The relationship between thoracic posture and ultrasound echo intensity of muscles spanning this region in healthy men and women.

PURPOSE: Skeletal muscle echogenicity intensity (EI) is considered a measure of muscle quality, being associated with old age and pathologies. Whether EI variations can be identified in healthy adults, due to habitual shortened or elongated muscle position is unknown. Thus, this study aimed to assess the relationship between thoracic kyphosis angulation and EI scores of muscles spanning this region ((Lower Trapezius (LT), Rhomboid Major (RM), Erector Spine (ES)) in healthy young people and in addition to examine the relationship between the change in thoracic kyphosis angle from relaxed to upright position (∆°) and the EI of these muscles. METHODS: Thoracic kyphosis in relaxed and erect standing was measured using a digital inclinometer in 29 healthy adults (16 women, 13 men), aged 25-35 years. The thoracic kyphosis angles including the difference between relaxed and erect postures (∆°) were correlated to the EI scores of right and left LT, RM and ES. RESULTS: No significant differences in EI were found between the 3 muscles EI or between sides, hence they were pooled together to a total thoracic EI score (TTEI). Although the TTEI did not correlate with relaxed or erect thoracic kyphosis, it was significantly but negatively correlated with ∆° in the entire group: Pearson's correlation coefficient of r = -0.544; p = .01 and in men; r = -0.732; p = .01, failing to reach significance in women; r = -0.457. CONCLUSION: The negative association between the EI of the explored muscles and ∆° could imply a possible relationship between these muscles range of movement excursions and their composition.

Angular and linear spinal parameters associated with relaxed and erect postures in healthy subjects.

Spinal posture assessment is an essential component in physical evaluation. Establishing reproducible value of spinal curves is necessary for detecting postural changes. Therefore, the main objectives of this study were to assess the reproducibility of spinal curves in relaxed standing of healthy subjects and to explore the extent and pattern of change upon transition from relaxed to a fully erect posture. Thirty young women and men were measured twice over a 1 week interval for recording the cervical, thoracic, and lumbar curves values using an ultrasound-based system. Thereafter, additional 28 men and women extracted from the same reference group were assigned for a single measurement session, in which the same angular values were obtained in relaxed and fully erect standing postures, as well as stature using stadiometer. Excellent, good, and poor reproducibility indices, standard error of measurement (SEM), and smallest real difference (SRD), were noted for the thoracic (interclass correlation coefficient, ICC(3,3) = 0.95, SEM = 1.2°, SRD = 3.3°), lumbar (ICC(3,3) = 0.85, SEM = 2.6°, SRD = 7.2°), and cervical (ICC(3,3) = 0.68, SEM = 3.8°, SRD = 10.5°) curves, respectively. Erecting from relaxed posture was associated with a significant (>SRD) thoracic angle difference of 7.2° in men and 4.8° in women which was expressed in a height increase of 1.3 cm in men and 0.8 cm in women. These changes were significantly larger in men in whom the angular and height differences were also significantly correlated (r = 0.7). Using this system, angular measurements are highly reproducible in the thoracic curvature in young healthy adults, leading to the use of the associated SRD as a criterion for thoracic postural flexibility.

Reproducibility and validity of digital inclinometry for measuring cervical range of motion in normal subjects.

BACKGROUND AND PURPOSE: Measurements of cervical range of motion (CROM) have been extensively reported in the past decade employing simple (goniometers) as well as sophisticated (electro-, magneto- and ultrasonography-based) systems. The recent introduction of the simple, user-friendly and relatively cheap digital inclinometer (DI) has opened a potentially new venue for measurement of this segment's motion. The purpose of the present study was to assess intra-tester reproducibility of DI-based findings as well as its validity in comparison to the ultrasonography-based Zebris CMS 70P (Zebris Medizintechnik Gmbh, Isny, Germany) for measuring CROM in normal subjects. METHODS: Active CROM of healthy women (n = 15) and men (n = 15) aged 24.2(2.4) years was measured on two sessions, Test 1 and Test 2, spread over 7.2(+/-0.7) days apart. On Test 1, the six primary movements of the neck (flexion, F; extension, E; right and left lateral flexion, RLF and LLF; and right and left rotations, RR and LR) were measured using the DI and the Zebris. On Test 2, the same measurements were performed using the DI only. All measurements were conducted by the same tester, with the subject in the seated position. The only exception was DI measurement of cervical rotation that was performed in the supine position due to the DI gravity-dependence, rendering DI measurements in the transverse plane irrelevant. RESULTS: No significant differences were revealed between the two instruments with respect to the sagittal and frontal planes, whereas the DI-based CROM in rotation was significantly greater then its Zebris-based counterpart. The inter-device interclass correlation coefficients (ICCs) for the frontal were 0.72 (RLF) and 0.62 (LLF), and 0.77 (F) and 0.83 (E). Poor correlations were indicated for the rotations. The intra-tester reproducibility derived from the test-retest DI measurement indicated good to excellent reproducibility in all planes with ICCs ranging from 0.82 (LLF) to 0.94 (E). The Standard Error of Measurement ranged from 1.6 degrees (RR) to 2.6 degrees (F). CONCLUSION: DI-based CROM measurements are reproducible and valid for recording sagittal and frontal plane motions in healthy subjects. The higher range in rotations, relative to the Zebris-based findings, is most probably attributable to the test position. Being relatively cheap, portable and convenient for tester and subject alike, the DI seems to be an effective instrument for assessing CROM.

