3D anatomy of the supraorbital and greater occipital nerve trajectories.

PURPOSE: This research aims to enhance understanding of the anatomy of the supraorbital nerve (SON) and greater occipital nerve (GON), focusing on their exit points, distal trajectories, and variability, utilizing a novel 3D representation. METHODS: Ten cadaveric specimens underwent meticulous dissection, and 3D landmarks were registered. Models were generated from CT scans, and a custom 3D method was employed to visualize nerve trajectories. Measurements, including lengths and distances, were obtained for the SON and GON. RESULTS: The SON exhibited varied exit points, with the lateral branches being the longest. The GON showed distinct branching patterns, which are described relative to various anatomical reference points and planes. No systematic left-right differences were observed for either nerve. 3D analysis revealed significant interindividual variability in nerve trajectories. The closest approximation between the SON and GON occurred between lateral branches. CONCLUSION: The study introduces a novel 3D methodology for analyzing the SON and GON, highlighting considerable anatomical variation. Understanding this variability is crucial for clinical applications and tools targeting the skull innervation. The findings serve as a valuable reference for future research, emphasizing the necessity for personalized approaches in innervation-related interventions.

Morphologic and Morphometric Measurements of the Foramen Ovale: Comparing Digitized Measurements Performed on Dried Human Crania With Computed Tomographic Imaging. An Observational Anatomic Study.

The foramen ovale (FO) of the sphenoid bone is clinically important for the interventional treatment of trigeminal neuralgia. Percutaneous procedures applied to treat the chronic pain condition typically involve the cannulation of this oval-like foramen located at the base of the skull. Anatomic variations of the FO have been reported to contribute to difficulties in the cannulation of this structure. Computed tomography (CT) can help the surgeon improve the accuracy and safety of the intervention. However, even with navigation technology, unsuccessful cannulation of the FO has been reported. The aim of this observational anatomic study was to define morphometric and morphologic data of the FO and to investigate for potential differences between measurements taken on dried human crania and digitized measurements of the FO measured on CT images. One hundred eighteen FOs were evaluated. Twenty FOs underwent CT scanning. The mean length of the foramen was 7.41±1.3 mm on the left side and 7.57±1.07 mm on the right. The mean width of the foramen was 4.63±0.86 mm on the left side and 4.33±0.99 on the right. The mean area on the left side was 27.11±7.58 and 25.73±6.64 mm 2 on the right. No significant left-right differences were found for any of these dimensions. The most important conclusion that we can draw is that the measurements can indeed be performed on CT images to obtain an accurate picture of the morphology. Considering the surgical importance of the FO and taking into consideration the limitations this study added to scientific knowledge, this study was constructive as far as neurosurgeons and anatomists are concerned.

Variability of Active Cervical Range of Motion Within and Between Days in Healthy Participants: A Prospective Observational Study.

OBJECTIVE: The purpose of this study was to determine the intraday and interday variability and systematic change over the day of active cervical range of motion (aCROM) measurements in asymptomatic persons using a clinically applicable measurement device. METHODS: A prospective observational study was performed. Sixteen adults (8 men and 8 women, median age 51 years) without neck pain in the last 3 months were recruited in 2 physiotherapy practices. Active cervical range of motion was estimated using the Apple iPhone application "3D Range of Motion." Measurements were performed 3 times a day for 7 days and spread over a period of 3 weeks. Mean values of aCROM were calculated. Intraday and interday variability was estimated by calculating limits of agreement. RESULTS: The limits of agreement for intraday variability ranged from ±12.1° for left rotation to ±15.5° for total rotation. For interday variability, the limits of agreement ranged from ±14.2° for right rotation to ±20.1° for total rotation. No systematic change over the day was found. CONCLUSION: This study showed substantial intraday and interday variability of aCROM measurements in asymptomatic people. No trend toward an increased or decreased aCROM was observed during the course of the day. When interpreting aCROM values, clinicians should consider the degree of variation in aCROM measurements over time.

Effects of Rehearsal Time and Repertoire Speed on Upper Trapezius Activity in Conservatory Piano Students.

