Impact of Traditional Versus Flavored Tongue Depressors on Pediatric Oropharynx Exam.

We compared patient-reported discomfort associated with oropharynx examination using traditional (unflavored) versus flavored tongue depressors among pediatric patients presenting to the emergency department in a single-blinded, placebo-controlled randomized trial using a convenience sample ages 3 to 12 years. Our primary outcome was patient discomfort. Secondary outcomes included provider perceptions of patient discomfort, provider-reported examination ease, and caregiver perceptions of patient discomfort. Of 96 recruited patients, 92 (95.8%) completed the study. Forty-six (50%) were randomized to a traditional tongue depressor. Mean patient-reported oropharynx examination discomfort scores were 2.3 cm (95% confidence interval = 1.4-3.2 cm) with traditional tongue depressors versus 1.9 cm (95% confidence interval = 1.0-2.8 cm) with flavored tongue depressors ( P = .72). There were similarly no significant differences between the 2 arms with regard to any of the secondary outcomes. We conclude that the use of flavored tongue depressors does not appear to significantly alleviate discomfort associated with examination of the oropharynx in pediatric patients.

Handheld Tissue Hardness Meters for Assessing the Mechanical Properties of Skeletal Muscle: A Feasibility Study.

OBJECTIVES: The purpose of this study was to examine the feasibility of using handheld tissue hardness meters to assess the mechanical properties of skeletal muscle. METHODS: This observational study included 33 healthy men (age, 22.4 ± 4.4 years) and 33 healthy women (age, 23.7 ± 4.2 years). Participants were placed in a supine position, and tissue hardness overlying the rectus femoris and the shear modulus of the muscle were measured on the right side of the body at 50% thigh length. In the same position, subcutaneous adipose tissue thickness and muscle thickness were measured using B-mode ultrasonography. To examine the associations of subcutaneous adipose tissue thickness, muscle thickness, and muscle shear modulus with tissue hardness, linear regression using a stepwise bidirectional elimination approach was performed. RESULTS: Stepwise linear regression revealed that subcutaneous adipose tissue thickness (r = -0.38, P = .002) and muscle shear modulus (r = 0.27, P = .03) were significantly associated with tissue hardness. CONCLUSIONS: Significant associations among adipose tissue thickness, muscle shear modulus, and tissue hardness show the limitations and feasibility of handheld tissue hardness meters for assessing the mechanical properties of skeletal muscles.

Development of the quantitative indicator of abdominal examination for clinical application: a pilot study.

OBJECTIVES: Abdominal examination (AE) is the evaluation of the status of illness by examining the abdominal region in traditional Korean medicine (TKM). Although AE is currently considered an important diagnostic method in TKM, owing to its clinical usage, no studies have been conducted to objectively assess its accuracy and develop standards. DESIGN: Twelve healthy subjects and 21 patients with functional dyspepsia have participated in this study. The patients were classified into epigastric discomfort group (n=11) and epigastric discomfort with tenderness group (n=10) according to the clinical diagnosis by AE. After evaluating the subjective epigastric discomfort in all subjects, two independent clinicians measured the pressure pain threshold (PPT) two times at an acupoint (CV 14) using an algometer. We then assessed the interrater and intrarater reliability of the PPT measurements and evaluated the validity (sensitivity and specificity) via a receiver operating characteristic plot and optimal cutoff value. RESULTS: The results of the interrater reliability test showed a very strong correlation (correlation coefficient range: 0.82-0.91). The results of intrarater reliability test also showed a higher than average correlation (intraclass correlation coefficient: 0.58-0.70). The optimal cutoff value of PPT in the epigastric area was 1.8 kg/cm(2) with 100% sensitivity and 54.54% specificity. CONCLUSIONS: PPT measurements in the epigastric area with an algometer demonstrated high reliability and validity for AE, which makes this approach potentially useful in clinical applications as a new quantitative measurement in TKM.

An update on cutaneous aging treatment using herbs.

