Quantitative Shear Wave Speed Assessment for Muscles With the Diagnosis of Taut Bands and/or Myofascial Trigger Points Using Probe Oscillation Shear Wave Elastography: A Pilot Study.

OBJECTIVE: To use probe oscillation shear wave elastography (PROSE) with two vibration sources to generate two shear waves in the imaging plane to quantitatively assess the shear wave speeds (SWSs) of muscles with and without the diagnosis of taut bands (TB) and/or myofascial trigger points (MTrPs). METHODS: Thirty-three patients were scanned with the PROSE technique. Shear waves were generated through continuous vibration of the ultrasound probe, while the shear wave motions were detected using the same probe. SWSs for the sides with and without TBs and/or MTrPs were computed and compared. The pressure pain thresholds (PPTs) were measured as an indicator of maximum pain tolerance of patients. The statistical differences between the SWSs with and without TBs and/or MTrPs with different PPT values were analyzed using the nonparametric Wilcoxon rank-sum test. RESULTS: The mean SWSs for the sides with TBs and/or MTrPs are faster than that of the contralateral side without TBs and/or MTrPs. A significant difference was observed between mean SWSs with and without TBs and/or MTrPs without any information of PPT, with rank-sum test P < .005. Additionally, with the information of PPT, a significant difference was observed between mean SWSs for the sides with and without TBs and/or MTrPs, for PPT values between 0 and 50 N/cm2 (P < .005), but for PPT values between 50 and 90 N/cm2 , it was difficult to differentiate mean SWSs with and without TBs and/or MTrPs. CONCLUSION: Our preliminary results show that SWSs measured from patients had a significant difference between the mean SWSs with and without TBs and/or MTrPs.

Considerations in physical therapy management of a non-responding patient with low back pain.

STUDY DESIGN: Case Study. BACKGROUND AND PURPOSE: Low back pain is a common condition managed by physical therapists (PT). Screening tools have been developed to assist the PT with medical screening of patients for serious disease. Sinister pathologies may present as musculoskeletal symptoms during the patient examination. It is important for the PT to frequently reevaluate their patient's response to therapeutic interventions and refer for further evaluation if they are not responding to conservative care. CASE DESCRIPTION: This case reports on the history and examination findings of a 36-year-old male presenting with recurrent low back pain. An emphasis is placed on the therapist's understanding and use of screening tools when interviewing patients and determining when medical referral may be indicated based on the patients history and examination findings. A review of the evidence on the diagnostic accuracy of screening strategies for malignancy in patients presenting with low back pain is presented. CONCLUSION: Sinister causes for low back pain are extremely rare. It is important that PTs be familiar with specific signs and symptoms that may indicate serious pathology when evaluating patients with low back pain. Identification of two red flags from this patient's history leads the clinician to refer the patient back to their primary care provider (PCP) for further investigation. They included: 1) the patient's inability to improve after one month and 2) clinicians' judgment. Use of "clinical judgment" may assist the PT in determining if their patient needs further investigation.

Cervical Traction for Managing Neck Pain: A Survey of Physical Therapists in the United States.

Study Design Cross-sectional survey. Objective To examine the use of traction by physical therapists for patients with neck pain, including how and when traction is used, the delivery modes and parameters, supplemental interventions, and influence of professional demographics on usage. Background Systematic reviews provide little support for traction in managing neck pain. While traction usage among physical therapists in other countries has been described, usage in the United States has not been examined. Methods A random sample of 4000 Orthopaedic Section members of the American Physical Therapy Association were surveyed. Associations among respondents' professional demographics and survey responses were explored with chi-square analyses (α = .05). Results The response rate was 25.5% (n = 1001); 76.6% (n = 767) of respondents reported using traction, and 93.1% reported that they would use traction for a patient presenting with signs of nerve root compression. Common delivery modes included manual methods (92.3%) and mechanical traction tables (88.3%). Using traction is often supplemented with other interventions (exercise, postural education, joint mobilization). A higher proportion of physical therapists with American Board of Physical Therapy Specialties orthopaedic certification reported using traction (88.6%) than did those without specialty certification (73.0%). Conclusion Most respondents reported that their use of cervical traction was consistent with proposed criteria that identify patients who are likely to benefit. They use various traction delivery modes/parameters within comprehensive plans of care incorporating multiple interventions. Professional demographics (clinical specialist credentialing) were associated with traction usage. J Orthop Sports Phys Ther 2017;47(3):200-208. Epub 30 Oct 2016. doi:10.2519/jospt.2017.6914.

Lumbar Traction for Managing Low Back Pain: A Survey of Physical Therapists in the United States.

