An Investigation of the Association between Transversus Abdominis Myofascial Structure and Activation with Age in Healthy Adults using Ultrasound Imaging.

BACKGROUND: Because of their importance in core stability, training the deep abdominal muscles, fascial structures and particularly the transversus abdominis, is a key component of many sport and physical therapy programs. However, there are gaps in knowledge about age-related changes in the structure and activation capacity of these muscles. HYPOTHESIS/PURPOSE: This study investigated the association between deep abdominal muscles and fascial structures and transversus abdominis activation with age in healthy adults. STUDY DESIGN: A cross-sectional study. METHODS: Eighty-six adults aged 18 to 77 participated in this study. An ultrasound image of their transversus abdominis, internal oblique, external oblique and associated fasciae was first captured at rest, then during a contraction of the transversus abdominis. Bivariate correlation analyses and hierarchical analyses were performed (significance level: p < 0.05). RESULTS: The thickness of these three muscles decreases with age ( ρ = -0.66 for external oblique, -0.51 for internal oblique and -0.58 for transversus abdominis), whereas the thickness of their fasciae increases ( ρ = 0.39 for the fascia of external oblique, 0.54 for the fascia between internal oblique and external oblique, and 0.74 for the fascia between internal oblique and transversus abdominis). Transversus abdominis activation decreases with age (r =-0.44). Age accounts for 19.5% of the variance in transversus abdominis activation. CONCLUSION: These results demonstrate that normal aging is associated with changes in deep abdominal myofascial structures and transversus abdominis activation. Assessment of these metrics can provide valuable baseline information for physical therapists involved in rehabilitation and strengthening programs targeting older individuals. LEVEL OF EVIDENCE: Level 2.

Anterior and posterior rectus abdominis sheath stiffness in relation to diastasis recti: Abdominal wall training or not?

INTRODUCTION: This study explores the anatomical relation of the rectus abdominis muscles with the anterior and posterior rectus sheaths. The elastic behavior of these fascial sheets is also assessed. Both of these analyses form an anatomic-biomechanical basis for diagnosis and treatment, especially in relation to diastasis recti abdominis (DRA). METHOD: Fundamental observational, biomechanical study. Seven post-mortem, embalmed human specimens were dissected. The abdominal muscles and the fascial sheets of the abdominal wall were dissected. 4 × 4 cm samples of the anterior and posterior rectus sheaths were loaded in longitudinal and transverse direction, while recording elongation by means of a displacement sensor. The main outcome measures were anatomical descriptions and elongation of fascia samples in mm (mean and standard ±â€¯deviation). RESULTS: In longitudinal direction the posterior rectus sheath samples stretched over 1.67 ±â€¯0.48 mm, while in transverse direction the mean stretch was 0.29 ±â€¯0.18 mm (p = 0.001). In contrast, no significant difference between longitudinal (0.78 ±â€¯0.43 mm) and transversal displacement (0.50 ±â€¯0.23 mm) was observed in the anterior rectus sheath (p = 0.56). DISCUSSION AND CONCLUSION: The posterior rectus sheath is functionally more related to the transverse abdominis muscle than to the rectus abdominis muscle. From this connection, in combination with the specific stiffness of the posterior fascia in the lateral direction, it is assumed that the transverse abdominis muscles play an important role in the etiology but also in reduction of DRA. The transverse abdominis and rectus abdominis muscles collaborate in support of the abdominal wall.

The influence of cervical movement on eye stabilization reflexes: a randomized trial.

