The Intra-Rater Reliability of Ultrasonography for the Measurement of Lumbar Multifidus and Erector Spinae Thickness in Different Positions in People with and without Active Extension-Related Non-Specific Low Back Pain.

Background: The paraspinal muscles, including multifidus (MF) and erector spinae (ES) play key roles in the stability and movement of the lumbar spine. This study aimed to determine the intra-rater reliability of the ES and MF muscle thickness measures of the rehabilitative ultrasound imaging (RUSI) in people with active extension pattern (AEP) non-specific chronic low back pain and controls. Methods: Fifteen females with AEP and 19 controls participated in this test-retest intra-rater reliability study, including two different testing sessions performed in four to seven days apart. The primary (raw) and derived (normalized) measures of the L4 MF and ES muscles`thickness were examined in three different positions (prone, sitting, and standing) on both days. A two-way mixed average of intra-class correlation coefficient (ICC3, K) with confidence interval (CI = 95%) was used to determine the relative reliability. The standard error of measurement (SEM) and minimal detectable change (MDC) values at a CI of 95% were computed to examine the absolute reliability. Results: The ICC values for the primary thickness of the L4 ES and MF muscles were from 0.85 to 0.91, except for MF muscle thickness in standing (ICC = 0.67) and sitting (ICC = 0.66) positions . The ICC values for derived data were lower in both groups. The SEM and MDC values were small enough to confirm the absolute reliability of the primary data. Conclusion: This study supports the use of RUSI for examining the primary measures of the L4 MF and ES muscles in asymptomatic and AEP participants, but it should be used cautiously for assessing the derived measures.

Effect of Forward Head Posture on Dynamic Balance Based on the Biodex Balance System.

Forward Head Posture (FHP) results in spine malalignment, muscle imbalance and cervical proprioception sensory input impairment. Subjective description of FHP is interpreted differently by clinicians and therefore the FHP is classified as slight, moderate and sever. This study aimed to evaluate balance disorder in individuals with severe forward head posture (FHP). Twenty individuals with severe FHP and 20 controls were enrolled. Dynamic postural stability was assessed in all participants using the Biodex Balance System (BBS) in semi dynamic position with eye open/eye closed conditions. Based on the findings, dynamic postural stability in the sagittal plane was different between the groups (P<0.05). It can be concluded that impairment of dynamic postural stability occurs in individuals with severe FHP. The findings suggest that clinicians take into account the importance of dynamic postural stability assessment in FHP subjects and consider the application of intervention programs for improvement of the dynamic balance.

Ultrasound echo intensity of cervical muscles in women with and without forward head posture.

Objective: Forward head posture (FHP) is a common abnormal posture in neck disorders. FHP causes an alteration of the strength in the cervical muscles. Since both muscle quantity and quality impress the muscle strength, this study aimed to compare the echo intensity of cervical muscles (index of muscle quality) between women with and without FHP.Method: Echo intensity of cervical muscles was measured by Adobe Photoshop software and compared between two groups.Results: The findings of the current study indicate the insignificant difference between two groups regarding the echo intensity of cervical muscles.Conclusion: Evaluation of echo intensity of cervical muscles may expand knowledge about the muscle quality and function.

Assessing the Reliability of Echo Intensity of Craniovertebral Muscle Group using B-Mode Ultrasound: A Technical Note.

An acceptable reliability is needed for each scale and a valid decision-making process. Ultrasonography is a simple, cost-effective, and accessible tool compared to magnetic resonance imaging (MRI) to assess echo intensity (EI) as a biomarker of muscle function in neck musculoskeletal problems. However, no evidence is available regarding the reliability of neck muscle echogenicity according to rehabilitative ultrasonography in clinical studies on forward head posture (FHP). We determined the reliability of neck muscles EI in individuals with and without FHP. Transverse images of deep neck flexors (Longus Coli) and suboccipital (Rectus capitis posterior minor) muscles were acquired from 20 individuals with FHP and 20 controls in one session. The intraclass correlation coefficient (ICC), minimum detectable change (MDC), and standard error of measurement (SEM) for EI were measured in this study. The ICC, SEM, and MDC ranges were 0.50 - 0.51, 2.73 - 3.41, and 7.56 - 9.46 for the Longus colli muscle and 0.48 - 0.49, 3.29 - 4.98, and 9.13 - 13.81 for the rectus capitis posterior minor (RCPm) muscle, respectively. Based on the present findings, EI showed acceptable reliability; therefore, it can be used for assessment of neck muscle morphology.

