Psychometric properties of quantitative sensory testing in healthy and patients with shoulder pain: A systematic review.

Quantitative Sensory Testing (QST) is a psychophysical battery of various tests developed to quantify the subjects' self-reported sensory experience. Although the use of QST is valuable for the clinical assessment of pain, standard evaluation protocols have not yet been established. This systematic review aimed to investigate the level of evidence for the psychometric properties of QST in healthy and patients with shoulder pain. Eight databases were searched for peer-reviewed studies published until August 2021. The methodological quality of studies was evaluated using the COSMIN checklist. Twelve studies were included for qualitative synthesis, which included three different tests (Pressure Pain Threshold (PPT), Conditioned Pain Modulation (CPM) and Temporal Summation (TS)). As the body of evidence consisted of studies of low methodological quality, the psychometric properties of PPT, CPM, and TS in healthy and patients with shoulder pain were classified as unknown. Although there is a risk that the conclusions may be 'superficial' in nature, the reliability seems to be nearly excellent for the PPT, however, the protocols' variation and the low methodological quality of the studies do not allow for clear conclusions. Further studies are required for the CPM and TS in patients with shoulder pain.

Cross-cultural adaptation of the spa therapy checklist (SPAC) in Greek.

The importance of spa therapy is growing worldwide, with care practitioners paying more attention to how this intervention can alleviate various health issues. Multiple studies have been performed and reported on the efficiency of balneotherapy, creating a need to understand the quality of the information in the existing studies and how they can inform practitioners in promoting evidence-based practice. The SPAC assessment tool describes and assesses the quality of reports of interventional trials in balneotherapy. The present study had two goals. The first goal was the translation and cross-cultural adaptation of the SPAC assessment tool in Greek language following an internationally accepted methodology. The second goal was to assess the reliability of the tool employing test-retest and interrater reliability studies in a sample of 15 relative RCT papers and to assess the criterion validity of the Greek version by comparing its results with the original English version when assessing the same 15 papers. The results revealed that the SPAC checklist was translated and adapted in Greek without difficulties between the translators. Reliability of the SPAC was found excellent in both test-retest (ICC = .98) and interrater (ICC = .95) indexes. The criterion validity assessment for Greek version of SPAC checklist was also almost perfect (ICC = .98). In the present study, the Greek version of the SPAC checklist was found to be a comprehensible, reliable, and valid tool to assess the quality of interventional trial reports on the efficacy of spa therapy for cure and health enhancement.

Validity and reliability of the Greek version of modified Baecke questionnaire.

OBJECTIVES: The purpose of this study was to translate and investigate the validity and reliability of the modified Baecke Physical Activity Questionnaire (mBQ) in the Greek adult population. STUDY DESIGN: This is a cross-cultural study. METHODS: The cross-cultural adaptation of the mBQ was performed according to official guidelines. The prefinal Greek translation was tested in 30 healthy participants. The reliability was determined (n = 100) by filling out the mBQ, two times, 1 week apart. For validation (n = 45), the scores between the mBQ and the International Physical Activity Questionnaire (IPAQ) were compared, and the correlation between mBQ and VO2max and between mBQ and interview (METS) were assessed. RESULTS: High statistical significant of test-retest reliability was found (intraclass correlation coefficient = 0.84; standard error of measurement = 0.48; smallest detectable difference = 16.7%; Cronbach's alpha = 0.92). Statistical significant correlation between the mBQ and the IPAQ (r = 0.425, P = 0.005), high correlation between the mBQ and METS (r = 0.691, P = 0.000), and moderate correlation between mBQ and VO2max (r = 0.388, P = 0.08) were found. CONCLUSION: The Greek mBQ was found to be reliable and valid for assessing the level of physical activity in the Greek population. CLINICALTRIALS. GOV IDENTIFIER: NCT04890756.

Cross-cultural Adaptation and Psychometric Properties of the Greek Version of the Central Sensitization Inventory.