To investigate the influence of the amount of cervical movement on the cervico-ocular reflex (COR) and vestibulo-ocular reflex (VOR) in healthy individuals. Eye stabilization reflexes, especially the COR, are changed in neck pain patients. In healthy humans, the strength of the VOR and the COR are inversely related. In a cross-over trial the amplitude of the COR and VOR (measured with a rotational chair with eye tracking device) and the active cervical range of motion (CROM) was measured in 20 healthy participants (mean age 24.7). The parameters were tested before and after two different interventions (hyperkinesia: 20 min of extensive active neck movement; and hypokinesia: 60 min of wearing a stiff neck collar). In an additional replication experiment the effect of prolonged (120 min) hypokinesia on the eye reflexes were tested in 11 individuals. The COR did not change after 60 min of hypokinesia, but did increase after prolonged hypokinesia (median change 0.220; IQR 0.168, p = 0.017). The VOR increased after 60 min of hypokinesia (median change 0.155, IQR 0.26, p = 0.003), but this increase was gone after 120 min of hypokinesia. Both reflexes were unaffected by cervical hyperkinesia. Diminished neck movements influences both the COR and VOR, although on a different time scale. However, increased neck movements do not affect the reflexes. These findings suggest that diminished neck movements could cause the increased COR in patients with neck complaints.

Eye stabilization reflexes in traumatic and non-traumatic chronic neck pain patients.

BACKGROUND: Many chronic neck pain patients experience problems with vision. These problems are possibly induced by deviations of the eye stabilization reflexes. It is not known whether these eye reflex alterations occur both in traumatic and non-traumatic neck pain patients. OBJECTIVE: To investigate if the cervico-ocular reflex (COR) and the vestibulo-ocular reflex (VOR) are changed in tertiary care patients with prolonged, chronic neck pain with various origin of complaints. DESIGN: Cross sectional study. METHODS: Ninety-one chronic neck pain patients were subdivided into three groups by origin of complaints, and compared with healthy controls. COR and VOR gains were measured with an infrared eye tracking device with the subject sitting on a rotating chair in a darkened room and with the head fixed. RESULTS: Neck pain patients had a higher COR gain (median 0.41, IQR 0.289) compared with healthy controls (median 0.231, IQR 0.179). The mean COR gain did not differ between the three patient groups (Whiplash Associated Disorders 0.444 (SD 0.221); traumatic 0.397 (SD0.205); non-traumatic 0.468 (SD0.236)). There was no difference in VOR gain between the groups. CONCLUSION: Chronic neck pain patients, who already received primary care, still have an elevated cervico-ocular reflex. The origin of complaints did not seem to be associated with this deviant oculomotor behavior.

Eye movements in patients with Whiplash Associated Disorders: a systematic review.

BACKGROUND: Many people with Whiplash Associated Disorders (WAD) report problems with vision, some of which may be due to impaired eye movements. Better understanding of such impaired eye movements could improve diagnostics and treatment strategies. This systematic review surveys the current evidence on changes in eye movements of patients with WAD and explains how the oculomotor system is tested. METHODS: Nine electronic data bases were searched for relevant articles from inception until September 2015. All studies which investigated eye movements in patients with WAD and included a healthy control group were screened for inclusion. Qualifying studies were retrieved and independently assessed for methodological quality using the Methodology Checklists provided by the Scottish Intercollegiate Guidelines Network. RESULTS: Fourteen studies out of 833 unique hits were included. Ten studies reported impaired eye movements in patients with WAD and in four studies no differences compared to healthy controls were found. Different methods of eye movement examination were used in the ten studies: in five studies, the smooth pursuit neck torsion test was positive, in two more the velocity and stability of head movements during eye-coordination tasks were decreased, and in another three studies the cervico-ocular reflex was elevated. CONCLUSIONS: Overall the reviewed studies show deficits in eye movement in patients with WAD, but studies and results are varied. When comparing the results of the 14 relevant publications, one should realise that there are significant differences in test set-up and patient population. In the majority of studies patients show altered compensatory eye movements and smooth pursuit movements which may impair the coordination of head and eyes.

Course and prognosis of recovery for chronic non-specific low back pain: design, therapy program and baseline data of a prospective cohort study.