Quadriceps architecture in individuals with patellofemoral pain: A systematic review.

OBJECTIVES: To identify differences in architectural parameters (size, fiber/pennation angle, fiber length, and echogenicity) of the quadriceps muscle, as a whole or any individual part of it, using imaging techniques in individuals with patellofemoral pain (PFP) compared to contralateral, asymptomatic limb or separate control group. BACKGROUND: Quadriceps muscles imbalance and weakness were proposed as risk factors for developing PFP. Although the muscle architecture (size, pennation/fiber angle and fiber length) is highly associated with skeletal muscle strength, it is not clear whether atrophy or any changes in architectural parameters of the quadriceps are presented in the PFP patients. METHODS: Observational studies in which the total size of the quadriceps or individual parts of it were measured using imaging techniques in the PFP patients were included in this review. Electronic databases (PubMed, SCOPUS, PEDro, CINAHL, WOS, and EMBASE) were searched between January 1990 and December 2019 with no restriction of language. Study selection and data extraction and quality assessment were conducted by two independent reviewers. RESULTS: Five cross-sectional studies were eligible to include in this review. Three out of five included studies that assessed the total size of the quadriceps and reported no significant differences between the PFP and healthy control group. Two out of five of the studies assessed the total size of the quadriceps between the symptomatic and asymptomatic limb of the PFP patients and reported the statistical difference between limbs. Only one study measured the fiber angle of the VMO muscle at the patella. Controversial results were found between studies that assessed the size of individual parts of the quadriceps. CONCLUSION: Due to the controversial results of the included studies, this systematic review failed to draw a conclusion on the role of quadriceps atrophy in PFP pathology. The limitation in PFP literature considering pennation/fiber angle, echogenicity and fiber length of individual parts of the quadriceps muscle, rises the need for research that focuses on the biomechanical properties of the quadriceps in PFP patients.

Relationship between thickness of deep neck muscles synergy and painful side in patients with cervicogenic headache.

Objective: This study was conducted to evaluate changes in the thickness of the upper deep neck muscles in patients with cervicogenic headache (CGH).Methods: The thickness of the longus capitis (LCap) muscle, rectus capitis posterior major (RCPM), and obliquus capitis superior (OCS) muscles was measured by B-mode ultrasonography in 22 CGH patients matched with 22 healthy subjects. Data were analyzed using SPSS version 16.Results: The thickness of all muscles in the CGH group was less than healthy subjects. The thickness of the LCap muscle and right RCPM muscle was significantly different between the CGH and healthy subjects (p < .05), but there was no difference in the thickness of the OCS and left RCPM muscles between the groups (p > .05). Moreover, the thickness differences were not related to the CGH side (p > .05).Discussion: These muscles were atrophic due to CGH, but this phenomenon was not related to the headache side and was bilateral.

Iliopsoas muscle thickness and pelvic alignment in pronated and normal foot postures.

It is hypothesized that the subtalar hyperpronation may provoke the development of a biomechanical chain of events in lower extremity alignment. Several studies have shown that pelvic alignment may alter in the presence of immediate foot hyperpronation induced by external forces. It is unknown whether these alterations are presented in chronic foot hyperpronation or not. It is also unknown if these potential postural changes could affect iliopsoas muscle size. Therefore, it appears necessary to carry out thorough research in this study. Twenty nine females with pronated foot posture and twenty seven females with normal foot posture participated in this study. The iliopsoas muscle was measured using ultrasound imaging (USI). Pelvic angle (PA) was measured using reflective markers and digital photography. Intrarater reliability of USI for the iliopsoas muscle thickness was also measured. The results indicated that the iliopsoas muscle thickness and the PA were not different in individuals with pronated foot compared to the normal foot group. However, a good intrarater reliability of USI was found for measuring the iliopsoas muscle thickness.