STUDY DESIGN: Cross-sectional survey. OBJECTIVES: To examine how many physical therapists use traction, the patients for whom traction is used, the preferred delivery modes/parameters of traction, the supplemental interventions used with traction, and whether professional characteristics influence traction usage. BACKGROUND: Several systematic reviews and clinical guidelines have questioned the effectiveness of traction for managing low back pain, yet some patients may benefit from lumbar traction. While traction usage among physical therapists in other countries has been described, usage among physical therapists in the United States has not been examined. METHODS: We surveyed a random sample of 4000 Orthopaedic Section members of the American Physical Therapy Association. Associations among respondents' professional characteristics and survey responses were explored with chi-square analyses (α = .05). RESULTS: The response rate was 25.5% (n = 1001), and 76.6% (n = 767) of respondents reported using traction. Most (58.4%) of the respondents used traction for patients with signs of nerve root compression, though many (31.4%) did not. Common delivery modes included manual methods (68.3%) and mechanical tables (44.9%), most often supplemental to other interventions (eg, stabilization exercises, postural education). Levels of professional preparation (doctoral/masters level versus bachelors/certificate level) were associated with many variables, as was attainment of an orthopaedic specialist certification. CONCLUSION: Most of the orthopaedic physical therapists in the United States who responded to our survey reported that they used lumbar traction, though not necessarily consistent with proposed criteria that identify patients most likely to benefit from traction. They used various traction delivery modes/parameters and used traction within comprehensive plans of care incorporating multiple interventions. Professional characteristics (education levels and clinical specialist credentialing) were associated with traction usage.

Electromyographic analysis of trunk and hip muscles during resisted lateral band walking.

The purpose of this study was to simultaneously quantify bilateral activation/recruitment levels (% maximum voluntary isometric contraction [MVIC]) for trunk and hip musculature on both moving and stance lower limbs during resisted lateral band walking. Differential electromyographic (EMG) activity was recorded in neutral, internal, and external hip rotation in 21 healthy participants. EMG signals were collected with DE-3.1 double-differential surface electrodes at a sampling frequency of 1,000 Hz during three consecutive lateral steps. Gluteus medius average EMG activation was greater (p = 0.001) for the stance limb (52 SD 18% MVIC) than moving limb (35 SD 16% MVIC). Gluteus maximus EMG activation was greater (p = 0.002) for the stance limb (19 SD 13% MVIC) than moving limb (13 SD 9% MVIC). Erector spinae activation was greater (p = 0.007) in hip internal rotation (30 SD 13% MVIC) than neutral rotation (26 SD 10% MVIC) and the moving limb (31 SD 15% MVIC) was greater (p = 0.039) than the stance limb (23 SD 11% MVIC). Gluteus medius and maximus muscle activation were greater on the stance limb than moving limb during resisted lateral band walking. Therefore, clinicians may wish to consider using the involved limb as the stance limb during resisted lateral band walking exercise.

Joint mobilization vs massage for chronic mechanical neck pain: a pilot study to assess recruitment strategies and estimate outcome measure variability.

OBJECTIVE: The purpose of this study was to determine the feasibility of a trial comparing cervical spine mobilization and massage as adjuncts to usual physical therapy treatments (superficial heat and head and neck posture education) for chronic neck pain. Specific objectives were to assess procedures and recruitment strategies and estimate the variability of the Neck Disability Index (NDI) and visual analog scale (VAS) in a population of subjects with chronic nonspecific neck pain and calculate a sample size for a definitive trial. METHODS: Subjects with nonspecific chronic neck pain (≥3 months) were randomized to receive either sedative massage or cervical spine joint mobilization in addition to postural education and home exercises. Neck Disability Index (primary outcome) and pain VAS scores were recorded for pretreatment, posttreatment, and change scores within each group to estimate effect size. Recruitment and follow-up success rates were tracked. RESULTS: Sixty potential subjects were screened: 34 were eligible and 23 were enrolled. The primary reason for not participating was the unwillingness to commit to the treatment schedule. Twenty subjects completed all (12) treatments. Three subjects discontinued treatment because they become asymptomatic. Pre and post mean NDI and VAS scores for the group receiving joint mobilization were 13.54/5.64 and 40.91/16.54, respectively. Pre and post mean NDI and VAS for the group receiving massage were 12.75/8.08 and 29.42/20.91, respectively. Several problems were encountered, and possible solutions were identified. Recruitment difficulties required alteration of the recruitment strategy. CONCLUSION: A full scale trial is feasible if appropriate changes are made in recruitment strategy including recruiting from a wider referral base, direct recruitment from the community, and/or expanding the study to multiple sites. A clinical trial will require 66 subjects per group to have a power of 80% to detect a 2-point difference in NDI score. This sample size will also provide more than 80% power to detect a 10-point difference in pain (VAS) between groups. Recruitment goals will be 76 per group to allow for dropouts.

