Procedure Selection and Patient Positioning Influence Spine Kinematics During High-Velocity, Low-Amplitude Spinal Manipulation Applied to the Low Back.

OBJECTIVES: This investigation compared indirect 3-dimensional angular kinematics (position, velocity, and acceleration) of the lumbar spine for 2 different high-velocity, low-amplitude (HVLA) spinal manipulation procedures (lumbar spinous pull or push), and altered initial patient lower limb posture. METHODS: Twenty-four participants underwent 6 HVLA procedures directed toward the presumed L4 vertebra, reflecting each combination of 2 variants of a spinal manipulation application technique (spinous pull and push) and 3 initial hip flexion angles (0°, 45°, and 90°) applied using a right lateral recumbent patient position. All contact forces and moments between the patient and the external environment, as well as 3-dimensional kinematics of the patient's pelvis and thorax, were recorded. Lumbar spine angular positions, velocities, and accelerations were analyzed within the preload and impulse stages of each HVLA trial. RESULTS: Lumbar spine left axial rotation was greater for the pull HVLA. The pull HVLA also generated a greater maximum (leftward) and lower minimum (rightward) axial rotation velocity and deceleration and greater leftward and rightward lateral bend velocities, acceleration, and deceleration components. Not flexing the hip produced the greatest amount of extension, as well as the lowest axial rotation and maximum axial rotation acceleration during the impulse. CONCLUSIONS: This investigation provides basic kinematic information for clinicians to understand the similarities and differences between 2 HVLA side-lying manipulations in the lumbar spine. Use of these findings and novel technology can drive future research initiatives that can both affect clinical decision making and influence teaching environments surrounding spinal manipulative therapy skill acquisition.

Development of a Linked Segment Model to Derive Patient Low Back Reaction Forces and Moments During High-Velocity Low-Amplitude Spinal Manipulation.

OBJECTIVE: The purpose of this paper is to present the experimental setup, the development, and implementation of a new scalable model capable of efficiently handling data required to determine low back kinetics during high-velocity low-amplitude spinal manipulation (HVLA-SM). METHODS: The model was implemented in Visual3D software. All contact forces and moments between the patient and the external environment (2 clinician hand contact forces, 1 contact force between the patient and the treatment table), the patient upper body kinematics, and inertial properties were used as input. Spine kinetics and kinematics were determined from a single HVLA-SM applied to one healthy participant in a right side-lying posture to demonstrate the model's utility. The net applied force was used to separate the spine kinetic and kinematic time-series data from the HVLA-SM into preload as well as early and late impulse phases. RESULTS: Time-series data obtained from the HVLA-SM procedure showed that the participant's spine underwent left axial rotation, combined with extension, and a reduction in left lateral bending during the procedure. All components of the reaction force, as well as the axial twist and flexion/extension reaction moments demonstrated a sinusoidal pattern during the early and late impulse phases. During the early impulse phase, the participant's spine experienced a leftward axial twisting moment of 37.0 Nm followed by a rightward moment of -45.8 Nm. The lateral bend reaction moment exhibited a bimodal pattern during the early and late impulse phases. CONCLUSION: This model was the first attempt to directly measure all contact forces acting on the participant/patient's upper body, and integrate them with spine kinematic data to determine patient low back reaction forces and moments during HVLA-SM in a side-lying posture. Advantages of this model include the brevity of data collection (<1 hour), and adaptability for different patient anthropometries and clinician-patient contacts.