BACKGROUND: Repetitive piano play may overload neck and shoulder muscles and tendons, leading to playing-related musculoskeletal disorders (PRMDs). METHODS: In this pilot study (EMG data of the extensor carpi radialis have been published separately), surface electromyography (sEMG) activity of the upper trapezius (UT) was captured in 10 conservatory piano students while playing a fast and a slow music score selected from the individual's repertoire, each 3 minutes long. Measurements were made at baseline and again after 2 hrs and 4 hrs of rehearsal time of the piano études. The amplitude of the sEMG signal was processed by a smoothing algorithm, and the frequency component with a non-orthogonal wavelets procedure. Amplitude of the sEMG was expressed in percent of maximal voluntary contraction (%MVC) at baseline, and the frequency component using median frequency based on the frequency band powers. Statistical analysis encompassed repeated measures ANOVAs for the amplitude and frequency components of the sEMG signal (set at 5%). The students also rated the intensity of rehearsals using a visual analog scale (VAS). RESULTS: The median values for the %MVC presented a global mean for the left trapezius of 5.86 (CI90% 4.71, 6.97) and 5.83 for the right trapezius (CI90% 4.64, 7.05). The rehearsals at moderate intensity increased the amplitude of %MVC of the upper trapezius by around 50% and decreased the median frequency. CONCLUSIONS: Playing faster presented higher magnitudes of activity of the upper trapezius. The decrease in the median frequency in response to long rehearsals may be a sign of muscle fatigue.

Cervical kinematics estimated by finite helical axis behaviour differs in patients with neck related problems as compared to healthy controls.

Purpose The present study analyses the kinematics of patients with neck problems and healthy controls by estimation of Finite Helical Axis behaviour. A cross sectional study design was used to investigate whether FHA behaviour differs due to neck problems. METHODS: 584 subjects were recruited from private and ambulatory institutional physiotherapy practices. Among these 171 patients with neck related problems were selected based on referral diagnosis by primary care general practitioners. Cervical kinematics were compared based on minimal convex hull, path length and mean angle of the Finite Helical Axis distribution as well as on the helical angle. Three active planar motions were registered: flexion-extension, axial rotation and lateral bending. RESULTS: Patients demonstrated a significantly reduced and less variable behaviour of the Finite Helical Axis during active flexion-extension and axial rotation motions as compared to healthy individuals and lateral bending. CONCLUSION: Patients with neck related problems demonstrate a more restricted motion behaviour with less variability in Finite Helical Axis distribution and orientation during active planar motions. At present it is not clear whether these kinematic differences are the result or the cause of dysfunction. These slides can be retrieved under Electronic Supplementary Material.

Changes in Vertebral Arterial Blood Flow During Premanipulative Tests in Participants With Upper Cervical Spine Motion Restriction.

OBJECTIVE: The purpose of the present study was to measure changes in blood flow velocity and volume flow rate (VFR) in the contralateral vertebral artery (VA) during end-range rotation and pre-manipulative hold at C1-C2 and to compare these measurements between participants with and without C1-C2 range of motion (ROM) restriction. METHODS: This research was approached as an exploratory study and designed as a parallel noninterventional controlled trial with intentionally equal allocation, for studying diagnostic tests. Fifteen women and 13 men (mean age 44) were recruited (volunteer sample) in physiotherapy clinics. No participant had any current neurologic or vertebrobasilar insufficiency symptoms. The measurements of 13 participants with a limited ROM C1-C2 and 15 with no limitation were compared. Blood flow velocity and VFR in the contralateral VA were measured using color duplex Doppler imaging in 3 neck positions: neutral, maximal rotation, and pre-manipulative hold of C1-C2. RESULTS: Pre-manipulative hold significantly (P < .01) decreased all blood flow velocity parameters and VFR, mainly in the left VA. End-range rotation showed a significant (P < .05) decrease in the peak systolic velocity in the left VA. No significant differences were found between participants grouped by the presence or absence of a C1-C2 ROM restriction. CONCLUSION: A C1-C2 rotational ROM restriction does not appear associated with change in a significantly reduced VA blood flow due to the neck position.

Effects of Rehearsal Time and Repertoire Speed on Extensor Carpi Radialis EMG in Conservatory Piano Students.