OBJECTIVES: Recent studies support the opinion that central sensitization (CS) plays an important role in the pathophysiology of many chronic pain conditions. CS refers to hyperexcitability of the central nervous system, which can result in pain hypersensitivity and other somatosensory symptoms. Recognition of CS-related symptomology is crucial in chronic pain evaluation and rehabilitation. The Central Sensitization Inventory (CSI) was created to evaluate symptoms that have been found to be associated with CS. The aim of the current study was the cross-cultural adaptation of the CSI into Greek (CSI-Gr). METHODS: To evaluate discriminate validity, 200 patients with chronic pain and 50 healthy control subjects participated. The sample was divided into 4 diagnostic groups (fibromyalgia, single pain complaints, multiple pain complaints, and a control group) and into 5 CSI severity subgroups, from subclinical to extreme. Convergent validity was determined by evaluation of the relationship between the CSI-Gr and the Pain Catastrophizing Scale (PCS). Additionally, 30 patients completed the CSI a second time for the purpose of a test/retest analysis. RESULTS: The results showed high internal consistency (Cronbach's alpha = 0.994) and test-retest reliability (intraclass correlation coefficient = 0.993). The standard error of measurement was 2.1. The CSI-Gr correlated moderately with the PCS (r = 0.68). Statistically significant differences were found among the 3 comparison groups, with patients who had fibromyalgia reporting the highest CSI severity and healthy control subjects reporting the lowest severity. CONCLUSIONS: As determined in the present study, the CSI-Gr was found to be a reliable and valid tool for recognition of CS-related symptomology.

Pole Dancing-Specific Muscle Strength: Development and Reliability of a Novel Assessment Protocol.

BACKGROUND: Pole dancing is a physically demanding sport that combines dance and acrobatic movements on a vertical pole. Despite its highly growing popularity, there is currently limited research in the field. The aim of this study was to create and evaluate a strength assessment protocol for athletes in pole dancing, with a specific focus on functional positions on the pole. METHODS: Thirty-two female pole dancing athletes participated in this study. Maximal voluntary isometric contractions (MVIC) were measured at three different sport-specific positions on the pole (shoulder abduction and adduction, and hip adduction), on two separate days (test and re-test) with a five to seven day interval between them. A hand-held dynamometer (Activ5- Activbody) stabilized on the pole was used for this study. RESULTS: The intra-session reliability was good to excellent for all sports-specific positions and for both sides of the body, across all different movements (ICC = 0.837-0.960, SEM = 5.02Kg-2.24Kg, and SDD = 27.46%-14.92%). Slightly better results were found regarding inter-session reliability (ICC = 0.927-0.970, SEM = 3.72Kg-1.97Kg, and SDD = 22.86%-15.19%). There was not a statistically significant difference between the MVICs between the left and right or dominant and non-dominant side in shoulder abduction (p = 0.105) and hip adduction (p = 0.282), in contrast to shoulder adduction (p = 0.00). CONCLUSION: The strength assessment protocol developed in the current study has proven to be a reliable and functional tool, with the potential for utilization in clinical practice as part of objective strength testing. Further studies are needed in order to expand the protocol to other muscle groups and positions and to generalize the results in all pole dancing populations such as male athletes.

Facilitators and barriers of empathetic behaviour in physiotherapy clinical practice: A qualitative focus group study.

BACKGROUND: Empathy is an essential competence of a person-centered approach, and a recognisable ability for providing physiotherapy quality healthcare. Empathetic communication enhances the improvement of patient outcomes and their experience of treatment. OBJECTIVE: The aim of the study was to present further insights considering facilitators and barriers of an empathetic communication between patients and physiotherapists. METHODS: A qualitative focus group study was designed according to COREQ guidance for qualitative studies. Two focus groups were conducted. The first group included six patients and two individuals from non-governmental organizations, whereas three physiotherapists, two academic physiotherapist personnel and two undergraduate physiotherapy students participated in the second group. Both groups were audio recorded, and all data was verbatim transcribed for coding thematic analysis. RESULTS: 9 themes were revealed regarding empathetic facilitators (qualities of good communication, relationship building, interprofessional collaborative practice, positive environment, love for the healthcare profession and professionalism), while 8 themes were revealed regarding barriers (challenging situations, working conditions, burn out, depreciation of empathetic communication, lack of training, lack of professionalism, lack of personal development and health professionals' own personal problems). CONCLUSION(S): The enhancement of empathy can be accomplished in a trustworthy relationship between patient and clinicians where the development of proficient communication skills are prioritized. However, hindering factors associated with health professionals, patients and the health system should be surmounted. ETHICAL APPROVAL NUMBER: 339-ΣΕ8/10-1-2020.

