Validation of the range of dry needling with the fascial winding technique in the carpal tunnel using ultrasound.

OBJECTIVES: To use ultrasound imaging to show how the needles in dry needling applied in the carpal tunnel can reach the transverse carpal ligament, acting on it in the form of traction-stretching when the fascial winding technique is performed. The potential associated risks are also assessed. DESIGN: Validation study. PARTICIPANTS: Healthy volunteers (n = 18). METHODS: Four dry needling needles were applied to the carpal tunnel, only using anatomical references, according to the original approach known as "four-pole carpal dry needling", and manipulating the needles following the so-called fascial winding technique according to the authors, in the form of unidirectional rotation. An ultrasound recording of the distance reached was then performed, and compared with the mechanical action achieved on the transverse carpal ligament. RESULTS: 93.1% of the needles placed came into contact with the transverse carpal ligament with traction-stretching of the ligament observed when the needles were manipulated with the fascial winding technique in 80.6%. The mean distance from the tip of the needle to the median nerve was 3.75 mm, with CI95% [3.10, 4.41] and it was 7.78 mm with CI95% [6.64, 8.91] to the ulnar artery. Pain immediately after the technique concluded was of mild intensity, almost nil 10 min later, and non-existent after one week. CONCLUSION: Dry needling with fascial winding technique in the carpal tunnel using the four-pole carpal dry needling approach is valid for reaching and traction of the transverse carpal ligament, and may stretch it and relax it. It is also safe with regard to the median nerve and ulnar artery, with a very mild level of pain.

Effect of vitamin C on collagen structure of cardinal and uterosacral ligaments during pregnancy.

OBJECTIVE: This study aimed to investigate changes in collagen structure in the cardinal and uterosacral ligaments of rats that were administered vitamin C during pregnancy. STUDY DESIGN: Eighteen female rats were divided into three groups: six pregnant rats administered 1.25mg/ml/day of vitamin C during pregnancy (Group A); six non-pregnant rats that were not administered vitamin C (Group B); and six pregnant rats that were not administered vitamin C during pregnancy (Group C). Fifteen days after delivery, the uteruses of all rats were removed. The intensity of staining (mild, moderate or severe) and the extent of positive staining areas (%) of type I and type III collagen H scores for types I and III collagen, and intensity of elastin fibres in the cardinal and uterosacral ligaments were investigated immunohistochemically. Differences between groups were analysed using Kruskal-Wallis and independent samples tests. RESULTS: The intensity and extent of type I and type III collagen, the H scores for type I and type III collagen, and the ratio of type III collagen H score: type I collagen H score differed significantly between groups. Pregnant rats administered vitamin C (Group A) had significantly higher values compared with non-pregnant rats (Group B): intensity of type I collagen (p=0.001), extent of type I collagen (p≤0.001), H score for type I collagen (p≤0.001), intensity for type III collagen (p=0.002), extent of type IV collagen (p=0.007), H score for type III collagen (p=0.017), type III collagen H score: type I collagen H score (p=0.039) and intensity of elastin fibres (p=0.097). A significant difference in the ratio of type III collagen H score: type I collagen H score was found between pregnant rats administered vitamin C (Group A) and pregnant rats not administered vitamin C (Group C) (p=0.002). CONCLUSIONS: The administration of vitamin C to rats during pregnancy had a favourable impact on collagen structure in the cardinal and uterosacral ligaments, suggesting that vitamin C supplementation during pregnancy may help to prevent pelvic organ prolapse and stress urinary incontinence.

Viscoelastic properties of the human tympanic membrane studied with stroboscopic holography and finite element modeling.