BACKGROUND: Repetitive actions while playing piano may overload forearm muscles and tendons, leading to playing-related musculoskeletal disorders (PRMDs), including lateral epicondylitis. METHODS: In this pilot study, surface electromyography (sEMG) activity of the extensor carpi radialis (ECR) was captured in 10 conservatory piano students while playing a fast and a slow music score selected from the individual's repertoire, each 3 minutes long. Measurements were made at baseline and again after 2 hrs and 4 hrs of rehearsal time of the piano études. The amplitude of the sEMG signal was processed by a smoothing algorithm, and the frequency component with a non-orthogonal wavelets procedure. Amplitude of the sEMG was expressed in percent of maximal voluntary contraction (%MVC) at baseline. Statistical analysis encompassed 2-way repeated measures ANOVAs for the amplitude and frequency components of the sEMG signal (a set at 5%). The students also rated the intensity of rehearsals using a VAS. RESULTS: The ECR presented with a mean amplitude of 23%MVC for the slow scores, which increased significantly to 36%MVC for the fast scores. The sEMG signal presented a significant though small decrease of 1.9%MVC in amplitude between baseline and 4 hrs of rehearsal time and no shift in frequency, which may indicate that the rehearsals were held at a physiological steady-state and suggesting optimization or complementary muscle loading. CONCLUSIONS: These data accentuated that the loading of the ECR (as reflected in the amplitude component) was higher than that seen for computer keyboard workers. The augmented loading of the ECR and reduced blood flow to forearm muscles may be a factor in the development of PRMDs in pianists.

Body mass prediction from femoral volume and sixteen other femoral variables in the elderly: BMI and adipose tissue effects.

OBJECTIVES: The frequently used prediction equations of body mass do not seem appropriate for elderly individuals. Here, we establish the relationship between femoral dimensions and known body mass in elderly individuals in order to develop prediction formulas and identify the factors affecting their accuracy. MATERIALS AND METHODS: The body mass linear least-squares regression is based on 17 femoral dimensions, including femoral volume, and 66 individuals. Body proportion and composition effects on accuracy are analyzed by means of the body mass index (BMI) and on a subset sample (n = 25), by means of the masses of adipose, bone and muscle tissues. RESULTS: Most variables significantly reflect body mass. Among them, six dimensions (e.g., biepicondylar breadth, femoral volume, and head femoral diameter) present percent standard errors of estimate ranging from 9.5 to 11% (r = 0.72-0.81) in normal BMI samples. Correlations are clearly lower in samples with normal and abnormal BMI [r = 0.38-0.58; % of standard error of estimate (SEE) = 17.3-19.6%] and not significantly correlated in females (femoral volume) who present high proportions of abnormal BMI and adipose tissue. In the subset, femoral volume is well correlated with bone mass (r = 0.88; %SEE = 7.9%) and lean body mass (r = 0.67; %SEE = 17.2%). DISCUSSION: Our body mass estimation equations for elderly individuals are relevant since relatively low correlations are recurrent in studies using younger individuals of known body mass. However, age, sex, lifestyle, and skeleton considerations of studied populations can provide information about the relevance of the body mass estimation, which is dependent on the BMI classification and the proportion of adipose tissue. Our general considerations can be used for studies of younger individuals.

3-Dimensional Cervical Movement Characteristics and the Influence of Thoracic Treatment on a Subgroup of Acute Neck Pain Patients.

OBJECTIVE: The purpose of this study was to investigate the influence of thoracic high-velocity low-amplitude thrust (HVLAT) manipulation on quantitative and qualitative 3-dimensional cervical spine kinematic patterns in a subgroup of patients with acute neck pain. METHODS: Thirty patients with acute neck pain, aged 20 to 59, received a thoracic HVLAT manipulation. Three-dimensional kinematics of the cervical spine were registered pretreatment and posttreatment using an electromagnetic tracking system. Quantitative and qualitative parameters were calculated for axial rotation, lateral bending, and flexion-extension movement. Subjective pain ratings were measured with the visual analogue scale and the Neck Disability Index and were collected pretreatment and posttreatment. RESULTS: After treatment, the range of motion of the main motion improved significantly for axial rotation (P = .034), lateral bending (P < .001), and flexion-extension (P = .031). Although for axial rotation as the main motion, the smoothness of the flexion-extension movement improved significantly after treatment (P = .036), the reverse was true for flexion-extension as the main motion. Visual analogue scale scores exhibited a statistically (P < .001) and clinically significant reduction of pain sensation. The mean change in Neck Disability Index scores only exhibited a statistically significant improvement 1 week after treatment. CONCLUSION: Thoracic HVLAT manipulation led to positive changes in quantitative and qualitative aspects of 3-dimensional cervical spine kinematics. Because of the 1-intervention group design, external factors influencing the healing process could not be eliminated.

To What Degree Does Active Cervical Range of Motion Differ Between Patients With Neck Pain, Patients With Whiplash, and Those Without Neck Pain? A Systematic Review and Meta-Analysis.