Asymmetry of Cervical Multifidus and Longus Colli Muscles Size in Participants With and Without Cervical Radicular Pain.

OBJECTIVES: The aim of this study was to determine the asymmetry of cervical multifidus (MF) and longus colli (LC) muscles in patients with unilateral chronic radicular neck pain (CRNP) and healthy subjects using ultrasonography. MATERIALS AND METHODS: Ninety five individuals (50 patients with unilateral CRNP and 45 healthy subjects) participated in this study. The size of the cervical MF and LC muscles; anterior posterior dimension (APD) and lateral dimension (LD); were bilaterally measured in a relaxed state using ultrasonography. RESULTS: Patients with CRNP showed greater asymmetry in the cervical MF and LC muscles size than the healthy subjects. The mean percentages differences between sides for MF and LC muscles size was higher in patients than that of healthy subjects (for both APD and LD; P<0.05). The ratio of smaller to larger dimensions of the cervical MF and LC muscles for patients were significantly less than that of healthy controls (for both APD and LD; P< 0.05). CONCLUSION: The results indicated that cervical MF and LC muscles showed higher asymmetry between sides and lesser ratio of smaller size to larger size in patients with CRNP as compared with healthy subjects. Current results confirmed the presence of MF and LC muscles atrophy in subjects with CRNP.

Evaluation of cervical spine muscles thickness in patients with cervical vertigo and healthy controls through ultrasonography.

[Purpose] Cervical vertigo as a common complaint is associated with some musculoskeletal disorders. However, to date, ultrasonographical parameters of cervical muscles in patients with cervical vertigo have not been investigated. This study was conducted to investigate size of cervical muscles in patients with cervical vertigo compared to healthy controls. [Participants and Methods] Thicknesses of cervical flexor and extensor muscles were evaluated through ultrasonography and results were compared between the patients and healthy controls by Independent Samples t-test or Mann-Whitney U nonparametric test. [Results] Results showed that, thickness of Longus Colli muscle was significantly different between the patients and healthy controls. [Conclusion] According to findings of the study, size of Longus Colli muscle is likely to be associated with etiology of cervical vertigo.

Intrarater reliability of musculoskeletal ultrasound imaging of psoas major muscle in patients with subacute low back pain and healthy controls.

Background: Psoas major (PM) is a challenging muscle from the functional and anatomical point of view. The dysfunction of this muscle can result in low back pain (LBP). This study aimed to assess the intrarater reliability of ultrasound imaging (USI) of PM muscle thickness in subacute LBP patients and healthy participants without LBP in rest and during muscle contraction conditions. Methods: PM thickness was measured in all lumbar segments (L1-L5) using a USI device in 10 healthy and 10 subacute LBP participants. The intrarater data were assessed on the same day with 1- hour interval and after 7 days. Intraclass correlation coefficients (ICC), standard error of measurement (SEM), minimal detectable change (MDC), and independent t test were used for analyses. Significant level was set at 0.05. Results: PM thickness in all lumbar levels had excellent reliability (ICC range 80-98) for both groups and conditions. SEM (0.42- 2.29) and MDC (1.16-6.34) were low, and PM thickness was greater than rest in contraction condition. There were no significant differences between the 2 groups in PM thickness. Conclusion: The USI demonstrated good intrarater reliability for assessing PM thickness in patients with subacute LBP. The thickness of PM in patients with subacute LBP was similar with that in healthy participants.

Ultrasound evaluation of the quadriceps muscles in pronated foot posture.

OBJECTIVE: The main goal of this study was to investigate the size of all portions of the quadriceps muscles in individuals with pronated foot posture compared to normal foot posture using ultrasound imaging. DESIGN: Twenty nine females with pronated foot posture and 29 age-, body weight-, body height-matched females with normal foot posture were recruited from university communities. The muscle thicknesses of the rectus femoris (RF), vastus medialis (VM), vastus medialis oblique (VMO), vastus lateralis (VL) and vastus intermedius (VI) were measured using ultrasound imaging. RESULTS: The thicknesses of the RF and VMO were significantly smaller in individuals with pronated foot posture compared to normal foot posture (p<0.05). No significant differences were observed in the VM, VL, and VI muscle thicknesses in both groups. CONCLUSION: Based on the results of the present study, it seems that besides the foot and lower leg muscles, an integrated assessment of proximal knee muscles, especially quadriceps, is required in individuals with pronated foot posture.