Skin aging is caused by several factors. Ultraviolet (UV) exposure as well as oxidative stress elevates inflammatory mediators causing degradation of the extracellular matrix, which is regarded as the major cause of skin wrinkles, one of the signs of aging. Topical applications of active ingredients protect against dermal photodamage and scavenge radicals that can delay skin aging. Matrix metalloproteinase inhibitors against degradation of collagen, elastin, and hyaluronan are the key strategy to combat cutaneous aging. In addition, active ingredients with the efficacy to enhance extracellular matrix production, including those with UV protection efficacy, play an important role in protecting the skin from aging. Naturally derived compounds for combating skin wrinkles are gaining more interest among the consumers as they are perceived to be milder, safer, and healthier. This article, therefore, briefly addresses the causes of skin aging and extensively summarizes on herbs appraisal for skin wrinkles treatment. Therefore, delaying aging of skin using the functional herbs would maintain the individual's appearance with high esthetic and psychosocial impacts.

Neural network study for standardizing pulse-taking depth by the width of artery.

To carry out a pulse diagnosis, a traditional Chinese medicine (TCM) physician presses the patient's wrist artery at three incremental depths, namely Fu (superficial), Zhong (medium), and Chen (deep). However, the definitions of the three depths are insufficiently clear for use with modern pulse diagnosis instruments (PDIs). In this paper, a quantitative method is proposed to express the pulse-taking depths based on the width of the artery (WA). Furthermore, an index, α, is developed for estimating WA for PDI application. The α value is obtained using an artificial neural network (ANN) model with contact pressure (CP) and sensor displacement (SD) as the inputs. The WA and SD data from an ultrasound instrument and CP and SD data from a PDI were analyzed. The results show that the mean prediction error and the standard deviation (STD) of the ANN model was 1.19% and 0.0467, respectively. Comparing the ANN model with the SD model by statistical method, it showed significant difference and the improvement in the mean prediction error and the STD was 71.62% and 29.78%, respectively. The α value can thus map WA with less individual variation than that of the values estimated directly using the SD model. Pulse signals at different depths thus can be acquired according to α value while using a PDI, providing TCM physicians with more reliable pulse information.

A generalizability theory study of athletic taping using the Technical Skill Assessment Instrument.

CONTEXT: Athletic taping skills are highly valued clinical competencies in the athletic therapy and training profession. The Technical Skill Assessment Instrument (TSAI) has been content validated and tested for intrarater reliability. OBJECTIVE: To test the reliability of the TSAI using a more robust measure of reliability, generalizability theory, and to hypothetically and mathematically project the optimal number of raters and scenarios to reliably measure athletic taping skills in the future. SETTING: Mount Royal University. DESIGN: Observational study. PATIENTS OR OTHER PARTICIPANTS: A total of 29 university students (8 men, 21 women; age = 20.79 ± 1.59 years) from the Athletic Therapy Program at Mount Royal University. INTERVENTION(S): Participants were allowed 10 minutes per scenario to complete prophylactic taping for a standardized patient presenting with (1) a 4-week-old second-degree ankle sprain and (2) a thumb that had been hyperextended. Two raters judged student performance using the TSAI. MAIN OUTCOME MEASURE(S): Generalizability coefficients were calculated using variance scores for raters, participants, and scenarios. A decision study was calculated to project the optimal number of raters and scenarios to achieve acceptable levels of reliability. Generalizability coefficients were interpreted the same as other reliability coefficients, with 0 indicating no reliability and 1.0 indicating perfect reliability. RESULTS: The result of our study design (2 raters, 1 standardized patient, 2 scenarios) was a generalizability coefficient of 0.67. Decision study projects indicated that 4 scenarios were necessary to reliably measure athletic taping skills. CONCLUSIONS: We found moderate reliability coefficients. Researchers should include more scenarios to reliably measure athletic taping skills. They should also focus on the development of evidence-based practice guidelines and standards of athletic taping and should test those standards using a psychometrically sound instrument, such as the TSAI.

Reproducibility of range of motion and muscle strength measurements in patients with hip osteoarthritis - an inter-rater study.