OBJECTIVES: To quantify differences in active cervical range of motion (aCROM) between patients with neck pain and those without neck pain, in patients with whiplash-associated disorders (WADs) and nontraumatic neck pain, and in patients with acute complaints versus those with chronic complaints. DATA SOURCES: Seven bibliographic databases were searched from inception to April 2015. In addition, a manual search was performed. STUDY SELECTION: Full articles on a numerical comparison of aCROM in patients with neck pain and asymptomatic control persons of similar ages were included. Two reviewers independently selected studies and assessed risk of bias. DATA EXTRACTION: Two reviewers extracted the data. Pooled mean differences of aCROM were calculated using a random-effects model. DATA SYNTHESIS: The search yielded 6261 hits; 27 articles (2366 participants, 13 low risk of bias) met the inclusion criteria. The neck pain group showed less aCROM in all movement directions compared with persons without neck pain. Mean differences ranged from -7.04° (95% CI, -9.70° to -4.38°) for right lateral bending (11 studies) to -89.59° (95% CI, -131.67° to -47.51°) for total aCROM (4 studies). Patients with WADs had less aCROM than patients with nontraumatic neck pain. No conclusive differences in aCROM were found between patients with acute and patients with chronic complaints. CONCLUSIONS: Patients with neck pain have a significantly decreased aCROM compared with persons without neck pain, and patients with WADs have less aCROM than those with nontraumatic neck pain.

Segond fracture: involvement of the iliotibial band, anterolateral ligament, and anterior arm of the biceps femoris in knee trauma.

OBJECTIVE: To evaluate the involvement of the iliotibial band (ITB), the anterolateral ligament (ALL), and the anterior arm of the biceps femoris in MRI-diagnosed Segond fracture and to evaluate other associated findings of Segond fracture. MATERIALS AND METHODS: We retrospectively reviewed the MRI of 13 cases of Segond fracture. The studies included proton density-weighted, T2-weighted, and proton density-weighted with fat saturation images in the three planes. We studied 2 cadaveric specimens with emphasis on the ALL. One cadaveric specimen was dissected while the other was sectioned in the sagittal plane. RESULTS: The mean age of the patients was 36 years (range, 17-52). There were 7 men and 6 women. The mean size of the Segond bone fragment was 8 × 10 × 2 mm. The distance from the tibia varied from 2 to 6 mm. Associated findings included anterior cruciate ligament (ACL) tear (n = 13), medial collateral ligament (MCL) tear (n = 8), meniscocapsular tear of the posterior horn of the medial meniscus (n = 5), and posterolateral corner involvement (n = 4). Bone marrow edema involved the mid-lateral femoral condyle and the posterior tibial plateau on both the medial and the lateral side. Edema at the Segond area was seen, but was limited. Fibular head edema was also seen. The ITB (11 out of 13) and ALL (10 out of 13) inserted on the Segond bone fragment. The anterior arm of the biceps tendon did not insert on the Segond fracture. CONCLUSION: Associated findings of Segond fracture include ACL tear, MCL tear, medial meniscus tear, and posterolateral corner injury. Both the ITB and the ALL may be involved in the Segond avulsion. The anterior arm of the biceps femoris tendon is not involved.

Reproducibility of the kinematics in rotational high-velocity, low-amplitude thrust of the upper cervical spine: a cadaveric study.

OBJECTIVE: This study aimed to investigate the reproducibility of the kinematics in rotational high-velocity, low-amplitude (HVLA) thrust of the upper cervical spine. METHODS: Twenty fresh human cervical specimens were studied in a test-retest situation with 2 manual therapists. Kinematics of C1-C2 and C0-C1 were examined during segmental rotational HVLA manipulation through an ultrasound-based tracking system. The thrust moment was analyzed by 3-dimensional aspects: the range of motion of axial rotation, flexion-extension, lateral banding, and the cross-correlation between the axial rotation and the coupled lateral banding components. RESULTS: During rotational HVLA thrust on C1-C2, the main axial rotation demonstrates an intraexaminer relationship varying from almost perfect to fair (intraclass correlation coefficient =0.71; intraclass correlation coefficient = 0.35) and a substantial interexaminer correlation of 0.73. CONCLUSIONS: This study showed substantial levels of reliability for the main axial rotation component of segmental manual rotational HVLA thrust on C1-C2. Intra- and interrater reliability for flexion-extension, lateral bending, and cross-correlation was low.