Quadriceps architecture in individuals with patellofemoral pain: a systematic review protocol.

OBJECTIVE: The objective of this review is to identify differences in quadriceps architectural parameters between healthy individuals and those with patellofemoral pain (PFP). INTRODUCTION: Patellofemoral pain is one of the most common causes of knee pain among physically active populations. Muscular imbalance may play an important role in patellar malalignment or patellar maltracking. A systematic review will clarify the possible architectural changes of quadriceps muscles in persons with PFP. INCLUSION CRITERIA: Eligible observational studies will include individuals younger than 50 years who have been diagnosed with unilateral or bilateral PFP. The comparator will be the contralateral, asymptomatic limb of the individual with PFP or a healthy matched subject. Studies that include measurement of quadriceps muscle size as the primary outcome will be considered. Studies in which participants had coexisting pathology, a history of lower limb surgery or injury, or pain originating from other joints will be excluded. METHODS: PubMed/MEDLINE (NLM), Scopus, Embase, Physiotherapy Evidence Database, Web of Science and CINAHL databases and multiple gray literature sources will be searched. Studies published since 1 January 1990 will be considered; there will be no language restriction. Retrieval of full-text studies, assessment of methodological quality and data extraction will be performed independently by two reviewers. If possible, meta-analyses will be performed, and a Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Summary of Findings presented.

The effect of functional stretching exercises on functional outcomes in spastic stroke patients: A randomized controlled clinical trial.

BACKGROUND: Stroke is the biggest cause of disability in adults. Spasticity is a primary impairment of stroke with a highly variable prevalence. In the present research, we aimed to determine the impact of functional stretching exercises on functional outcomes in stroke patients. METHODS: Thirty stroke patients were randomized into two groups-Experimental group and control group for the purposes of the study. The subjects in the experimental group participated in a functional stretching training program at the rehabilitation center thrice a week for four weeks. The subjects in both groups were evaluated in 3 intervals, once at baseline, once at the end of the program, and once at 2 months following the program. Clinical assessments, such as measuring spasticity, were conducted using the Modified Modified Ashworth Scale (MMAS). Functional outcomes were also evaluated, using the Timed Up and Go (TUG) test, as well as the Timed 10-Meter Walk Test (WTT). Friedman test in SPSS version 22.0 was used to analysis the response variables with respect to each stage of evaluation. Spearman rank correlation was also used to measure correlation among clinical assessments and functional outcomes. RESULTS: The comparison between two groups showed significant differences only in the Modified Modified Ashworth Scale and Visual Analogue Scale (VAS) post treatment. The experimental group showed significant differences in the MMAS (p = 0.002), WTT (p < 0.001), and TUG (p < 0.001) scores. Nevertheless, the scores of the control group were not significantly different in different stages of evaluation. CONCLUSION: The findings of the study suggest that using functional stretching exercises can improve functional outcomes in chronic spastic stroke patients.

Quadriceps force production during straight leg raising at different hip positions with and without concomitant ankle dorsiflexion.

OBJECTIVE: Due to the significant prevalence of knee disorders and patellofemoral pain syndrome, as well as the importance of quadriceps strengthening in knee rehabilitation programs, it is necessary to specify the best method to activate and strengthen the quadriceps muscles. The current study aimed at comparing the maximum generated isometric force during an active straight-leg-raising (SLR) maneuver in a sitting position by changing the hip rotational position with and without the simultaneous contraction of the ankle dorsiflexor muscles. METHODOLOGY: The current study was performed on 30 healthy males recruited with a non-random and available sampling method. The maximum generated force was measured during the SLR maneuver in six compound internal and external rotations and in a neutral position with and without ankle dorsiflexor contraction. The obtained generated force was analyzed using repeated measures ANOVA. RESULTS: The generated forces in the SLR with and without contracting the ankle dorsiflexors were significantly different (p = 0.001), and taking different positions of hip rotation led to significant changes in the generated force (p = 0.005). CONCLUSION: The adoption of external hip rotation with the contraction of ankle dorsiflexors during the SLR maneuver generated the most force. Based on the interaction of these conditions, the general recommendation is to perform the SLR exercise in an external hip rotation with the simultaneous contraction of the ankle dorsiflexors in subjects with quadriceps muscle weakness.

