific Chronic Low Back Pain in Community-Dwelling Older Adults Aged 60 Years and Older: A Systematic Review and Meta-Analysis.

Chronic low back pain (CLBP) is common among older adults. This systematic review aimed to summarize: (1) the prevalence and incidence of CLBP in older adults, and (2) demographic, psychological, and clinical factors positively/negatively associated with prevalence/incidence of CLBP among older adults. Four databases were searched to identify relevant publications. Ten studies (31,080 older adults) were included after being screened by 5 independent reviewers using predetermined criteria. The methodological quality of these studies was evaluated by standardized tools. The quality of evidence for all factors were appraised by modified GRADE for cohort studies. Twenty-eight and 1 factors were associated with a higher prevalence and a lower 5-year cumulative incidence of CLBP, respectively. No prognostic factor was identified. There was very limited to limited evidence that females, obesity, anxiety, depression, mental disorders, self-expectation of recovery, self-perceived health status, lifestyle (smoking, daily fluoride consumption), previous falls or lower body injury, retirement/disability due to ill health, family history of body pain, comorbidity (knee osteoarthritis, or chronic obstructive pulmonary disease with/without hypertension), weak abdominal muscles, leg pain, leg pain intensity, widespread pain, pain interference on functioning, use of pain medication, occupational exposure (driving for >20 years, or jobs involving bending/twisting for >10 years), disc space narrowing and severe facet osteoarthritis were significantly related to a higher prevalence of CLBP in older adults. However, very limited evidence suggested that intermediate level of leisure-time physical activity was associated with a lower prevalence of CLBP in older adults. Given the aging population and limited information regarding risk factors for CLBP in older adults, future high-quality prospective studies should identify relevant risk factors to help develop proper preventive and treatment strategies. PERSPECTIVE: Despite the high prevalence of non-specific chronic low back pain among older adults, there is only very limited to limited evidence regarding factors associated with a higher prevalence of chronic low back pain in this population. Given the aging population, high-quality prospective studies are warranted to address this gap.

Domains of Balance Training Delivered in Rehabilitation Programs Following Hip Fracture Surgery in Older Adults: A Systematic Review.

BACKGROUND AND PURPOSE: The aim of this systematic review was to assess the domains and characteristics of balance training (BT) interventions delivered in rehabilitation programs following hip fracture to identify potential treatment gaps. METHODS: Manual and electronic searches (Web of Science, Medline, EMBASE, CINAHL, and ProQuest) were conducted. We selected randomized controlled trials with older adults following hip fracture surgery that included either specific BT or gait, mobility, or transfer training. Two independent reviewers extracted data and rated the methodological quality using the Physiotherapy Evidence Database scale. A third reviewer provided consensus. Extracted BT data included balance domain, progression, frequency, duration, intensity, level of supervision, setting, and rehabilitation phase. RESULTS AND DISCUSSION: We included 17 trials from 19 studies; 11 studies were rated as moderate to high methodological quality, but only 8 were considered to have high-quality BT components. Half of the interventions included only one balance domain, with stability during movement being the most commonly included domain. The primary balance progression utilized was reducing hand support. Dual task, anticipatory postural adjustment, reactive strategies, and perceptual training domains were rarely included. Balance training duration and intensity were poorly described. Although most programs were home-based with minimal levels of supervision, a few extended beyond postacute phase of rehabilitation. CONCLUSION: Further consideration should be given to include more challenging BT domains with planned progressions to maximize patient recovery through hip fracture rehabilitation programs.

Perioperative pain management and chronic postsurgical pain after elective foot and ankle surgery: a scoping review.

PURPOSE: Chronic postsurgical pain (CPSP) can occur after elective mid/hindfoot and ankle surgery. Effective treatment approaches to prevent the development of CPSP in this population have not been extensively investigated. The impact of multimodal strategies to prevent CPSP following elective mid/hindfoot surgery is unknown because of both the heterogeneity of acute pain management and the lack of a recognized definition particular to this surgery. This review aimed to identify and evaluate current pain management strategies after elective mid/hindfoot and ankle surgery. SOURCES: Manual and electronic searches (MEDLINE, Embase, and Cochrane Library) were conducted of literature published between 1990 and July 2017. Comparative studies of adults undergoing elective mid/hindfoot and ankle surgery were included. Two reviewers independently reviewed studies and assessed their methodological quality. PRINCIPAL FINDINGS: We found seven randomized-controlled trials meeting our inclusion criteria. Interventions focused on regional anesthesia techniques such as continuous popliteal sciatic and femoral nerve blockade. Participants were typically followed up to 48 hr postoperatively. Only one study assessed pain six months following elective mid/hindfoot and ankle surgery. CONCLUSION: There is an overwhelming lack of evidence regarding CPSP and its management for patients undergoing elective mid/hindfoot and ankle surgery. The lack of a recognized and standard definition of CPSP after this group of surgeries precludes accurate and consistent evaluation.