Quality of life and quality of education among physiotherapy students in Europe.

Background: The study of physiotherapy is challenging and can affect the students' well-being and quality of life. The aim of this study was to describe and compare factors that could affect well-being among students across Europe. Methods: In this descriptive cross-sectional study using an online questionnaire survey, students of bachelor's physiotherapy programs from 23 European faculties, from 8 countries, were interviewed on mental health and stress burden, sleep quality, dietary habits, and physical activity. Results: Although 75% of students rated their quality of life positively and 47% were satisfied with their mental health, 65% showed higher levels of stress and 51% described impaired sleep quality. The minimum physical activity of 150 min weekly was described by 79% of students, within which 67% engaged in strengthening twice a week. Students with a higher stress load/worse psychological health also showed worse sleep quality and lower amount of physical activity, women were significantly worse off. In terms of physical activity and sleep quality, students from Finland and Kosovo achieved the best results, while students from Italy, Greece, and Portugal achieved the worst. Students from Italy indicated the greatest dissatisfaction with the organisation of the study system and communication with teachers, while in Kosovo students rated the communication and study organisation the highest. All students had a problem with adhering to nutritional habits. Students from Italy and Spain, with the lowest body mass indexes and weight averages, were closest to the nutrition recommendations. Conclusion: We demonstrated that physiotherapy students are burdened with stress, suffer from sleep disorders, and do not follow the recommendations regarding nutrition nor physical activity. There are significant differences between universities and countries in some aspects.

Corrigendum: Quality of life and quality of education among physiotherapy students in Europe.

[This corrects the article DOI: 10.3389/fmed.2024.1344028.].

Clinical reasoning using ChatGPT: Is it beyond credibility for physiotherapists use?

BACKGROUND: Artificial Intelligence (AI) tools are gaining popularity in healthcare. OpenAI released ChatGPT on November 30, 2022. ChatGPT is a language model that comprehends and generates human language, providing instant data analysis and recommendations. This is particularly significant in the dynamic field of physiotherapy, where its integration has the potential to enhance healthcare efficiency. OBJECTIVES: This study aims to evaluate whether ChatGPT-3.5 (free version) provides consistent and accurate clinical responses, its ability to imitate human clinical reasoning in simple and complex scenarios, and its capability to produce a differential diagnosis. METHODS: Two studies were conducted using the ChatGPT-3.5. Study 1 evaluated the consistency and accuracy of ChatGPT's responses in clinical assessment using ten user-participants who submitted the phrase "Which are the main steps for a completed physiotherapy assessment?" Study 2 assessed ChatGPT's differential diagnostic ability using published case studies by 2 independent participants. The case reports consisted of one simple and one complex scenario. RESULTS: Study 1 underscored the variability in ChatGPT's responses, which ranged from comprehensive to concise. Notably, essential steps such as re-assessment and subjective examination were omitted in 30% and 40% of the responses, respectively. In Study 2, ChatGPT demonstrated its capability to develop evidence-based clinical reasoning, particularly evident in simple clinical scenarios. Question phrasing significantly impacted the generated answers. CONCLUSIONS: This study highlights the potential benefits of using ChatGPT in healthcare. It also provides a balanced perspective on ChatGPT's strengths and limitations and emphasizes the importance of using AI tools in a responsible and informed manner.

Virtual Reality-Based Exercise Therapy for Patients with Chronic Musculoskeletal Pain: A Scoping Review.