Multifidus muscle size changes at different directions of head and neck movements in females with unilateral chronic non-specific neck pain and healthy subjects using ultrasonography.

OBJECTIVE: The aim of the study was to compare the dimensions of cervical multifidus muscle (CMM) in different conditions. METHODS: Twenty five women with neck pain and 25 healthy subjects participated in this study. The dimensions of the CMM were measured at rest, 50% and 100% maximum isometric voluntary contraction (MIVC) at six directions of neck movements, using ultrasonography. RESULTS: The size of multifidus was smaller in patients than healthy individuals at rest state (P < 0.05). A significant smaller CMM dimension was found in the affected side compared with unaffected side in patients group (P < 0.05). The result of ANOVA for MLD showed a significant difference for contraction levels (P < 0.001) and neck movements (P < 0.001) in both groups. The MLD of the CMM was significantly different between CMM at rest and 50%, and 100% MIVC (P < 0.001). No significant differences were found between the groups at 50% and 100% MIVC (P > 0.05 in both instances). The most prominent CMM size change was observed during neck extension, flexion, ipsilateral lateral-flexion, and ipsilateral rotation, respectively (P < 0.05). CONCLUSIONS: Results of the present study indicate that the size of CMM was decreased in patients with neck pain in rest state. The size of CMM changes in all directions of neck movements, although the most prominent was during neck extension. This points out CMM stabilization role's in different directions of neck movements.

A comparison of foot kinetic parameters between pronated and normal foot structures during forward jump landing.

BACKGROUND: Pronated foot is one of the most important factors that may lead to musculoskeletal injuries of the lower extremities. It is known that in a pronated foot, excessive mechanical loads are applied to the lower limb structures, which result in the altered foot biomechanics, including vertical ground reaction forces (VGRFs) and rate of loading (ROL). Therefore, the aim of this study was to determine the changes in foot kinetic parameters in the pronated compared to the normal foot structures. METHODS: In this cross-sectional study, 15 individuals (mean age of 23.27 ± 3.28 years) with asymptomatic pronated feet and 15 normal subjects (mean age of 23.40 ± 3.11 years) were recruited from both genders by using a simple non-random sampling method. VGRF, ROL, and the resultant vector of time to stabilization (RVTTS) were evaluated during the forward jump landing task by using a force plate. RESULTS: The findings showed that the following parameters were significantly higher in the group of pronated feet than in the normal subjects: VGRF (3.30 ± 0.17 vs. 2.81 ± 0.15, p = .042), ROL (0.10 ± 0.01 vs. 0.07 ± 0.006, p = .020), and RVTTS (2592.80 ± 141.24 vs. 2114.00 ± 154.77, p = .030). CONCLUSION: All the measured foot kinetic parameters were higher in the pronated foot subjects than in the normal participants. An impaired movement control and greater forces imposed on the foot region of the pronated foot, compared to the normal foot individuals, were discovered indicating the former group's possible increase of susceptibility to various musculoskeletal injuries.

A comparison of lower limb muscle activation pattern using voluntary response index between pronated and normal foot structures during forward jump landing.