Ultrasound of the knee with emphasis on the detailed anatomy of anterior, medial, and lateral structures.

OBJECTIVE: To describe the detailed ultrasound anatomy of the anterior, medial, and lateral aspects of the knee and present the ultrasound examination technique used. MATERIALS AND METHODS: We present ultrasound using images of patients, volunteer subjects, and cadaveric specimens. We correlate ultrasound images with images of anatomical sections and dissections. RESULTS: The distal quadriceps tendon is made up of different laminas that can be seen with ultrasound. One to five laminas may be observed. The medial retinaculum is made up of three anatomical layers: the fascia, an intermediate layer, and the capsular layer. At the level of the medial patellofemoral ligament (MPFL) one to three layers may be observed with ultrasound. The medial supporting structures are made up of the medial collateral ligament and posterior oblique ligament. At the level of the medial collateral ligament (MCL), the superficial band, as well as the deeper meniscofemoral and meniscotibial bands can be discerned with ultrasound. The posterior part, corresponding to the posterior oblique ligament (POL), also can be visualized. Along the posteromedial aspect of the knee the semimembranosus tendon has several insertions including an anterior arm, direct arm, and oblique popliteal arm. These arms can be differentiated with ultrasound. Along the lateral aspect of the knee the iliotibial band and adjacent joint recesses can be assessed. The fibular collateral ligament is encircled by the anterior arms of the distal biceps tendon. Along the posterolateral corner, the fabellofibular, popliteofibular, and arcuate ligaments can be visualized. CONCLUSION: The anatomy of the anterior, medial, and lateral supporting structures of the knee is more complex than is usually thought. Ultrasound, with its exquisite resolution, allows an accurate assessment of anatomical detail. Knowledge of detailed anatomy and a systematic technique are prerequisites for a successful ultrasound examination of the knee.

Distal insertions of the semimembranosus tendon: MR imaging with anatomic correlation.

OBJECTIVE: The purpose of this study is to investigate the distal insertions of the semimembranosus tendon with MR imaging, correlated with findings in cadavers. MATERIALS AND METHODS: Four fresh cadaveric specimens were studied with 3-T MR imaging. Sequences included proton density (PD) sequences (TE, 13; TR, 4957; FOV, 170 × 170; matrix, 424 × 413; NA, 2; slice thickness, 2.5 mm) in the axial, coronal, and sagittal planes and 3D fast field echo (FFE) sequences (TR 9.4; TE 6.9; FOV, 159 × 105; matrix, 200 × 211; NA, 2; slice thickness, 0.57 mm). One specimen was dissected and three specimens were sectioned with a bandsaw in the axial, coronal, and sagittal plane. The sections were photographed and correlated with MR images. To standardize the analysis, the semimembranosus muscle and tendon were assessed at seven levels for the axial sections, and at three levels for the coronal and sagittal sections. RESULTS: Anatomic dissection revealed six insertions of the distal semimembranosus tendon: direct arm, anterior arm, posterior oblique ligament extension, oblique popliteal ligament extension, distal tibial expansion (popliteus aponeurosis), and meniscal arm. Axial MR images showed five of six insertions: direct arm, anterior arm, oblique popliteal ligament extension, posterior oblique ligament extension, and distal tibial expansion. Sagittal MR images showed four of six insertions: direct arm, anterior arm, oblique popliteal ligament arm, and distal tibial expansion. Sagittal MR images were ideal for showing the direct arm insertion, but were less optimal than the axial images for showing the other insertions. The anterior arm was seen but volume averaging was present with the gracilis tendon. Coronal MR images optimally revealed the anterior arm, although magic angle artifact was present at its posterior aspect. The common semimembranosus tendon and meniscal arm were also well depicted. The division in anterior arm, direct arm, and oblique popliteal ligament arm was poorly seen on coronal images due to volume averaging. CONCLUSIONS: Although the anatomy of the distal semimembranosus tendon is complex, six different semimembranosus insertions can be identified on routine proton density and FFE sequences at 3 T. Analysis of images at defined levels in the three imaging planes simplifies MR interpretation of the anatomy of the distal semimembranosus tendon.

Bony palmar ridges of the phalanges of the human fingers.