A new anatomically-accurate Finite Element (FE) model of the tympanic membrane (TM) and malleus was combined with measurements of the sound-induced motion of the TM surface and the bony manubrium, in an isolated TM-malleus preparation. Using the results, we were able to address two issues related to how sound is coupled to the ossicular chain: (i) Estimate the viscous damping within the tympanic membrane itself, the presence of which may help smooth the broadband response of a potentially highly resonant TM, and (ii) Investigate the function of a peculiar feature of human middle-ear anatomy, the thin mucosal epithelial fold that couples the mid part of the human manubrium to the TM. Sound induced motions of the surface of ex vivo human eardrums and mallei were measured with stroboscopic holography, which yields maps of the amplitude and phase of the displacement of the entire membrane surface at selected frequencies. The results of these measurements were similar, but not identical to measurements made in intact ears. The holography measurements were complemented by laser-Doppler vibrometer measurements of sound-induced umbo velocity, which were made with fine-frequency resolution. Comparisons of these measurements to predictions from a new anatomically accurate FE model with varied membrane characteristics suggest the TM contains viscous elements, which provide relatively low damping, and that the epithelial fold that connects the central section of the human manubrium to the TM only loosely couples the TM to the manubrium. The laser-Doppler measurements in two preparations also suggested the presence of significant variation in the complex modulus of the TM between specimens. Some animations illustrating the model results are available at our website (www.uantwerp.be/en/rg/bimef/downloads/tympanic-membrane-motion).

The integrated continence system: a manual therapy approach to the treatment of stress urinary incontinence.

Stress urinary incontinence (SUI) constitutes a large-scale public health concern. The integrated continence system (ICS) developed by the authors is an evidence-based model that demonstrates how urinary incontinence is maintained through the interaction of three structural systems (intrinsic urethral closure, urethral support and lumbopelvic stability) and three modifiable factors (motor control, musculoskeletal and behavioural). The purpose of the ICS is first, to demonstrate the important role that manual physiotherapists can play in the treatment of SUI and second, to guide clinical practice decisions in order to improve clinical outcomes among women with SUI.

Ultrasound-guided suprascapular nerve block technique.

BACKGROUND: In this article, we describe a case report of using real-time, high-resolution ultrasound guidance to facilitate blockade of the suprascapular nerve. We describe a case report and technique for using a portable ultrasound scanner (38 mm broadband (13-6 MHz) linear array transducer (SonoSite Micromaxx SonoSite, Inc. 21919 30th Drive SE Bothwell W. A..)) to guide suprascapular nerve block. METHODS: A 44-year old male patient presented with severe, painful osteoarthritis with adhesive capsulitis of his right shoulder. The ultrasound transducer in a transverse orientation was placed over the scapular spine. Moving the transducer cephalad the suprascapular fossa was identified. While imaging the supraspinatus muscle and the bony fossa underneath, the ultrasound transducer was moved laterally (maintaining a transverse transducer orientation) to locate the suprascapular notch. The suprascapular nerve was seen as a round hyperechoic structure at 4 cm depth beneath the transverse scapular ligament in the scapular notch. The nerve had an approximate diameter of 200 mm. Real-time imaging was used to direct injection in the scapular notch. Ultrasound scanning confirmed local anesthetic spread. RESULTS: The patient's pain intensity decreased. Shoulder movement and function improved. These improvements were maintained at 12 weeks. CONCLUSION: Ultrasound guidance does not expose patients and personnel to radiation. It is also less expensive than other imaging modalities. This technique has applications in both acute and chronic pain management.

Attachments of the ligamentum nuchae to cervical posterior spinal dura and the lateral part of the occipital bone.

OBJECTIVE: To describe previously unrecorded attachments of the ligamentum nuchae to the cervical posterior spinal dura, and to posterolateral parts of the occipital bone in an anatomical study, with particular reference to the deep aspects of the suboccipital triangle and upper cervical region. DESIGN: Dissections of 10 heads and necks from embalmed cadavers were made in the suboccipital and upper cervical region, either in whole specimens or in parasagitally sectioned specimens. RESULTS: In parasagittally sectioned material, continuity was observed between the ligamentum nuchae and the posterior cervical spinal dura as the latter passed deeply from the midline toward the dura, but only at the first and second cervical vertebral levels. The ligamentum nuchae also passed bilaterally on to the occipital bone as far as the sutures between the occipital bone and the temporal bones, approaching the inferior nuchal line superiorly. CONCLUSION: The present study is the first to describe the full morphology of the relationship between the ligamentum nuchae and the cervical posterior spinal dura and the lateral aspects of the occipital bone. This is of significance for understanding the biomechanics of the cervical spine, particularly rotational movements of the head in the sagittal or transverse planes. This may have implications in manipulative therapy for conditions as cervicogenic headache and for various degenerative disorders affecting the cervical spine.