Cervical motion testing: methodology and clinical implications.

BACKGROUND: Measurement of cervical motion (CM) is probably the most commonly applied functional outcome measure in assessing the status of patients with cervical pathology. In general terms, CM refers to motion of the head relative to the trunk as well as conjunct motions within the cervical spine. SPECIAL FEATURES: Multiple techniques and instruments have been used for assessing CM. These were associated with a wide variety of parameters relating to accuracy, reproducibility, and validity. Modern measurement systems enable recording, processing, and documentation of CM with a high degree of precision. SUMMARY: Cervical motion measures provide substantial information regarding the severity of motion limitation and level of effort in cervically involved patients. They may also be used for following up performance during and after conservative or invasive interventions.

Cervical muscles strength testing: methods and clinical implications.

BACKGROUND: Neck muscles are responsible for directing the head and for maintaining its posture. As a result, the muscular mechanical output is correspondingly moderate but not insignificant as evidenced by a positive therapeutic effect when reconditioning is indicated. SPECIAL FEATURES: Cervical muscle strength (CS) measurement and interpretation occupy a unique niche in the domain of muscle performance. Due to the wide variety of devices and protocols, a vast range of strength scores has been reported, denying the formation of reliable reference values. METHODS: A literature search based on the keywords "cervical/head/neck" strength was conducted. The search yielded 34 relevant papers which were reviewed according to preset criteria. SUMMARY: Overall studies indicate that compared to normal subjects patients suffering from neck-related disorders present with significant reduction in CS, whereas women are weaker than men by about 40%. Noteworthy a significant drop in CS in both sexes is delayed until the seventh decade. In terms of its reproducibility, CS findings have been investigated using primarily relative parameters, and hence, the associated error is not yet established. Therefore, application of CS as a clinical outcome measure, particularly for assessing change due to intervention, should be critically conducted.

Reproducibility of sagittal pelvic tilt measurements in normal subjects using digital inclinometry.

Standing sagittal pelvic tilt posture is widely assessed qualitatively, yet no efficient non-invasive quantitatively method is available for measuring pelvic tilt position or its amplitude. The main objective of the current study was to assess the intra- and inter-tester reproducibility of digital inclinometry-based (DI) measurements of pelvic tilt in healthy subjects. Pelvic inclination was measured while standing in neutral position (NP), maximal anterior pelvic tilt (APT) and maximal posterior pelvic tilt (PPT) which served for calculating the total pelvic tilt (TPT) range of motion (TPT=PPT-APT). On two separate test occasions two convenience samples of healthy women and men (N=15 in each) were each measured by two different testers. In both groups the intra-tester reproducibility indices of NP, APT, PPT and TPT were acceptable as revealed by high and significant ICCs and low standard error of measurements (SEM). In women the inter-tester reproducibility indices, of the same variables, were high as distinguished by no significant differences between testers and high and significant ICCs. In men, significant differences were found in APT and PPT but the between-testers TPT scores were similar. Collectively these findings indicate that pelvic inclinometry yields acceptable reproducibility which in the light of the facility of the method may render it an efficient clinical tool.

Reproducibility of pressure pain threshold and visual analog scale findings in chronic whiplash patients.