PURPOSE: On imaging studies, bony ridges can be seen at the palmar aspect of the phalanges of the fingers. Our purpose was to address the following: (1) which structures insert on to the ridges and what is the histological appearance? (2) Is there a difference between the different fingers? (3) Is there a correlation between the ridges and age? MATERIALS AND METHODS: Two observers retrospectively evaluated 270 radiographs (135 men; 135 women; mean age 44 years), and 33 CT scans (22 men; 11 women; mean age 46 years). Three cadaveric hands were also studied. The ridges were graded using a 4-point scale. A Chi-square test was used to compare the different fingers (p < 0.05) and to study the prominence of the ridges in relation to age (p < 0.05). RESULTS: On histology with routine stains the A2 pulley was inserted on the ridges of the proximal phalanx, and the flexor superficialis and A4 pulley on the ridges of the middle phalanx. On histology, the insertion showed a transition zone consisting of fibrocartilage. The prominence of the ridges was significantly different between fingers with III and IV categorized higher than II and III. There was a significant correlation with age for all fingers except for the middle phalanx of II and III. CONCLUSION: The bony palmar ridges have characteristics of enthesophytes. They correspond to the insertion site of the A2 pulley, and the flexor superficialis tendon and A4 pulley, at the proximal and middle phalanx, respectively. The ridges become more prominent with age, and their prominence is different between the fingers with III and IV categorized higher than II and V.

Exploring reliable photogrammetry techniques for 3D modeling in anatomical research and education.

In anatomical research and education, three-dimensional visualization of anatomical structures is crucial for understanding spatial relationships in diagnostics, surgical planning, and teaching. While computed tomography (CT) and magnetic resonance imaging (MRI) offer valuable insights, they are often expensive and require specialized resources. This study explores photogrammetry as an affordable and accessible approach for 3D modeling in anatomical contexts. Two photogrammetry methods were compared: conventional open-source software (Colmap) and Apple's RealityKit Object Capture. Human C3 vertebrae were imaged with a 24 MP camera, with and without a cross-polarization filter. Reconstruction times, vertex distances, surface area, and volume measurements were compared to CT scans. Results revealed that the Object Capture method surpassed the conventional approach in reconstruction speed and user-friendliness. Both methods exhibited similar vertex distance from reference mesh and volume measurements, although the conventional approach produced larger surface areas compared to CT-based models. Cross-polarization filters eliminated the need for pre-processing and improved outcomes in challenging lighting conditions. This study demonstrates that photogrammetry, especially Object Capture, as a reliable and time-efficient tool for 3D modeling in anatomical research and education. It offers accessible alternatives to traditional techniques with advantages in texture mapping. While further validation of various anatomical structures is required, the accessibility and cost-effectiveness of photogrammetry make it a valuable asset for the field. In summary, photogrammetry would have the potential to revolutionize anatomical research and education by providing cost-effective, accessible, and accurate 3D modeling. The study underscores the promise of advancing anatomical research and education through the integration of photogrammetry with ongoing improvements in user-friendliness and accessibility.

Impact of direct access on the quality of primary care musculoskeletal physiotherapy: a scoping review from a patient, provider, and societal perspective.

Introduction: Worldwide many countries provide direct access in physiotherapy. The aim of this scoping review was to synthesize the available evidence on the quality of primary care musculoskeletal physiotherapy from different perspectives. Methods: Systematic searches were conducted in three databases up to September 2022. Studies were included when regarding assessment of at least one of the following perspectives: patient (quality of Life, patient satisfaction, pain, functioning, adverse events), provider (treatment compliance, responsibility, liability, status, prestige, job satisfaction), and society (number of referrals, amount of medical imaging, medication use, number of sessions needed for rehabilitation, and overall costs and cost-effectiveness). Selection and methodological quality assessment of systematic reviews were performed. Data extraction and analysis were performed separately for systematic reviews and individual primary studies. Results: Five systematic reviews as well as 17 primary studies were included. From a patient perspective, no significant effect of direct access was found for pain and a tendency in favour of direct access was found for quality of life, functioning, and well-being. Concerning providers, higher treatment compliance was found in direct access to physiotherapy and decision-making was more accurate. From a societal perspective, significant differences in favour of direct access physiotherapy were found for waiting time, prescribed medication, and medical imaging. In addition, there was a tendency towards lower health care costs. Conclusions: Emerging evidence suggests that direct access physiotherapy could provide at least equal quality of care for patients and better opportunities for providers and the society on selected outcomes.

Automated analysis of trapeziometacarpal joint kinematics using four-dimensional computed tomography.