Meningovertebral ligaments and their putative significance in low back pain.

OBJECTIVE: To determine the presence and morphology of the meningovertebral ligaments (ligaments of Hofmann) as well as postulate their possible contribution to low back pain. DESIGN: Sagittal dissections were performed on 12 embalmed cadaver specimens including the L5/S1 intervertebral level cephalad to T1. Meningovertebral ligaments were labeled and documented in both the lumbar and thoracic regions. RESULTS: Meningovertebral ligaments were found in both the lumbar and thoracic regions of all cadaveric specimens. These ligaments were much more prevalent in the lumbar vertebral column but were also present throughout the thoracic vertebral column. The meningovertebral ligaments in the lumbar region were more robust as well as more frequently encountered than those found in the thoracic region. CONCLUSION: Dural sac attachments to the posterior aspect of the vertebral bodies and the posterior longitudinal ligament could act to traction the dural sac in the event of nuclear bulge or herniation. The prevalence of these ligaments in the lumbar spine, coupled with the high incidence of herniated nucleus pulposus and disc bulges in this region, may compound the effects of disc pathology and result in increased low back pain.

The effects of transforaminal ligaments on the sizes of T11 to L5 human intervertebral foramina.

OBJECTIVE: This study was designed to determine the effects of the presence of transforaminal ligaments (TFL) on the superior-to-inferior dimension (SI) and anterior-to-posterior dimension (AP) of the compartment containing the ventral ramus of the spinal nerve (VR) in the intervertebral foramen (IVF). DESIGN: Four lumbar spines, including T12 and in one case T11, were obtained from embalmed cadavers and carefully dissected to expose the contents of the IVF. All ligamentous structures in the vicinity of the IVF were preserved. The greatest SI and AP of each IVF were measured. When present, TFL help define a compartment at the exit zone of the IVF that contains the VR. The SI and AP of these compartments were also measured. RESULTS: Of 49 IVF examined, at least one TFL was present in 35. In the 34 IVF with horizontally oriented TFL, the mean SI of the compartments for the VR was 31.5% smaller than that of the IVF (one-way ANOVA, p < .01). No significant differences were seen between the AP of the IVF and compartments for the VR in the levels with vertically oriented TFL (n = 11). CONCLUSIONS: TFL were found to be present in 71% of lower thoracic and lumbar IVF. If TFL were present, the SI of the compartment containing the VR in the IVF was significantly decreased (mean = 31.5%). This finding suggests that often there may be less space at the exit zone of the IVF for the ventral ramus than traditionally thought, which could contribute to the incidence of neurological symptomatology in this region, especially after trauma or degenerative changes.

Anatomical and biomechanical characteristics of upper cervical ligamentous structures: a review.

Anatomical and biomechanical characteristics of upper cervical ligamentous structures are discussed. These ligaments tend to operate in a manner slightly different from others in the axial skeleton, while still maintaining normal checks in motion. This paper provides review of these ligamentous functions.

Acupuncture points of the brachial plexus.

This publication is the third of a total of six papers intended to name acupuncture points following the anatomic nomenclatures. In the first publication, acupuncture points in the head are named using terminal branches of the trigeminal nerve and the muscles of facial expression. In the second publication, acupuncture points in the neck are named using the cutaneous nerves of the cervical plexus and neuromuscular attachments formed by the spinal accessory nerve on the trapezius muscle. In this third publication, acupuncture points existing on the upper limbs are described following the terminal branches of the brachial plexus.