Usefulness of the Trendelenburg test for identification of patients with hip joint osteoarthritis.

Abstract This study examined validity indices of the Trendelenburg test as a measure of hip abductor muscle performance (adduction of pelvis-on-femur [P-O-F]) when identifying subjects with and without hip joint osteoarthritis (OA). Muscle performance of the hip abductor muscles was obtained in standing by using the P-O-F position measured with a goniometer and in supine using a handheld dynamometer (HHD) and a manual muscle test (MMT). We studied 20 healthy adults (10 men and 10 women) and 20 adults (10 men and 10 women) with radiographically documented hip joint OA. Indices including sensitivity, specificity, and positive likelihood ratios examined values obtained from the P-O-F position and the MMT when used to identify subjects with and without hip joint OA. Sensitivity of the P-O-F position for identifying subjects with hip joint OA was 0.55, and specificity was 0.70, yielding a positive likelihood ratio of 1.83. Sensitivity of normalized hip abductor MMT strength for identifying subjects with hip joint OA was 0.35 and specificity was 0.90, yielding a positive likelihood ratio of 3.5. Based on validity information from the present study, the Trendelenburg test (P-O-F angle) is not useful in identifying subjects in the early stages of hip joint OA.

An electromyographic analysis of the Ab-Slide exercise, abdominal crunch, supine double leg thrust, and side bridge in healthy young adults: implications for rehabilitation professionals.

The purpose of this study was to examine the effectiveness of a commercial abdominal machine (Ab-Slide) and three common abdominal strengthening exercises (abdominal crunch, supine double leg thrust, and side bridge) on activating abdominal and minimizing extraneous (nonabdominal) musculature-namely, the rectus femoris muscle. We recruited 10 males and 12 females whose mean (+/- SD) percent body fat was 10.7 +/- 4 and 20.7% +/- 3.2%, respectively. Electromyographic (EMG) data were recorded using surface electrodes for the rectus abdominis, external oblique, internal oblique, and rectus femoris. We recorded peak EMG activity for each muscle during each of the four exercises and normalized the EMG values by maximum muscle contractions (% MVIC). A two-factor repeated-measures analysis of variance assessed differences in normalized EMG activity among the different exercise variations (p < 0.05). Post hoc analyses were performed using the Bonferroni-adjusted alpha to assess between-exercise pair comparisons (p < 0.002). Gender did not affect performance; hence, data were collapsed across gender. We found a muscle x exercise interaction (F9,189 = 5.2, p < 0.001). Post hoc analyses revealed six pairwise differences. The Ab-Slide elicited the greatest EMG activity for the abdominal muscles and the least for the rectus femoris. The supine double leg thrust could be a problem for patients with low-back pathology due to high rectus femoris muscle activity.

Comparison of the Neck Disability Index and the Neck Bournemouth Questionnaire in a sample of patients with chronic uncomplicated neck pain.

OBJECTIVE: This study compares the sensitivity to change of the Neck Disability Index (NDI) and the Neck Bournemouth Questionnaire (NBQ) in patients with chronic uncomplicated neck pain. METHODS: This prospective longitudinal study was completed in an outpatient physical therapy clinic. Subjects, with uncomplicated neck pain (no concurrent shoulder pain or nerve root symptoms) for more than a 3-month duration, participated in a 4-week course of therapy that included moist heat, neck exercises, and either mobilization or massage. Outcome measures included standardized response means (sensitivity to change), Cronbach alpha (internal consistency), and 2-way Spearman correlations between the 2 questionnaires and between a pain Visual Analog Scale and each questionnaire (convergent validity). RESULTS: Mean (SD) score change of the NDI was 6.22 (5.12), and of the NBQ, 14.00 (11.99). Standardized response means were 1.21 and 1.17, respectively. Both questionnaires were more sensitive to change than the pain Visual Analog Scale (0.68). There was moderate correlation between the change scores of all 3 outcome tools (Spearman 0.46-0.57). The NBQ had higher internal consistency than the NDI. CONCLUSIONS: The NDI and the NBQ performed comparably in this group of patients with chronic uncomplicated neck pain. Both are sensitive to change and would be efficient outcome tools in studies of chronic neck pain. Both had acceptable internal consistency and are appropriate for use as single-outcome scales.