BACKGROUND: There has been increasing focus on factors predicting the development of chronic musculoskeletal disorders. For patients already experiencing chronic non-specific low back pain it is also relevant to investigate which prognostic factors predict recovery. We present the design of a cohort study that aims to determine the course and prognostic factors for recovery in patients with chronic non-specific low back pain. METHODS/DESIGN: All participating patients were recruited (Jan 2003-Dec 2008) from the same rehabilitation centre and were evaluated by means of (postal) questionnaires and physical examinations at baseline, during the 2-month therapy program, and at 5 and 12 months after start of therapy. The therapy protocol at the rehabilitation centre used a bio-psychosocial approach to stimulate patients to adopt adequate (movement) behaviour aimed at physical and functional recovery. The program is part of regular care and consists of 16 sessions of 3 hours each, over an 8-week period (in total 48 hours), followed by a 3-month self-management program. The primary outcomes are low back pain intensity, disability, quality of life, patient's global perceived effect of recovery, and participation in work. Baseline characteristics include information on socio-demographics, low back pain, employment status, and additional clinical items status such as fatigue, duration of activities, and fear of kinesiophobia. Prognostic variables are determined for recovery at short-term (5 months) and long-term (12 months) follow-up after start of therapy. DISCUSSION: In a routine clinical setting it is important to provide patients suffering from chronic non-specific low back pain with adequate information about the prognosis of their complaint.

Differences in standing and forward bending in women with chronic low back or pelvic girdle pain: indications for physical compensation strategies.

STUDY DESIGN: This cohort study compares motion characteristics during forward bending of a group of chronic female patients either with low back pain (LBP) or pelvic girdle pain (PGP) and healthy subjects using computer-video analysis. OBJECTIVE: This study determines whether subcategories of back pain patients could be distinguished by motion characteristics of the pelvis and lumbar spine. SUMMARY OF BACKGROUND DATA: Compared with healthy subjects, patients with low back pain bend forward in distinct manners. Clustering these motion patterns into specific patient subgroups has been challenging since a basis for subcategorizing was lacking. Chronic LBP can be distinguished from PGP using specific evidence-based diagnostic tests. This allows comparing the motion characteristics of subgroups of chronic patients with either LBP or PGP. METHODS: Forward bending was recorded in both female patients groups and healthy female individuals, using a computer video analysis system. Trunk motion, pelvic tilt, and lumbar lordosis are represented as sagittal plane angles. From these angles, the relative contribution of the lumbar spine and hip joint to forward bending can be derived. RESULTS: Specific and discriminating motion characteristics were found between groups. During erect stance in the PGP group, the pelvis is significantly tilted backwards. At maximally forward bending, the ROM of the trunk is limited in all patient groups, but only the PGP group has significantly limited hip motion. During the initial part of forward bending, lumbar motion is increased in PGP patients and decreased in LBP patients. In the final part of forward bending contribution of the lumbar spine is increased in both patient groups. CONCLUSION: BP and PGP patients show specific, consistent, and distinct motion patterns. These motion patterns are assumed to be functional compensation strategies, following altered neuromuscular coordination.

Physical characteristics of women with severe pelvic girdle pain after pregnancy: a descriptive cohort study.

STUDY DESIGN: Descriptive cohort study. OBJECTIVE: This study aims to further elucidate the differences in physical characteristics of women with severe pregnancy-related pelvic girdle pain (PGP). SUMMARY OF BACKGROUND DATA: There is increasing interest in pelvic girdle pain (PGP). To our knowledge, this is the first study on a large population of patients with severe PGP, after pregnancy, based on high cutoff scores on diagnostic PGP tests. METHODS: Two hundred five patients were selected from the outpatient clinic of a rehabilitation center. Patients were divided in 3 inclusion groups based on the total number of positive scores on 5 diagnostic tests; i.e., active straight leg raise test, posterior pelvic pain provocation test, long dorsal sacroiliac ligament test, and hip abduction and adduction strength tests. These inclusion groups were related to the data on trunk strength test, general provocation tests, Quebec Back Pain Disability Scale (QBPDS) and activities of daily living. RESULTS: A typical pattern of PGP emerges from this study. The mean group score on the active straight leg raise, posterior pelvic pain provocation, and long dorsal sacroiliac ligament tests became higher when more than 3 inclusion tests were positive. Hip abduction and adduction strength became lower with more positive tests. The QBPDS score was overall high and significantly higher for 5 positive tests compared with 3 and 4 positive tests. This shows that the number of positive tests, the individual score on the diagnostic tests, and the QBPDS could all be an indicator for severity of PGP. Among the general pain provocation tests, both the passive hip flexion test and the upper and middle sacral thrust test scored high. The maximal isometric strength of trunk muscles was below the 10th percentile compared with women without complaints and was even less for 5 positive inclusion tests. It is confirmed that there is a typical order for difficulties with daily activities for PGP patients as follows (most difficult first): standing still, cycling, walking, sitting, and lying. CONCLUSION: The study shows that the level of severity in PGP can be adequately assessed by a combination of specific tests.