BACKGROUND: Assessment of range of motion (ROM) and muscle strength is fundamental in the clinical diagnosis of hip osteoarthritis (OA) but reproducibility of these measurements has mostly involved clinicians from secondary care and has rarely reported agreement parameters. Therefore, the primary objective of the study was to determine the inter-rater reproducibility of ROM and muscle strength measurements. Furthermore, the reliability of the overall assessment of clinical hip OA was evaluated. Reporting is in accordance with proposed guidelines for the reporting of reliability and agreement studies (GRRAS). METHODS: In a university hospital, four blinded raters independently examined patients with unilateral hip OA; two hospital orthopaedists independently examined 48 (24 men) patients and two primary care chiropractors examined 61 patients (29 men). ROM was measured in degrees (deg.) with a standard two-arm goniometer and muscle strength in Newton (N) using a hand-held dynamometer. Reproducibility is reported as agreement and reliability between paired raters of the same profession. Agreement is reported as limits of agreement (LoA) and reliability is reported with intraclass correlation coefficients (ICC). Reliability of the overall assessment of clinical OA is reported as weighted kappa. RESULTS: Between orthopaedists, agreement for ROM ranged from LoA [-28-12 deg.] for internal rotation to [-8-13 deg.] for extension. ICC ranged between 0.53 and 0.73, highest for flexion. For muscle strength between orthopaedists, LoA ranged from [-65-47N] for external rotation to [-10 -59N] for flexion. ICC ranged between 0.52 and 0.85, highest for abduction. Between chiropractors, agreement for ROM ranged from LoA [-25-30 deg.] for internal rotation to [-13-21 deg.] for flexion. ICC ranged between 0.14 and 0.79, highest for flexion. For muscle strength between chiropractors, LoA ranged between [-80-20N] for external rotation to [-146-55N] for abduction. ICC ranged between 0.38 and 0.81, highest for flexion. Weighted kappa for the overall assessment of clinical hip OA was 0.52 between orthopaedists and 0.65 between chiropractors. CONCLUSIONS: Reproducibility of goniometric and dynamometric measurements of ROM and muscle strength in patients with hip OA is poor between experienced orthopaedists and between experienced chiropractors. Orthopaedists and chiropractors can to a moderate degree differentiate between hips with or without osteoarthritis.

Posteroanterior spinal stiffness at T5, T10, and L3 levels in normal subjects.

OBJECTIVE: To measure, by using standardized device and protocol, posteroanterior (PA) spinal stiffness at the 5th and 10th thoracic (T5 and T10) and 3rd lumbar (L3) vertebral levels in asymptomatic adult volunteers. DESIGN: A cross-sectional study. SETTING: Osteopathic Heritage Foundation Physical Medicine Core Research Laboratory where the Therapeutic Spinal Mobilizer was fabricated to standardize the testing protocol. PARTICIPANTS: Sixteen asymptomatic adult volunteers. METHODS: Volunteers were in the prone position on the treatment plinth and the loading block of the loading piston was placed at T5, T10, and L3. The subjects were instructed to remain still, to not contract any muscle, and to stop breathing mid cycle for 15 seconds when the data acquisition was initiated for a 10-second test cycle. The force was measured by using the load cell, and the spinal deformation was measured by the linear variable differential transducer. The data were extracted and subjected to descriptive statistics and analysis of variance to determine the effect of independent variables on spinal stiffness. RESULTS: The PA spinal stiffness at 3 spinal levels was significantly different (P < .0001). The spinal stiffness was significantly affected by the testing load, age, gender, and body weight of the subjects (P < .0001). The PA stiffness of the entire sample at 3 spinal levels ranged from 4.8-8.8 N/mm. The spinal stiffness values could be predicted as the function of testing load and body weight (P < .01). CONCLUSIONS: Results of this experiment suggest that the standardized and repeatable methodology will result in reliable stiffness values. Because the spinal stiffness is an indicator of patient's symptoms and it is an important variable in selection of treatment regimen, it is important to be able to measure this variable with a standardized protocol. Values from asymptomatic subjects can be used to study and to compare the symptomatic patients.

A mechano-acoustic indentor system for in vivo measurement of nonlinear elastic properties of soft tissue.