RéSUMé: OBJECTIF: La douleur chronique post-chirurgicale (DCPC) peut survenir après une chirurgie non urgente de la section moyenne ou postérieure du pied, ou de la cheville. Les approches thérapeutiques efficaces pour prévenir l'apparition de DCPC dans cette population n'ont pas été examinées en profondeur. L'impact des stratégies multimodales pour prévenir la DCPC après une chirurgie non urgente de la section moyenne ou postérieure du pied est inconnu, tant en raison de l'hétérogénéité de la prise en charge de la douleur aiguë que du manque de définition reconnue spécifique à ce type de chirurgie. Ce compte-rendu a pour objectif d'identifier et d'évaluer les stratégies de prise en charge de la douleur actuellement utilisées après une chirurgie de la section moyenne ou postérieure du pied, ou de la cheville. SOURCES: Des recherches manuelles et électroniques (MEDLINE, Embase, et Librairie Cochrane) ont été menées dans la littérature publiée entre 1990 et juillet 2017. Les études comparatives portant sur des adultes subissant une chirurgie non urgente de la section moyenne ou postérieure du pied ou de la cheville ont été incluses. Deux chercheurs ont indépendamment passé en revue les études et évalué leur qualité méthodologique. CONSTATATIONS PRINCIPALES: Nous avons trouvé sept études randomisées contrôlées respectant nos critères d'inclusion. Les interventions se concentraient sur des techniques d'anesthésie régionale tels que les blocs continus des nerfs sciatiques poplités et fémoraux. Les participants bénéficiaient en général d'un suivi jusqu'à 48 h après l'opération. Une seule étude a évalué la douleur six mois après une chirurgie non urgente de la section moyenne ou postérieure du pied ou de la cheville. CONCLUSION: L'absence de données probantes est colossale en ce qui touche à la DCPC et à sa prise en charge pour les patients subissant une chirurgie non urgente de la partie moyenne ou postérieure et de la cheville. L'absence de définition normalisée et reconnue de la DCPC après ce type de chirurgie en exclut toute évaluation précise et cohérente.

The biological basis of degenerative disc disease: proteomic and biomechanical analysis of the canine intervertebral disc.

INTRODUCTION: In the present study, we sought to quantify and contrast the secretome and biomechanical properties of the non-chondrodystrophic (NCD) and chondrodystrophic (CD) canine intervertebral disc (IVD) nucleus pulposus (NP). METHODS: We used iTRAQ proteomic methods to quantify the secretome of both CD and NCD NP. Differential levels of proteins detected were further verified using immunohistochemistry, Western blotting, and proteoglycan extraction in order to evaluate the integrity of the small leucine-rich proteoglycans (SLRPs) decorin and biglycan. Additionally, we used robotic biomechanical testing to evaluate the biomechanical properties of spinal motion segments from both CD and NCD canines. RESULTS: We detected differential levels of decorin, biglycan, and fibronectin, as well as of other important extracellular matrix (ECM)-related proteins, such as fibromodulin and HAPLN1 in the IVD NP obtained from CD canines compared with NCD canines. The core proteins of the vital SLRPs decorin and biglycan were fragmented in CD NP but were intact in the NP of the NCD animals. CD and NCD vertebral motion segments demonstrated significant differences, with the CD segments having less stiffness and a more varied range of motion. CONCLUSIONS: The CD NP recapitulates key elements of human degenerative disc disease. Our data suggest that at least some of the compromised biomechanical properties of the degenerative disc arise from fibrocartilaginous metaplasia of the NP secondary to fragmentation of SLRP core proteins and associated degenerative changes affecting the ECM. This study demonstrates that the degenerative changes that naturally occur within the CD NP make this animal a valuable animal model with which to study IVD degeneration and potential biological therapeutics.