This scoping review aimed to identify interventions utilizing virtual-reality-based exercise therapy in patients with chronic musculoskeletal pain. Searches were conducted in four databases using descriptors related to virtual reality, exercise, and chronic musculoskeletal pain. Two reviewers screened the titles and abstracts of the studies to assess eligibility, with a third author resolving any discrepancies. Data were extracted and summarized in a narrative format by three independent raters. Clinical trials were evaluated using the PEDro scale to assess the effectiveness of virtual-reality-based exercise therapy in chronic musculoskeletal pain patients. A total of 162 articles were identified from the databases. After applying the inclusion criteria, nine articles were considered suitable for analysis, including six randomized clinical trials. The selected articles were categorized based on study characteristics, virtual-reality-based exercise therapy interventions (including technologies and equipment used), exercise interventions, outcome measures, and effectiveness. The findings indicate that virtual-reality-based exercise therapy shows promising results in reducing pain, improving disability, enhancing range of motion, and increasing treatment satisfaction in patients with chronic musculoskeletal pain. However, it is not possible to conclude that virtual-reality-based exercise therapy is superior to other treatments due to the limited number of available studies, heterogeneity in application protocols, and varying methodological quality. Further research is needed to draw more definitive conclusions.

Cross-cultural validation of the Oxford Elbow Score and Mayo Elbow Performance Score in Greek.

BACKGROUND: Oxford Elbow Score (OES) and Mayo Elbow Performance Score (MEPS) are two of the most commonly used instruments for the functional assessment of elbow joint. The aim of this study was to cross-culturally validate the OES and MEPS into Greek language and examine their convergent validity, internal consistency, test-retest reliability and floor and ceiling effects. METHODS: The two instruments were translated into Greek with the back translation method. Their final Greek versions (OES-GR and MEPS-GR) were completed by 40 patients with elbow disorders. The patients completed also the Greek version of the Disabilities of the Arm Shoulder and Hand (DASH-GR). The patients re-completed the OES-GR after 24 h. RESULTS: The OES-GR was found to have good internal consistency (Cronbach's α = 0.85, 95%CI = 0.74-0.92), in contrast to the MEPS-GR (Cronbach's α = 0.47, 95%CI = 0.15-0.70). Both instruments were found to have good convergent validity with the DASH-GR (for MEPS-GR rs = -0.64, 95% CI -0.79 to -0.41; for OES-GR rs = -0.84, 95%CI = -0.91 to -0.72). Good was also the convergent validity of the OES-GR with the MEPS-GR (rs = 0.71, 95%CI = 0.51 to 0.84). The test-retest reliability for each domain of the OES-GR was found good to excellent (total score ICC = 0.91, 95%CI = 0.83-0.95; pain ICC = 0.90, 95%CI = 0.81-0.95; function ICC = 0.81, 95%CI = 0.68-0.90; social-psychological ICC = 0.91, 95%CI = 0.84-0.95). CONCLUSION: The findings about the internal consistency, test-retest reliability, convergent validity and ceiling/floor effects of the OES-GR suggest that it is a quite valid and reliable instrument which can be used with confidence in Greek patients with elbow disorders. LEVEL OF EVIDENCE: N/A.

In the Shoulder or in the Brain? Behavioral, Psychosocial and Cognitive Characteristics of Unilateral Chronic Shoulder Pain with Symptoms of Central Sensitization.

The recognition of central sensitization (CS) is crucial, as it determines the results of rehabilitation. The aim of this study was to examine associations between CS and catastrophizing, functionality, disability, illness perceptions, kinesiophobia, anxiety, and depression in people with chronic shoulder pain (SP). In this cross-sectional study, 64 patients with unilateral chronic SP completed a few questionnaires including the Central Sensitization Inventory, the Oxford Shoulder Score, the Tampa Scale for Kinesiophobia, the Hospital Anxiety and Depression Scale, the Pain Catastrophizing Scale, the Brief Illness Perception Questionnaire and the "arm endurance" test. On the basis of three constructed linear regression models, it was found that pain catastrophizing and depression (model 1: p < 0.001, R = 0.57, R2 = 0.33), functionality (model 2: p < 0.001, R = 0.50, R2 = 0.25), and helplessness (model 3: p < 0.001, R = 0.53, R2 = 0.28) were significant predictors for CS symptoms in chronic SP. Two additional logistic regression models also showed that depression (model 4: p < 0.001, Nagelkerke R2 = 0.43, overall correct prediction 87.5%) and functionality (model 5: p < 0.001, Nagelkerke R2 = 0.26, overall correct prediction 84.4%) can significantly predict the classification of chronic SP as centrally sensitized. Patients who were classified as centrally sensitized (n = 10) were found to have significantly worse functionality, psychological factors (anxiety, depression, kinesiophobia, catastrophizing), and pain intensity (p < 0.05). Catastrophizing, depression, and functionality are predictive factors of CS symptoms in patients with chronic shoulder pain. Health care providers should adopt a precision medicine approach during assessment and a holistic rehabilitation of patients with unilateral chronic SP.