BACKGROUND: Assessment of pain in patients with whiplash-associated disorders has been previously reported using a variety of instruments. However, the reproducibility of the findings derived from such measurements has not been explored with respect to this particular patients group. OBJECTIVES: To evaluate the intratester and intertester reproducibility of pressure pain threshold (PPT) findings and the intratester reproducibility of visual analog scale (VAS) findings relating to the cervical region of chronic whiplash patients for the determination of smallest real difference values. METHODS: Twenty-one chronic whiplash patients: 13 women and 8 men participated in this study. The intratester paradigm was based on 2 testing sessions over a period of 5 to 11 days (7.95+/-1.90) and incorporated recording of VAS scores and also PPT scores relating to 3 pairs of right and left homologous cervical sites. The intertester study was conducted within the first testing session and referred to the PPT measurement only. In this session, patients were also asked to fill in the Neck Disability Index questionnaire. RESULTS: The interclass correlation coefficient-derived reproducibility of the PPT scores was good to excellent within and between testers ranging 0.85 to 0.91 and 0.88 to 0.97, respectively. There was, however, a significant difference between the testers. The VAS scores demonstrated lower reproducibility (interclass correlation coefficient=0.67). On the basis of the standard error of measurement, the smallest real difference of PPT ranged 40.2 to 58.9 kPa whereas the corresponding figure for the VAS was 3.76 cm. CONCLUSIONS: On the basis of the current patient sample, this study demonstrates that although PPT findings may generally be applied for monitoring change in chronic whiplash patients, the use of VAS scores should be limited to patients whose initial score is above 4. It is also suggested that if the PPT is to serve as an outcome measure, its measurement should be performed by the same tester.

Cervical motion in patients with chronic disorders of the cervical spine: a reproducibility study.

STUDY DESIGN: Test-retest of cervical motion in patients with chronic disorders of the cervical spine. OBJECTIVES: To determine the reproducibility of cervical motion and examine the feasibility of its representation by a single parameter. SUMMARY OF BACKGROUND DATA: Reproducibility of cervical motion findings has been largely limited to normal subjects, leaving a conspicuous void regarding the measurement error in clinical groups. METHODS: There were 2 groups of 25 chronic patients with whiplash and degenerative changes of the cervical spine tested twice (4-7 days). Head movement was measured along the 6 directions, as well as during rotation out of flexion and extension (cervical degenerative changes only). RESULTS: Compared to normal subjects, both groups had a 25% to 35% reduction in cervical motion. High intraclass correlation coefficients (ICCs) (range 0.8-0.92) were derived for all directions. The ICCs for rotation out of flexion and extension were low. The relative standard error of measurement ranged from 15% to 28% for all directions, whereas the corresponding scores of the total cervical motion excursion were 10.6 (cervical degenerative changes) and 13.6% (whiplash). CONCLUSIONS: Judged by the ICCs cervical motion, findings were reproducible. However, in view of the measurement error as well as the homogenous reductions, total cervical range of motion should be considered a suitable parameter for interpretation of cervical motion limitations in these patients.

Cervical radiofrequency neurotomy in patients with chronic whiplash: a study of multiple outcome measures.

OBJECT: Cervical radiofrequency neurotomy (CRFN) is used in the treatment of patients with chronic pain and disability due to whiplash injury. Confirmation of its efficiency has, however, been based solely on pain and psychological distress factors. The aim of the present study was to extend the assessment of CRFN efficacy by adding other outcome measures to shed light on neuromotor-functional-psychological interactions by undertaking comparison of pre- and 1-year postintervention data. METHODS: Forty patients with chronic whiplash injury-associated disorders were evaluated prior to and at two separate sessions after CRFN. The evaluation included Neck Disability Index, cervical range of motion, isometric cervical muscle strength, cervical pressure pain threshold, Symptom Check List-90-Revised, and subjective Self-Report of Improvement (SRI). The authors found that the CRFN had a significantly positive effect on all measured parameters. A case-by-case analysis revealed improvement in 70% of the patients at the final follow-up examination. Using stringent cutoff values, between 30 and 60% of the patients experienced measurable improvement. Evaluation of SRI results indicated that more than 80% of the patients were satisfied with the procedure. CONCLUSIONS: Approximately 1 year after intervention, CRFN was associated with an acceptable rate of success, as reflected by objective and subjective outcome measures.

Performance of cervical motion in chronic whiplash patients and healthy subjects: the case of atypical patients.