BACKGROUND: Pronated of the foot is one of the important factors contributing to musculoskeletal problems affecting the lower extremities. It is known that in a pronated foot, excessive mechanical load is applied to the lower limb structures which may result in altered biomechanics and muscle activation patterns. The aim of this study was to determine changes in the muscle activation pattern of the lower extremities in individuals with pronated, compared to normal, feet, using the voluntary response index (VRI). METHODS: In this cross sectional study, 15 asymptomatic pronated foot individuals (mean age 23.27 ± 3.28 years) and 15 normal subjects (mean age 23.40 ± 3.11 years) were recruited by simple non-random sampling. Electrical activities of gluteus medius (GM), vastus lateralis (VL), vastus medialis (VM), biceps femoris, semitendinosus (ST), and medial gastrocnemius (MG) muscles were recorded during a forward jump landing task. Voluntary response index (VRI) variables, included similarity index (SI) and magnitude (Mag) were also evaluated. RESULTS: Muscle activity of VM (p < 0.001) and ST (p = 0.010) were significantly higher but VL (p = 0.039) and MG (p = 0.001) were significantly lower in pronated foot, compared to normal subjects. Similarity index was found to be different (p < 0.001) between pronated foot and healthy individuals. No significant difference was found in terms of Mag between the two groups (p = 0.576). CONCLUSION: The altered pattern of lower limb muscle activation identified in the pronated foot during landing may be attributed to the different activation involving VL, VM, MG and ST muscles. Adaptations to the biomechanical effects, due to the pronated foot causing altered activation of VL, VM, MG, and ST muscles, results in an altered pattern of muscle activation. This change in activation pattern may harm the effectiveness of movement control processes; and might also predispose individuals with pronated feet, to injuries. It seems that an altered motor strategy with the aim of minimizing biomechanical changes, predisposes individuals to injuries. However, further large scale studies are needed to support the findings of the present study.

The Effect of Functional Stretching Exercises on Neural and Mechanical Properties of the Spastic Medial Gastrocnemius Muscle in Patients with Chronic Stroke: A Randomized Controlled Trial.

BACKGROUND: Following spasticity, neural and mechanical changes of the paretic muscle often occur, which affect the muscle function. The aim of this study was to investigate the effect of functional stretching exercises on neural and mechanical properties of the spastic muscle in patients with stroke. MATERIALS AND METHODS: This study was a single-blinded, randomized control trial. Forty five patients with stroke (experimental group: n = 30; control group: n = 15) participated in this study. Subjects in the experimental group participated in a functional stretching program 3 times a week for 4 weeks. Subjects in both groups were evaluated before the training, at the end of training, and then during a 2-month follow-up. Neural properties, including H-reflex latency and Hmax/Mmax ratio, were acquired. Mechanical properties, including fascicle length, pennation angle, and muscle thickness in the spastic medial gastrocnemius muscle, were evaluated. Repeated measure analysis of variance was used in the analysis. RESULTS: Time by group interaction in the pennation angle (P = .006), and in muscle thickness (P = .030) was significant. The results indicated that the H-reflex latency (P = .006), pennation angle (P < .001), and muscle thickness (P = .001) were altered after stretching training program and these changes were at significant level after 2-month follow-up. CONCLUSION: The results indicated that the use of functional stretching exercises can cause significant differences in neural and mechanical properties of spastic medial gastrocnemius muscle in patients with chronic stroke.

Immediate effect of common peroneal nerve electrical stimulation on quadriceps muscle arthrogenic inhibition in patients with knee osteoarthritis.

OBJECTIVE: To investigate the immediate effect of electrical stimulation of the common peroneal nerve on the maximum voluntary activation of the quadriceps muscle in patients with knee osteoarthritis. METHODOLOGY: Fifteen subjects with knee osteoarthritis (mean age: 50.5 ± 13 years) participated in this study. To measure the arthrogenic inhibition ratio of quadriceps, a burst of electrical stimulation was superimposed on the maximum voluntary contraction, and the percentage of change in the force production was computed. The same measurement was also performed with concurrent electrical stimulation of the common peroneal nerve. RESULTS: All the patients with knee osteoarthritis showed significant arthrogenic inhibition of the quadriceps muscle. The stimulation of the common peroneal nerve was able to reduce this inhibition and increase the capacity of the muscle to produce a significantly higher knee extension force (p = 0.028). CONCLUSIONS: Electrical stimulation of the common peroneal nerve concurrent with the maximum voluntary effort can remove the arthrogenic inhibition of the quadriceps muscle in patients with knee osteoarthritis. This finding could have clinical implications in the management of patients with knee disorders.