OBJECTIVES: Soft tissue exhibits nonlinear stress-strain behavior under compression. Characterizing its nonlinear elasticity may aid detection, diagnosis, and treatment of soft tissue abnormality. The purposes of this study were to develop a rate-controlled Mechano-Acoustic Indentor System and a corresponding finite element optimization method to extract nonlinear elastic parameters of soft tissue and evaluate its test-retest reliability. METHODS: An indentor system using a linear actuator to drive a force-sensitive probe with a tip-mounted ultrasound transducer was developed. Twenty independent sites at the upper lateral quadrant of the buttock from 11 asymptomatic subjects (7 men and 4 women from a chiropractic college) were indented at 6% per second for 3 sessions, each consisting of 5 trials. Tissue thickness, force at 25% deformation, and area under the load-deformation curve from 0% to 25% deformation were calculated. Optimized hyperelastic parameters of the soft tissue were calculated with a finite element model using a first-order Ogden material model. Load-deformation response on a standardized block was then simulated, and the corresponding area and force parameters were calculated. Between-trials repeatability and test-retest reliability of each parameter were evaluated using coefficients of variation and intraclass correlation coefficients, respectively. RESULTS: Load-deformation responses were highly reproducible under repeated measurements. Coefficients of variation of tissue thickness, area under the load-deformation curve from 0% to 25% deformation, and force at 25% deformation averaged 0.51%, 2.31%, and 2.23%, respectively. Intraclass correlation coefficients ranged between 0.959 and 0.999, indicating excellent test-retest reliability. CONCLUSIONS: The automated Mechano-Acoustic Indentor System and its corresponding optimization technique offers a viable technology to make in vivo measurement of the nonlinear elastic properties of soft tissue. This technology showed excellent between-trials repeatability and test-retest reliability with potential to quantify the effects of a wide variety of manual therapy techniques on the soft tissue elastic properties.

Sliding pressure algometer, a development in eliciting pressure pain thresholds at the boundaries of surface markings of abnormally tender regions.

The pressure algometer probe tip is usually held stationary and pressure is steadily increased from zero until a pressure pain threshold (PPT) is elicited. In order to explore the extent of surface markings of abnormally tender regions in more detail an improved method is proposed whereby the pressure algometer is not kept still. It is slid over the tissues at a predetermined downward pressure and velocity to produce compressive, tensile and shear stress within underlying tissues. It is moved over surrounding non-tender regions until it reaches the surface overlying an abnormally tender region where a PPT is evoked. The probe is removed immediately and the skin marked. When this is repeated from different directions, the boundary of the surface markings of a tender region will appear in corresponding detail. Provided that this 'sliding pressure algometer' produces sufficiently similar amounts of stress when applied on separate occasions, it can be used to monitor the progress of a condition or the effects of treatment. To reduce cost and increase availability, this pressure algometer may be made of a plastic syringe converted into a gas-tight chamber.

Age-related hyperkyphosis: its causes, consequences, and management.

SYNOPSIS: Age-related hyperkyphosis is an exaggerated anterior curvature in the thoracic spine that occurs commonly with advanced age. This condition is associated with low bone mass, vertebral compression fractures, and degenerative disc disease, and contributes to difficulty performing activities of daily living and decline in physical performance. While there are effective treatments, currently there are no public health approaches to prevent hyperkyphosis among older adults. Our objective is to review the prevalence and natural history of hyperkyphosis, associated health implications, measurement tools, and treatments to prevent this debilitating condition. LEVEL OF EVIDENCE: Diagnosis/prognosis/therapy, level 5.J Orthop Sports Phys Ther 2010;40(6):352-360, Epub 15 April 2010. doi:10.2519/jospt.2010.3099.

Reliability of the spin-T cervical goniometer in measuring cervical range of motion in an asymptomatic Indian population.

OBJECTIVE: To examine the intratester reliability of the Spin-T goniometer, a cervical range of motion device, in a normal Indian population. METHODS: Subjects comprised 30 healthy adults with mean age of 34 years (range, 18-65 years). The subjects were stabilized in the sitting position and the Spin-T goniometer mounted on the head of the subject. The study design was a within-subject repeated intratester reliability trial conducted for cervical range of motion in 6 directions of movement. Three measurements were taken in each direction (flexion, extension lateral flexion, and lateral rotation) per participant. Reliability coefficients, intraclass correlation coefficients, and 95% confidence interval were derived from repeated-measures analysis of variance (ANOVA). Where differences in ANOVA were detected, a paired t test was conducted and the typical error values and coefficient of variance were calculated. RESULTS: All repeated measures showed high intraclass correlation coefficients (all >0.96, P < .01). The ANOVA detected no differences between trials for all movements except rotation. The typical error values for the rotation trials did not exceed 2.5 degrees and the coefficient of variance did not exceed 4%, which is clinically acceptable considering the normally variable cervical range of movement. CONCLUSION: In this study, the Spin-T goniometer proved to be a reliable measuring instrument for cervical range of movement in an Indian population. The use of a laser pointer fixed to the instrument ensured a consistent neutral start position.