STUDY DESIGN: A comparative study of cervical motion performance in chronic whiplash (CW) patients and healthy subjects. OBJECTIVES: To examine the efficiency of total cervical range of motion (TCROM), which consists of the combined score of all six primary movements and their mean coefficient of variation (MCV), in differentiating CW patients from healthy subjects as well as typical from atypical patients. Additionally to explore in the patients possible relationships between their cervical motion profile and functional and personality traits. SUMMARY OF BACKGROUND DATA: Previous studies revealed that cervical motion was an efficient discriminator between healthy and CW patients. However, none of these studies provided either guidelines regarding cutoff scores or insight as to what should be considered typical compared with atypical patient with respect to cervical motion performance. METHODS: Cervical motion was measured in 75 healthy subjects and 101 CW patients in each of the six primary movements. In addition, patients filled the functional neck disability index (NDI) and personality symptom check list (SCL-R-90) questionnaire. RESULTS: Total CROM was significantly lower and the MCV was significantly higher in patients compared with healthy subjects. Age and gender affected TCROM significantly in both groups while MCV remained unaffected, respectively. Atypical patients were identified by having a TCROM < 58 degrees and or MCV > 22%, both scores corresponding to 2 SDs below and above group means, respectively. These benchmarks resulted in classifying as atypical 6% of the CW group who also scored drastically higher in the NDI and SCL-R-90 questioners. CONCLUSIONS: Using MCV and TCROM adds new insight regarding what should be considered as atypical cervical motion profile in CW patients. Several aspects of this complex clinical entity are discussed.

Cervical muscles weakness in chronic whiplash patients.

BACKGROUND: Isometric cervical strength has been used for assessing the severity of cervical spine pathologies. However there is a conspicuous dearth of information relating to cervical strength data in patients suffering from chronic whiplash. Therefore the objective of this study was to compare absolute and ratio-based isometric cervical strength scores in chronic whiplash patients with reported corresponding scores in healthy subjects. METHODS: Isometric cervical strength was measured in the directions of flexion, extension, right and left lateral flexion in 97 patients, 51 women and 46 men, using a wall-mounted dynamometer. FINDINGS: Compared to published values of normal subjects, whiplash patients suffered sharp reductions of about 90% in both genders and in all directions. The consistency of the isometric cervical strength scores as indicated by the mean coefficient of variation was relatively low, 17% and 20% in men and women respectively. The flexion/extension strength ratio ranged 0.8--0.9, slightly higher than the reported range for normal subjects. This ratio was highly correlated (r=0.91, P=0.01) with the mean coefficient of variation in a subgroup of 9 patients. INTERPRETATION: In the absence of an obvious reason such as sever atrophy or grossly dysfunctional neurological control the indicated weakness of the cervical muscles may be associated with learned pain avoidance behavior which is typical among this group of patients.

Reproducibility indices applied to cervical pressure pain threshold measurements in healthy subjects.

OBJECTIVES: To apply various statistical indices for reproducibility analysis of pressure pain threshold measurements and to derive a preferred pressure pain threshold measurement protocol based on these indices. METHODS: The pressure pain threshold of 3 pairs of right and left homologous cervical region sites were measured in 20 healthy subjects (10 women, 10 men) using a hand-held pressure algometer. Measurements took place on 2 occasions (test 1 and test 2) separated by a mean interval of 1 week. On each testing session, the site-related pressure pain thresholds were measured 3 times each according to 2 different protocols. Protocol A consisted of a repetitive order, namely 3 consecutive measurements at each site before proceeding to the next, whereas protocol B consisted of an alternate order in which 3 consecutive rounds of all individually tested sites took place. For test 1, protocol A was followed by protocol B with an hour interval. For test 2, the reverse order took place. RESULTS: The findings revealed no significant differences between the two protocols and indicated a significant rise (P < 0.0001) in the absolute scores from test 1 to test 2 in both protocols. Absolute values (mean +/-SD) derived from the entire sample of pressure pain threshold sites ranged from 140 +/- 60 to 198.7 +/- 95 kPa (1.60 +/- 0.6 to 1.99 +/- 0.95 kg/cm, respectively). No significant gender or side differences were noted. Pearson r as well as the intraclass correlation coefficient revealed good to excellent reproducibility for both protocols and for all sites measured: r = 0.79-0.94 and intraclass correlation coefficient(3,3) = 0.85-0.96, respectively. To define site-specific cutoff values indicating change at the 95% confidence level, 1.96*SEM was calculated, and its values ranged from 31.6 to 58.2 kPa, which correspond to 16.8% to 32.8% of the absolute mean values. In addition, the limits of agreement, which depict the individual test-retest differences relative to their mean, indicated a heteroscedastic trend. DISCUSSION: The two protocols yielded very similar results. However, on the grounds of patient's comfort and compliance as well as facility of application, protocol B stands out as the more preferred between the two.