The Effectiveness of Exercise on Recovery and Clinical Outcomes in Patients With Soft Tissue Injuries of the Hip, Thigh, or Knee: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

OBJECTIVE: The purpose of this systematic review was to determine the effectiveness of exercise for the management of soft tissue injuries of the hip, thigh, and knee. METHODS: We conducted a systematic review and searched MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials, and CINAHL Plus with Full Text from January 1, 1990, to April 8, 2015, for randomized controlled trials (RCTs), cohort studies, and case-control studies evaluating the effect of exercise on pain intensity, self-rated recovery, functional recovery, health-related quality of life, psychological outcomes, and adverse events. Random pairs of independent reviewers screened titles and abstracts and assessed risk of bias using the Scottish Intercollegiate Guidelines Network criteria. Best evidence synthesis methodology was used. RESULTS: We screened 9494 citations. Eight RCTs were critically appraised, and 3 had low risk of bias and were included in our synthesis. One RCT found statistically significant improvements in pain and function favoring clinic-based progressive combined exercises over a "wait and see" approach for patellofemoral pain syndrome. A second RCT suggests that supervised closed kinetic chain exercises may lead to greater symptom improvement than open chain exercises for patellofemoral pain syndrome. One RCT suggests that clinic-based group exercises may be more effective than multimodal physiotherapy in male athletes with persistent groin pain. CONCLUSION: We found limited high-quality evidence to support the use of exercise for the management of soft tissue injuries of the lower extremity. The evidence suggests that clinic-based exercise programs may benefit patients with patellofemoral pain syndrome and persistent groin pain. Further high-quality research is needed.

The effectiveness of passive physical modalities for the management of soft tissue injuries and neuropathies of the wrist and hand: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.

OBJECTIVE: The purpose of this systematic review was to determine the effectiveness of passive physical modalities compared to other interventions, placebo/sham interventions, or no intervention in improving self-rated recovery, functional recovery, clinical outcomes and/or administrative outcomes (eg, time of disability benefits) in adults and/or children with soft tissue injuries and neuropathies of the wrist and hand. METHODS: We systematically searched MEDLINE, EMBASE, PsycINFO, and the Cochrane Central Register of Controlled Trials, accessed through Ovid Technologies, Inc, and CINAHL Plus with Full Text, accessed through EBSCO host, from 1990 to 2015. Our search strategies combined controlled vocabulary relevant to each database (eg, MeSH for MEDLINE) and text words relevant to our research question and the inclusion criteria. Randomized controlled trials, cohort studies, and case-control studies were eligible. Random pairs of independent reviewers screened studies for relevance and critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with low risk of bias were synthesized following best evidence synthesis principles. RESULTS: We screened 6618 articles and critically appraised 11 studies. Of those, 7 had low risk of bias: 5 addressed carpal tunnel syndrome (CTS) and 2 addressed de Quervain disease. We found evidence that various types of night splints lead to similar outcomes for the management of CTS. The evidence suggests that a night wrist splint is less effective than surgery in the short term but not in the long term. Furthermore, a night wrist splint and needle electroacupuncture lead to similar outcomes immediately postintervention. Finally, low-level laser therapy and placebo low-level laser therapy lead to similar outcomes. The evidence suggests that kinesio tape or a thumb spica cast offers short-term benefit for the management of de Quervain disease. Our search did not identify any low risk of bias studies examining the effectiveness of passive physical modalities for the management of other soft tissue injuries or neuropathies of the wrist and hand. CONCLUSIONS: Different night orthoses provided similar outcomes for CTS. Night orthoses offer similar outcomes to electroacupuncture but are less effective than surgery in the short term. This review suggests that kinesio tape or a thumb spica cast may offer short-term benefit for the management of de Quervain disease.

The effectiveness of exercise for the management of musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.