Test/retest reliability of maximum mouth pressure measurements with the MicroRPM in healthy volunteers.

BACKGROUND: Respiratory muscle strength is an important part of lung function. Assessment of the respiratory muscles' ability to generate force is important for recognizing respiratory muscle weakness in both sick and healthy people. OBJECTIVE: To assess the test/retest reliability of the MicroRPM portable manometer's measurements of maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP) in the sitting and standing positions; the number of expiratory maneuvers needed with the MicroRPM for reliability in MIP and MEP measurement; and the MicroRPM's test/retest reliability in other respiratory function indices, such as the maximum rate of pressure development (MRPD), the time constant of relaxation (tau), and the maximum relaxation rate (MRR). METHODS: We recruited 15 healthy volunteers (mean age 21.6 ± 1.1 years). We assessed respiratory muscle strength on 3 separate occasions, each a week apart. We calculated reliability with the intraclass correlation coefficient (ICC), the standard error of measurement (SEM) and the smallest detectable difference (SDD). RESULTS: MicroRPM reliably measured MIP and MEP in both the sitting position (ICC 0.86-0.90, SEM 9-10, SDD 18-22) and standing position (ICC 0.78-0.83, SEM 12-14, SDD 23-26). After a 5-breath practice, 2 expiratory/inspiratory maneuvers on each testing occasion gave adequate MIP and MEP reliability (ICC > 0.90). MRR reliability was moderate to excellent (ICC 0.58-0.87), MRPD reliability was moderate (ICC 0.59-0.64), and tau reliability was insufficient (ICC 0.27-0.67). CONCLUSIONS: The MicroRPM reliably measures MIP and MEP, but its MRPD, MRR, and tau measurements should be considered with caution.

Novel Software for Pain Drawing Analysis.

Introduction Pain drawings (PDs) are an important component of the assessment of a patient with pain. Although analog pain drawings (APDs), such as pen-on-paper drawings, have been extensively used in clinical assessment and clinical research, there is a lack of digital pain drawing (DPD) software that would be able to quantify and analyze the digital pain distribution obtained by the patients. The aim of this work is to describe a method that can quantify the extent and location of pain through novel custom-built software able to analyze data from the digital pain drawings obtained from the patients. Methods The application analysis and software specifications were based on the information gathered from the literature, and the programmers created the custom-built software according to the published needs of the pain scientific community. Results We developed a custom-built software named "Pain Distribution," which, among others, automatically calculates the number of the pixels the patient has chosen and therefore quantifies the pain extent, provides the frequency distribution from a group of images, and has the option to select the threshold over which the patient is considered with central sensitization (CS). Additionally, it delivers results and statistics for both every image and the frequency distribution, providing mean values, standard deviations, and CS indicators, as well as the ability to export them in *.txt file format for further analysis. Conclusion A novel Pain Distribution application was developed, freely available for use in any setting, clinical, research, or academic.

University Students Perception of Online Education: Is Engagement Enough?