Possible role of the long dorsal sacroiliac ligament in women with peripartum pelvic pain.

BACKGROUND: To enhance the understanding of the pathophysiology of women with peripartum pelvic pain, it is necessary to couple anatomical insights with relevant clinical research. In this context, the long dorsal sacroiliac ligament is especially of interest because it was noticed that women diagnosed with peripartum pelvic pain frequently experience pain within the boundaries of this ligament. Njoo (1) found a high intertester reliability and a high specificity for long dorsal sacroiliac ligament pain. The present article focuses on the possible role of the long dorsal sacroiliac ligament in the pain pattern of women with peripartum pelvic pain. The diagnostic and therapeutic consequences are considered. STUDY DESIGN: A cross-sectional analysis was performed in a homogenous group of women meeting strict criteria for posterior pelvic pain since pregnancy, diagnosed as having peripartum pelvic pain and excluded for any history of fracture, neoplasm or previous surgery of the lumbar spine, the pelvic girdle, the hip joint or the femur. The patients were also excluded for signs indicating radiculopathy: asymmetric Achilles tendon reflex and/or (passive) straight leg raising restricted by pain in the lower leg. METHODS: The study group comprised 178 women diagnosed with peripartum pelvic pain, selected from the outpatient clinic of a specialized rehabilitation center. Selection was based on criteria enabling a strict division between lumbar and pelvic complaints. Pain in the long dorsal sacroiliac ligament was detected by standardized palpation of the long dorsal sacroiliac ligament by specifically trained physicians and scored on a modified scale. Comparisons with the posterior pelvic pain provocation test and the active straight leg raise test was carried out. RESULTS: The present study confirms that the long dorsal sacroiliac ligament frequently shows tenderness on palpation in patients with peripartum pelvic pain. Sensitivity was 76%. Sensitivity in a group of 133 women of the study group that scored positive on both active straight leg raise and posterior pelvic pain provocation tests was 86%. When only severe pelvic patients were included, sensitivity increased to 98%. In comparisons between the posterior pelvic pain provocation and the long dorsal sacroiliac ligament tests on the left and right side, Pearson's correlation coefficient was 0.33 and 0.41, respectively. In comparisons between the active straight leg raise and the long dorsal sacroiliac ligament tests on the left and right side, Pearson's correlation coefficient was 0.35 and 0.41, respectively. CONCLUSIONS: The present study, carried out on a group of peripartum pelvic pain patients with strict in- and exclusion criteria, attempts to further elucidate the pathophysiology of patients with peripartum pelvic pain by adding a simple pain provocation test. It is concluded that the combination of the active straight leg raise, the posterior pelvic pain provocation and the long dorsal sacroiliac ligament pain tests combined with the proposed in- and exclusion criteria seems promising in differentiating between mainly lumbar and pelvic complaints. Although the sensitivity of the long dorsal sacroiliac ligament pain test seems promising, further clinical study is necessary in targeting specifically the long dorsal sacroiliac ligament. It is suggested that studies initiated to show the prevalence of sacroiliac joint pain in patients presenting nonspecific lumbopelvic pain, by using intra-articularly double block injection techniques, should include a peripheral injection of at least the long dorsal sacroiliac ligament.