A newmethod to analyze the subjective visual vertical in patients with bilateral vestibular dysfunction

OBJECTIVE: The aim of this study was to assess the subjective visual vertical in patients with bilateral vestibular dysfunction and to propose a new method to analyze subjective visual vertical data in these patients. METHODS: Static subjective visual vertical tests were performed in 40 subjects split into two groups. Group A consisted of 20 healthy volunteers, and Group B consisted of 20 patients with bilateral vestibular dysfunction. Each patient performed six measurements of the subjective visual vertical test, and the mean values were calculated and analyzed. RESULTS: Analyses of the numerical values of subjective visual vertical deviations (the conventional method of analysis) showed that the mean deviation was 0.326±1.13º in Group A and 0.301±1.87º in Group B. However, by analyzing the absolute values of the subjective visual vertical (the new method of analysis proposed), the mean deviation became 1.35±0.48º in Group A and 2.152±0.93º in Group B. The difference in subjective visual vertical deviations between groups was statistically significant (p,<0.05) only when the absolute values and the range of deviations were considered. CONCLUSION: An analysis of the absolute values of the subjective visual vertical more accurately reflected the visual vertical misperception in patients with bilateral vestibular dysfunction.

Software para avaliação da subjetiva vertical visual: um estudo transversal observacional / Software for subjective visual vertical assessment: an observational cross-sectional study

A orientação espacial em relação ao eixo gravitacional é de suma importância para a manu tenção da postura, marcha e para a maioria das atividades motoras realizadas pelo ser humano. A subjetiva vertical visual é um exame que avalia a percepção individual de verticalidade. OBJETIVOS: Os objetivos deste estudo foram: (1) desenvolver um sistema virtual para avaliar a subjetiva vertical visual, (2) produzir uma ferramenta simples para a prática clínica e (3) medir os valores da subjetiva vertical visual em indivíduos saudáveis usando a nova ferramenta. Forma de estudo: estudo obser vacional transversal. MÉTODO: Trinta voluntários saudáveis realizaram a subjetiva vertical visual em ambas as condições, estática e dinâmica. O exame consistia em ajustar uma linha virtual na posição vertical usando o mouse do computador. Na condição estática, a linha virtual foi projetada em uma tela branca. Na condição dinâmica, círculos pretos giravam no sentido horário e anti-horário. Seis medidas foram feitas e o desvio médio em relação a vertical real, calculado. RESULTADOS: Os desvios médios da subjetiva vertical visual foram: estática -0,372º ± 1,21; dinâmica sentido horário 1,53º ± 1,80 e dinâmica sentido anti-horário -1,11º ± 2,46. CONCLUSÃO: Este software mostrou ser prático e preciso para ser inserido na rotina de exames clínicos.

Spatial orientation in relation to the gravitational axis is significantly important for the maintenance of the posture, gait and for most of the human's motor activities. The subjective visual vertical exam evaluates the individual's perception of vertical orientation. OBJECTIVES: The aims of this study were (1) to develop a virtual system to evaluate the subjective visual vertical exam, (2) to provide a simple tool to clinical practice and (3) to assess the subjective visual vertical values of healthy subjects using the new software. Study Design: observational cross-sectional study. METHODS: Thirty healthy volunteers performed the subjective visual vertical exam in both static and dynamic conditions. The exam consisted in adjusting a virtual line in the vertical position using the computer mouse. For the static condition, the virtual line was projected in a white background. For the dynamic condition, black circles rotated in clockwise or counterclockwise directions. Six measurements were taken and the mean deviations in relation to the real vertical calculated. RESULTS: The mean values of subjective visual vertical measurements were: static -0.372º; ± 1.21; dynamic clockwise 1.53º ± 1.80 and dynamic counterclockwise -1.11º ± 2.46. CONCLUSION: This software showed to be practical and accurate to be used in clinical routines.

The use of a neck brace does not influence visual vertical perception / O uso do colar cervical não influência na percepção de verticalidade visual

Subjective visual vertical (SVV) evaluates the individual's capacity to determine the vertical orientation. Using a neck brace (NB) allow volunteers' heads fixation to reduce cephalic tilt during the exam, preventing compensatory ocular torsion and erroneous influence on SVV result. OBJECTIVE: To analyze the influence of somatosensory inputs caused by a NB on the SVV. METHOD: Thirty healthy volunteers performed static and dynamic SVV: six measures with and six without the NB. RESULTS: The mean values for static SVV were -0.075º±1.15º without NB and -0.372º±1.21º with NB. For dynamic SVV in clockwise direction were 1.73º±2.31º without NB and 1.53º±1.80º with NB. For dynamic SVV in counterclockwise direction was -1.50º±2.44º without NB and -1.11º±2.46º with NB. Differences between measurements with and without the NB were not statistically significant. CONCLUSION: Although the neck has many sensory receptors, the use of a NB does not provide sufficient afferent input to change healthy subjects' perception of visual verticality.