OBJECTIVE: The purpose of this systematic review was to evaluate the effectiveness of exercise compared to other interventions, placebo/sham intervention, or no intervention in improving self-rated recovery, functional recovery, clinical, and/or administrative outcomes in individuals with musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand. METHODS: We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Paired reviewers independently screened studies for relevance and assessed the risk of bias using the Scottish Intercollegiate Guidelines Network criteria. We synthesized the evidence using the best evidence synthesis methodology. RESULTS: We identified 5 studies with a low risk of bias. Our review suggests that, for patients with persistent lateral epicondylitis, (1) adding concentric or eccentric strengthening exercises to home stretching exercises provides no additional benefits; (2) a home program of either eccentric or concentric strengthening exercises leads to similar outcomes; (3) home wrist extensor strengthening exercises lead to greater short-term improvements in pain reduction compared to "wait and see"; and (4) clinic-based, supervised exercise may be more beneficial than home exercises with minimal improvements in pain and function. For hand pain of variable duration, supervised progressive strength training added to advice to continue normal physical activity provides no additional benefits. CONCLUSION: The relative effectiveness of stretching vs strengthening for the wrist extensors remains unknown for the management of persistent lateral epicondylitis. The current evidence shows that the addition of supervised progressive strength training does not provide further benefits over advice to continue normal physical activity for hand pain of variable duration.

A posterior ring apophyseal fracture and disc herniation in a 21-year-old competitive basketball player: a case report.

OBJECTIVE: To describe the diagnosis and management of a competitive male basketball player with discogenic low back pain and presence of an old posterior ring apophyseal fracture (PRAF). This case will highlight the importance of early recognition and considerations regarding patient management for this differential of radiating low back pain. CLINICAL FEATURES: A 21-year-old provincial basketball player presented with recurrent radiating low back pain into the left groin and lower limb. After several weeks of persistent symptoms including pain, muscle weakness, and changes in the Achilles deep tendon reflex, imaging was obtained that revealed a large disc extrusion with an old posterior ring apophyseal fracture. In collaboration with a spine surgeon and family physician, the patient was treated using a conservative, multimodal approach. Treatment consisted of graded mobilizations, spinal manipulative therapy, interferential current, and soft tissue therapy to the lumbar spine. Rehabilitation exercises focused on centralizing symptoms and improving strength, proprioception and function of the lower limb. After a period of 8 weeks, the patient was able to complete all activities of daily living without pain in addition to returning to basketball practice. SUMMARY: PRAF is a unique condition in the immature spine and recent evidence suggests that those involved in sports requiring repetitive motion of the lumbar spine may be at increased risk. The astute clinician must consider this differential in young populations presenting with discogenic low back pain, as a timely diagnosis and necessary referral may allow for effective conservative management to reduce symptoms. Equally as important, one must be aware of the complications from PRAF as a contributing source of low back pain and dysfunction into adulthood. Knowing when to refer for advanced imaging and/or a surgical consult given the variable clinical presentation and prognosis is an essential component to care.

OBJECTIF: Décrire le diagnostic et la prise en charge d'un joueur de basketball de compétition atteint de lombalgie d'origine discale et présentant une ancienne fracture des apophyses postérieures. Ce cas mettra en évidence l'importance d'un dépistage précoce ainsi que des considérations relatives à la prise en charge du patient pour ce différentiel de lombalgie irradiée. CARACTÉRISTIQUES CLINIQUES: Un joueur de basketball provincial de 21 ans présentait une lombalgie irradiée récurrente au niveau de la partie gauche de l'aine et du membre inférieur. Après plusieurs semaines de symptômes persistants parmi lesquels la douleur, une faiblesse musculaire et des modifications du réflexe achilléen, l'imagerie médicale a été obtenue. Cette dernière a révélé une importante extrusion discale ainsi qu'une ancienne fracture des apophyses postérieures. En collaboration avec un chirurgien spécialiste de la colonne vertébrale et un médecin de famille, le patient a été soigné à l'aide d'une approche multimodale conventionnelle. Le traitement consistait en des mobilisations graduelles, en des manipulations vertébrales, en une électrothérapie à courants interférentiels, et en un traitement des tissus mous au niveau du rachis lombaire. Les exercices de rééducation étaient axés sur la centralisation des symptômes et l'accroissement de la puissance, de la proprioception et du fonctionnement du membre inférieur. Après huit semaines, le patient était en mesure de réaliser l'ensemble des activités de la vie quotidienne sans ressentir de douleur et de reprendre les entraînements de basketball. RÉSUMÉ: Les fractures des apophyses postérieures sont un état unique de la colonne vertébrale immature. Des données probantes récentes suggèrent que les sujets pratiquant une activité sportive requérant un mouvement répétitif du rachis lombaire peuvent présenter un risque plus élevé. Les cliniciens avisés doivent tenir compte du différentiel chez les populations de jeunes personnes souffrant d'une lombalgie d'origine discale dans la mesure où un diagnostic en temps opportun et un aiguillage nécessaire peuvent permettre une prise en charge conventionnelle efficace pour réduire les symptômes. Il est tout aussi important et nécessaire d'avoir connaissance des complications associées aux fractures des apophyses postérieures, qui peuvent entraîner une lombalgie et un dysfonctionnement du rachis lombaire à l'âge adulte. Savoir quand se référer à des technologies d'imagerie de pointe ou à l'avis d'un chirurgien au vu de la présentation clinique et du pronostic variables est une composante essentielle du traitement.