BACKGROUND: Universities have halted non-essential services, with many restricting campus-based teaching, and continuing courses through online resources, including (controversially) lab-work. Such technologically enhanced approaches have been proven to have high levels of engagement among university students. OBJECTIVE: This study focuses on the perception of quality of online learning by first-year university students, between two semesters, amidst the COVID-19 pandemic. METHODS: A 24-item questionnaire was designed with Likert response scale. It consisted of general perception questions of academic life and questions specific to the quality of delivery of a specific class. Eighty one eligible students were asked to fill the same questionnaire for each semester. Students' responses and their grades from the final exams in each semester were compared. RESULTS: Out of 81 eligible students, 75.31% of students responded to the survey. They were less interested in their studies in the second "online" semester (p=0.05). Students expressed dissatisfaction with the quality of online classes (p=0.03). Academic life fulfillment was also affected (p=0.02). Students' perception of the amount of free time they had between semesters did not change significantly (p=0.16). Students appeared dissatisfied with their active participation during the online class (p=0.007), even though they felt less stressed attending lectures from home (p=0.041). However, they found that workload was bearable and similar between semesters (p=0.83). Students also had significantly more trouble concentrating during online lectures (p<0.001). Students' grades significantly improved by an average of 1.07 (out of 10) in the final exams at the end of the second semester (p<0.001). CONCLUSION: These unprecedented circumstances require innovation and cooperation on the part of university programs to maintain rigorous standards of higher education, taking into account students' evolving perception and needs.

Cross-cultural validation of the start back screening tool in a Greek low back pain sample.

BACKGROUND: Keele STarT Back Screening Tool (SBST) is a popular 9-item prognostic recovery questionnaire for low back pain (LBP) with validation studies in several cultural settings, but not Greek. OBJECTIVES: The cross-cultural adaptation and validation of the SBST into Greek among LBP and LBP-associated leg pain patients. METHODS: A five-stage forward-backward translation procedure developed the Greek SBST. LBP and sciatica patients completed SBST, Roland-Morris Disability Questionnaire (RMDQ), Hospital Anxiety and Depression Scale (HADS), Short-form Health Survey (SF-12), Sciatica Bothersomeness Index (SBI), numeric pain rating scale (NPRS) and body chart pain location sites. Measurement properties (internal consistency, content, construct and discriminatory validity) were explored. Test-retest reliability was explored by re-administering SBST after 7-10 days across patients whose symptoms remained unchanged. RESULTS: 124 LBP patients (75 females, 49.1 ± 14.2 years-old) 43.5% of whom had sciatica completed Greek SBST. No floor/ceiling effects were detected. Mean score distributions were statistically different across SBST groups. Moderate to strong correlations were found for SBST (total and psychosocial scores) with RMDQ, SBI, HADS and SF-12 (Spearman's ρ = 0.42-0.60). Most associations between individual SBST items and reference standards were moderately correlated (ρ = 0.32-0.49). Greek SBST yielded acceptable discriminant validity with RMDQ (AUC of 0.80). Items 1, 3, 4, and 9 yielded acceptable discrimination against reference standards. Test-retest reliability was satisfactory for total score (ICC2,2 = 0.93) and individual items (kappa = 0.59-0.88). Cronbach's α was 0.70 (total score) and 0.76 (psychosocial subscale). CONCLUSIONS: The Greek SBST was comprehensible, valid and reliable and may thus, be used across Greek cross-cultural rehabilitation research and practice.

Health-related Quality of Life in Children with Autism Spectrum Disorder and Children with Down Syndrome.

INTRODUCTION: Measuring health- related quality of life (HRQoL) is very important for children with developmental disorders such as autism spectrum disorder (ASD) and Down syndrome (DS). However, no HRQoL studies found in the literature for the differences between children with ASD and children with DS. AIM: The aim of this study was to examine HRQoL in children with ASD and children with DS. METHODS: The participants consisted of 206 children with ASD (61), DS (55) and typical development (TD) (90), aged 5-10 years old, after administering anonymous questionnaires to their parents-caregivers. The Pediatric Quality of Life Inventory ™ 4.0- Parent Report (PedsQL) was used to measure HRQoL. One-way analysis of variance and χ2 were applied for comparisons among groups. RESULTS: TD group scored higher than ASD and DS in all comparisons. Post-hoc (Tukey) comparisons revealed that the statistically univariate effect was due to differences between the TD group and the other two groups, ASD and DS (p<0.01). The ASD group achieved significantly lower scores than DS in the emotional functioning scale. Post-hoc analysis did not reveal any significant differences between the DS and the ASD group in the physical health, psychosocial health and the total PedsQL summary scores. CONCLUSIONS: Children with ASD and DS had significantly lower HRQoL compared to a TD population, and this finding was not affected by age. Children with ASD demonstrated a significantly lower score in the emotional functioning scale than children with DS but are similar in the physical health scale. It is thus considered necessary to take the physical health scale into account when assessing and designing treatment for children with ASD. Future research studies should focus on HRQoL indicators that could serve as a standard diagnostic tool for the development of therapies and outcomes of assessment findings in ASD and DS.