Sagittal skin contour of the cervical spine: interexaminer and intraexaminer reliability of the flexicurve instrument.

OBJECTIVES: To evaluate reliability of a simple instrument, the flexicurve, in determining cervical sagittal skin contour. METHODS: This study obtained repeated random measurements involving 3 investigators and 30 subjects once per day over a 2-day trial period. Thirty normal subjects were examined for cervical spine skin contour twice by 3 separate investigators with a 1-day delay. With subjects in a neutral standing position, investigators placed the flexicurve on the posterior portion of the subject's neck from the external occipital protuberance to the vertebral prominens and traced the flexicurve shape onto paper. The tracings were divided into 6 equal arcs and digitized. Statistical computation was performed on the depth at 5 points, arc angle, and arc radius of curvature. Interexaminer and intraexaminer correlation coefficients (ICCs) were calculated to determine reliability. RESULTS: All interexaminer correlation coefficients were in the poor range (<0.40). For the arc radius, arc angle, depth at top one third, and depth at bottom two thirds, the intraexaminer correlation coefficients were in the poor range. For the 3 deepest depths, the intraexaminer correlation coefficients were in the fair range (0.4-0.50). CONCLUSION: The flexicurve showed marginal reliability with most (12/16) ICCs in the poor range (ICC <0.40) and 4 values in the fair range (0.4 < ICC < 0.5).

EMG biofeedback assisted KT-1000 evaluation of anterior tibial displacement.

Two studies were undertaken to evaluate the use of EMG biofeedback to encourage hamstring relaxation during KT-1000 measurement of anterior tibial displacement. In study 1, 60 ACL-deficient patients were studied in three groups using 15 lb and 20 lb in each group: in group 1 the patients were simply retested 15 min after the initial test sequence, in group 2 they were initially retested with EMG biofeedback and then again without, and in group 3 they were retested twice with EMG biofeedback. No significant difference in mean anterior tibial displacement was seen between the initial measurements and retest measurements when no EMG biofeedback was used. A significant increase in mean anterior tibial displacement was seen when the retesting was performed with EMG biofeedback. No further increase was seen with repeated retesting with EMG biofeedback. In study 2, 40 patients were evaluated 4-12 months following ACL reconstruction. KT-1000 measurements of anterior tibial displacement of both the operated and non-operated knees were made at 15 lb and 30 lb with and without the use of EMG biofeedback. EMG biofeedback was associated with a significant increase in unilateral measurement of anterior tibial displacement. When side-to-side differences were compared, there was a small but statistically significant increase in anterior tibial displacement with the use of EMG biofeedback. Although the use of EMG biofeedback to encourage hamstring relaxation does increase unilateral measurements of anterior tibial displacement, it does not appear to have a clinically significant effect on measurement of side-to-side difference. It may have a role in testing patients who have difficulty achieving hamstring relaxation or in aiding inexperienced examiners.

The reliability of balance tests performed on the kinesthetic ability trainer (KAT 2000).

The Kinesthetic Ability Trainer (KAT 2000) is a balance platform designed for training and functional testing of the neuromuscular control system. Forty healthy and sports-active persons were tested and 1 month later retested to investigate the reliability of the KAT 2000 testing "one-leg static balance" and "two-leg dynamic balance". A significant improvement at retesting on the same day was seen in both tests; furthermore the dynamic test result improved significantly with retesting 1 month later. The data obtained made it possible to calculate the 95% confidence limits for an unchanged test result for a single person and a group of persons. The results show a clear learning effect when the persons are retested, especially in the dynamic test. The KAT 2000 can be used as a tool for testing groups of persons both in short- and long-term studies, but it cannot be used for testing single persons due to the great variance in the test results. Further investigations involving injured persons are needed to determine the range of improvement after intervention.

A new symmetry-based scoring method for posture assessment: evaluation of the effect of insoles with mineral derivatives.