Conservative management of an elite ice hockey goaltender with femoroacetabular impingement (FAI): a case report.

OBJECTIVE: To detail the presentation of an elite male ice hockey goaltender with cam-type femoroacetabular impingement (FAI) and acetabular labral tears. This case will outline the prevalence, clinical presentation, imaging criteria, pathomechanics, and management of FAI, with specific emphasis on the ice hockey goaltender. CLINICAL FEATURES: A 22-year old retired ice hockey goaltender presented to a chiropractor after being diagnosed by an orthopaedic surgeon with MRI confirmed left longitudinal and chondral flap acetabular labral tears and cam-type femoroacetabular impingement (FAI). As the patient was not a candidate for surgical intervention, a multimodal conservative treatment approach including manual therapy, electroacupuncture and rehabilitation exercises were implemented. SUMMARY: FAI is prevalent in ice hockey players, particularly with goaltenders. Both skating and position-dependent hip joint mechanics involved in ice hockey may exacerbate or contribute to acquired and congenital forms of symptomatic FAI. As such, practitioners managing this population must address sport-specific demands in manual therapy, rehabilitation and physical training, to improve functional outcomes and prevent future injury.

OBJECTIF: Décrire la présentation d'un gardien de but de hockey sur glace d'élite souffrant d'un conflit fémoroacétabulaire (CFA) de type came et de déchirures du labrum acétabulaire. Ce cas présentera la prévalence, la présentation clinique, les critères d'imagerie, la pathomécanique et la prise en charge du CFA, en mettant l'accent sur le gardien de but de hockey sur glace. CARACTÉRISTIQUES CLINIQUES: Un gardien de but de hockey sur glace à la retraite de 22 ans a consulté un chiropraticien après avoir reçu, de la part d'un chirurgien orthopédique, un diagnostic, confirmé par IRM, de déchirures du labrum acétabulaire chondrales et longitudinales du côté gauche et d'un conflit fémoroacétabulaire (CFA). Comme le patient n'était pas candidat à une intervention chirurgicale, une approche thérapeutique conventionnelle multimodale comprenant la thérapeutique manuelle, l'électroacupuncture et des exercices de réadaptation a été mise en œuvre. RÉSUMÉ: Le CFA est prévalent chez les joueurs de hockey sur glace, en particulier chez les gardiens de but. Les pas de patinage et le mécanisme dépendant de la position de l'articulation de la hanche utilisés dans le hockey sur glace peuvent exacerber les formes congénitales ou acquises du CFA symptomatique, ou y contribuer. Ainsi, les praticiens prenant en charge cette population doivent traiter les demandes propres au domaine sportif en ayant recours à la thérapeutique manuelle, à la réadaptation et à l'exercice physique, afin d'améliorer les résultats fonctionnels et de prévenir les lésions futures.