A subjetiva vertical visual (SVV) avalia a capacidade do indivíduo determinar a posição vertical. O uso do colar cervical (CC) fixa a cabeça do voluntário, reduzindo a inclicação cefálica durante o exame e prevenindo a torção ocular compensatória que influencia na SVV. OBJETIVO: Analisar a influência de informações sometossensoriais causadas pelo uso de um CC na SVV. MÉTODO: Trinta voluntários saudáveis realizaram a SVV estática e dinâmica: seis medidas com e seis medidas sem o CC. RESULTADOS: O valor médio da SVV estática foi -0,075º±1,15º sem CC e -0,372º±1,21º com. Na SVV dinâmica no sentido horário foi 1,73º±2,31º sem CC e 1,53º±1,80º com. Na SVV dinâmica no sentido anti-horário foi -1,50º±2,44º sem CC e -1,11º±2,46º com. As diferenças entre as medidas com e sem CC não foram estatisticamente significativas. CONCLUSÃO: Apesar de o pescoço possuir inumeros receptores sensoriais, o uso do CC não fornece aferências suficientes para alterar a percepção de visual de verticalidade de voluntários saudáveis.

Proposta de avaliação fisioterapêutica para pacientes com distúrbio do equilíbrio postural / Proposal of physiotherapeutic evaluation for patients with balance disorders

INTRODUÇÃO: Disfunções no sistema vestibular são responsáveis por diversos sintomas como a tontura, vertigem e desequilíbrio, podendo estar associado ou não a outros sinais e sintomas. As disfunções centrais manifestam sintomas muito semelhantes aos das lesões periféricas, mas podem ser diferenciados por algumas características específicas como direção e duração do nistagmo. Tais sensações experimentadas pelos indivíduos acometidos causam um grande desconforto levando-os à restrição de movimentos, reduzindo sua participação em atividades domésticas e sociais. Os exercícios da reabilitação vestibular visam reduzir tais sintomas a fim de melhorar o equilíbrio e a estabilidade postural do indivíduo durante a realização das atividades previamente abandonadas. Para elaborar um programa de reabilitação vestibular é necessária uma avaliação completa e abrangente com o objetivo de encontrar as disfunções responsáveis pelo desequilíbrio postural e, consequentemente, planejar um tratamento adequado e eficaz. OBJETIVO: O objetivo do presente estudo foi revisar artigos existentes na literatura que descrevem testes, escalas e questionários usados para avaliação do equilíbrio postural e elaborar um roteiro de avaliação para pacientes com desequilíbrio postural. METODOLOGIA: Este trabalho revisou e analisou os testes, escalas e dados quantitativos para avaliação do equilíbrio postural. RESULTADOS E CONCLUSÃO: A partir desta análise foi proposto e elaborado um roteiro de avaliação para pacientes com distúrbio do equilíbrio postural que engloba desde a história do paciente até a reabilitação de testes específicos.

INTRODUCTION: Vestibular dysfunctions are responsible for many symptoms like dizziness, vertigo and posture imbalance, associated or not with other symptoms. Central vestibular dysfunction can cause symptoms that are similar to the ones caused by peripheral lesions, although they can be distinguished by specific characteristics such as the nystagmus direction and duration. These sensations that some injured people feel cause a wide distress leading to movements limitation, reducing their social and domestics activities participation. Exercises for vestibular rehabilitation tend to reduce the symptoms, improving the postural balance and stability during the activities previously abandoned. To elaborate a vestibular rehabilitation program a complete and contained evaluation is necessary to be able to focus in the principal problem and devise an adequate and effective treatment. OBJECTIVE: The aim of this study was to review articles in the literature that describes tests, scales and questionnaires used to evaluate the postural stability and elaborate an evaluating protocol for patients with postural imbalance. METHODS: This study reviewed and analyzed the evaluating methods found in the literature for the last 15 years and verified if they could quantify the patient’s data and symptoms. RESULTS AND CONCLUSION: Based on this analysis, an evaluating protocol for patients with postural stability dysfunction was elaborated that approaches the patients history and specific tests.