BACKGROUND: There is a need for a validated rapid procedure for the evaluation of posture, defined as lateral balance/imbalance at the pelvic, shoulder, and neck levels. This would enable clinicians to determine the importance of symmetry in the pathophysiology of musculoskeletal disorders and to assess the efficacy of devices and treatments claiming to normalize or improve posture. In this investigation, the efficacy of such a device, a set of insoles with a hypothesized proprioceptive-like action, was evaluated through use of the described procedure. OBJECTIVES: To develop a new scoring system to evaluate body posture on the basis of symmetry and to use this scoring system to investigate the efficacy of insoles containing a combination of mineral derivatives designed to balance posture through a neurophysiological effect. METHODS: The posture score was based on the evaluation of 4 postural parameters: pelvic and shoulder lateral balance/imbalance, static shoulder rotation, and amplitude of head rotation. In the placebo-controlled study, 32 patients were tested in a double-blind fashion, either with placebo insoles or with insoles containing mineral derivatives. The same study was repeated in unblind conditions in 137 patients selected from 2 chiropractic clinics in an open-label protocol. STUDY DESIGNS: A crossover placebo-controlled, double-blind study and a multicenter, large-scale, open-label study in patients selected from chiropractic clinics. RESULTS: A basal postural evaluation in 137 patients revealed that no patient had a perfect symmetry-ie, a perfectly or nearly perfectly balanced posture. The insoles with mineral derivatives induced a highly significant and similar improvement in the postural score in both the crossover double-blind study (32 patients; 56.7% improvement) and the open-label study (137 patients; 60.7% improvement, P < 0.001). CONCLUSIONS: All patients tested and selected in chiropractic clinics exhibited asymmetries and postural imbalances according to the newly developed scoring method, and this method was successful in assessing the efficacy of insoles exerting a profound and immediate postural effect through a hypothesized neurophysiological mode of action.

Stiffness judgments are affected by visual occlusion.

OBJECTIVE: The current protocol for judging posteroanterior (PA) spinal stiffness has been shown to provide unreliable estimates of PA stiffness. It is possible that a failure to standardize therapists' use of vision in the test protocol partly contributes to the disagreement between raters. This study sought to establish whether vision affects stiffness judgments and so needs to be standardized when judging PA stiffness. DESIGN: Perceptual study using a mechanical device to provide stiffness stimuli with physiotherapists and lay people as judges. SETTING: University psychophysics laboratory. INTERVENTIONS: Occlusion of vision via opaque goggles. MAIN OUTCOME MEASURES: Measures of interstimulus discriminability and bias. RESULTS: Occluding vision had no effect on judges' ability to discriminate between stiffness stimuli; however, the same stimuli were judged as significantly stiffer under the visual occlusion condition. CONCLUSION: The data from this study suggest that vision needs to be controlled when using manual tests to judge PA spinal stiffness.

An in vivo strain gage study of elongation of the anterior cruciate ligament.

The purpose of this paper is to study the load-elongation characteristics of a Grade II sprain of the anterior cruciate ligament (ACL) at the time of local anesthesia arthroscopy. The data may be used to increase diagnostic and prognostic accuracy when evaluating Grade II ACL sprains and to structure properly a rehabilitation program following ACL injury. This report is based on the data from two in vivo strain gage studies of Grade II ACL sprains. Following instrumentation of the ligament, several events common to physical examination and rehabilitation programs were tested. The Lachman test produced greater elongation of the anteromedial fibers than did the anterior drawer or pivot shift test. A fairly high force of 80 pounds may be required by the examiner's hands to test satisfactorily the anteromedial fibers in the acutely injured large athlete. The proper order for a rehabilitation program should be crutch walking, cycling, walking, slow running, and faster running. Patients should be cautioned to run on a perfectly level surface. Cycling produced 7% as much elongation as an 80 pound Lachman test, and the one leg half squat 21% as much. Quadriceps rehabilitation can be done more safely using these exercises. Quadriceps exercises by knee extension against a 20 pound weight boot in the range of full extension to 22 degrees flexion created peak elongation of the anteromedial fibers ranging from 87 to 121% of that produced by an 80 pound Lachman test. We recommend that quadriceps exercises and testing by knee extension through a full range of motion not be done during the first year following ACL injury or reconstruction.(ABSTRACT TRUNCATED AT 250 WORDS)