Neck pain causes respiratory dysfunction.

This paper describes a presumptive mechanism for the development of changes in respiratory function due to chronic neck pain. The patient with neck pain presents a number of factors that could constitute a predisposition of leading to a respiratory dysfunction: (a) the decreased strength of deep neck flexors and extensors, (b) the hyperactivity and increased fatigability of superficial neck flexors, (c) the limitation of range of motion, (d) the decrease in proprioception and disturbances in neuromuscular control, (e) the existence of pain and (f) the psychosocial influence of dysfunction. The possible connection of neck pain and respiratory function could have a great impact on various clinical aspects notably patient assessment, rehabilitation and pharmacological prescription.

The effects of the Mulligan Sustained Natural Apophyseal Glide (SNAG) mobilisation in the lumbar flexion range of asymptomatic subjects as measured by the Zebris CMS20 3-D motion analysis system.

BACKGROUND: Mulligan's mobilisation techniques are thought to increase the range of movement (ROM) in patients with low back pain. The primary aim of this study was to investigate the application of the Mulligan's Sustained Natural Apophyseal Glide (SNAG) technique on lumbar flexion ROM. The secondary aim was to measure the intra- and inter-day reliability of lumbar ROM employing the same procedure. METHODS: 49 asymptomatic volunteers participated in this double-blinded study. Subjects were randomly assigned to receive either SNAG mobilisation (n = 25), or a sham mobilisation (n = 24). The SNAG technique was applied at the L3and L4 spinal levels with active flexion in sitting by an experienced manual therapist. Three sets of 10 repetitions at each of the two spinal levels were performed. The sham mobilisation was similar to the SNAG but did not apply the appropriate direction or force. Lumbar ROM was measured by a three dimensional electronic goniometer (Zebris CMS20), before and after each technique. For the reliability, five measurements in two different days (one week apart) were performed in 20 healthy subjects. RESULTS: When both interventions were compared, independent t tests yielded no statistically significant results in ROM between groups (p = 0.673). Furthermore no significant within group differences were observed: SNAG (p = 0.842), sham (p = 0.169). Intra- and inter-day reliability of flexion measurements was high (ICC(1,1) > 0.82, SEM < 4.0 degrees , SDD<16.3%) indicating acceptable clinical applicability. CONCLUSION: While the Zebris proved to be a reliable device for measuring lumbar flexion ROM, SNAG mobilisation did not demonstrate significant differences in flexion ROM when compared to sham mobilisation. TRIAL REGISTRATION: Current Controlled Trials NCT00678093.

Lower limb sensorimotor network: issues of somatotopy and overlap.

Functional magnetic resonance imaging (fMRI) was used (1) to describe the pattern of whole brain activity during motion of isolated joints of the lower limb, (2) to examine the somatotopic organization of lower limb joint representations in the primary sensorimotor cortex and the anterior lobe of the cerebellum and 3) to quantify the degree of overlap between these lower limb joint activations. Eighteen healthy, right leg dominant volunteers participated in a motor block-design study, performing repetitive knee, ankle and toes flexion/extension movements. In order to relate lower limb joints activation to the well-described patterns of finger movement, serial finger-to-thumb opposition was also assessed. All movements were auditory paced at 72 beats/min (1.2 Hz). Isolated lower limb joints movement activated a distributed sensorimotor network, including primary and non-primary sensorimotor areas. Although a large overlap was evident in primary sensorimotor cortex (SM1) and cerebellum representations of the three lower limb joints, a somatotopic arrangement was recognizable with reference to center of mass coordinates of each individual joint in the above areas. Detection of active brain regions during movement of the lower limb joints is feasible with fMRI although a carefully optimized methodology protocol is required.