The aim of this study was to develop an automated approach model to define in vivo kinematics of the trapeziometacarpal (TMC) joint using four-dimensional computed tomography. A total of 15 healthy volunteers were included and their TMC joint kinematics were studied during a retropulsion-opposition-retropulsion movement. We used cardan angles estimated from transformation matrices using a ZYX-decomposition and analysed the motion of the thumb metacarpal relative to the trapezium, the thumb metacarpal relative to the index metacarpal, and the trapezium relative to the index metacarpal. The study also included an analysis of the joint hysteresis effect and a joint proximity model that estimated the joint contact area during a retropulsion-opposition-retropulsion movement. The automated approach significantly decreased the time needed to analyse each case and makes this model applicable for further research on TMC kinematics.

Skeletal Muscle Echo Intensity Values Differ Significantly across Ultrasound Parameter Settings.

Echo intensity determined by muscle ultrasound has been proposed as an efficient method for the assessment of muscle quality. The influence of changing ultrasound parameter settings on echo intensity values was assessed using a standardized approach. In this repeated measures cross-sectional study, sixteen repeated scans of rectus femoris, gracilis, and rectus abdominis were taken in 21 middle-aged persons with a portable Mindray M7 premium ultrasound machine equipped with a linear 5.0-10.0 MHz transducer. The settings of three parameters were fixed: gain, depth, and frequency. The settings of the following adjustable parameters were changed over their entire range: dynamic range, gray map, line density, persistence, and IClear. Repeated measures analyses were performed to evaluate the effect of changing the settings on echo intensity values. In all three muscles, dynamic range, gray map, and IClear correlated significantly (rrm-values ranging between -0.86 and 0.45) with echo intensity. In all three muscles, the echo intensity values differed significantly across the dynamic range (p < 0.013), gray map (p < 0.003), and IClear (p < 0.003). In middle-aged subjects, echo intensity values of lower limb and trunk muscles are significantly related to ultrasound parameters and significantly differ across their respective setting range. For the assessment of muscle quality through ultrasound, it is suggested to fix parameter settings within their midrange in order to minimize the effect of setting-dependent factors on EI values.

Investigating patellar motion using weight-bearing dynamic CT: normative values and morphological considerations for healthy volunteers.

BACKGROUND: Patellar instability is a well-known pathology in which kinematics can be investigated using metrics such as tibial tuberosity tracheal groove (TTTG), the bisect offset (BO), and the lateral patellar tilt (LPT). We used dynamic computed tomography (CT) to investigate the patellar motion of healthy subjects in weight-bearing conditions to provide normative values for TTTG, BO, and LPT, as well as to define whether BO and LPT are affected by the morphology of the trochlear groove. METHODS: Dynamic scanning was used to acquire images during weight-bearing in 21 adult healthy volunteers. TTTG, BO, and LPT metrics were computed between 0° and 30° of knee flexion. Sulcus angle, sulcus depth, and lateral trochlear inclination were calculated and used with the TTTG for simple linear regression models. RESULTS: All metrics gradually decreased during eccentric movement (TTTG, -6.9 mm; BO, -12.6%; LPT, -4.3°). No significant differences were observed between eccentric and concentric phases at any flexion angle for all metrics. Linear regression between kinematic metrics towards full extension showed a moderate fit between BO and TTTG (R2 0.60, ß 1.75) and BO and LPT (R2 0.59, ß 1.49), and a low fit between TTTG and LPT (R2 0.38, ß 0.53). A high impact of the TTTG distance over BO was shown in male participants (R2 0.71, ß 1.89) and patella alta individuals (R2 0.55, ß 1.91). CONCLUSION: We provided preliminary normative values of three common metrics during weight-bearing dynamic CT and showed the substantial impact of lateralisation of the patella tendon over patella displacement. RELEVANCE STATEMENT: These normative values can be used by clinicians when evaluating knee patients using TTTG, BO, and LPT metrics. The lateralisation of the patellar tendon in subjects with patella alta or in males significantly impacts the lateral displacement of the patella. KEY POINTS: Trochlear groove morphology had no substantial impact on motion prediction. The lateralisation of the patellar tendon seems a strong predictor of lateral displacement of the patella in male participants. Participants with patella alta displayed a strong fit between the patellar lateral displacement and tilt. TTTG, BO, and LPT decreased during concentric movement. Concentric and eccentric phases did not show differences for all metrics.