The association of pain with gait spatiotemporal parameters in children with hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorder.

BACKGROUND: Children with hypermobility spectrum disorder/hypermobile Ehlers-Danlos syndrome (HSD/hEDS) have a high prevalence of chronic pain, which may influence gait dynamics. However, little is known about pain outcomes and their association with gait spatiotemporal parameters in children with HSD/hEDS. RESEARCH QUESTION: Does pain correlate with gait spatiotemporal parameters in children with HSD/hEDS? METHODS: Eighteen children with HSD/hEDS and eighteen typically developing (TD) children participated in the study. The current level of pain (0-10 on the numeric rating scale), modified Brief Pain Inventory, and Pain Catastrophizing Scale-Child version were implemented to assess pain in children with HSD/hEDS. All children completed a gait analysis at a self-selected speed. Mean and variability (measured using the coefficient of variation) of gait spatiotemporal parameters were analyzed. Gait parameters included stride length, stride time, gait speed, percent stance time, and step width. A Mann-Whitney U-test was used to compare the gait parameters between children with HSD/hEDS and TD children. Spearman correlations were used to examine the relationships between pain and gait spatiotemporal parameters in children with HSD/hEDS. RESULTS: Children with HSD/hEDS had a longer percent stance time compared to TD children (p = 0.03). Lower pain interference in relationships with other people was significantly associated with faster gait speeds (ρ = -0.55, p = 0.03). Children with HSD/hEDS also had greater pain interference during mobility (ρ = 0.5, p = 0.05) and going to school (ρ = 0.65, p = 0.01), which were significantly correlated with greater stride length variability. Greater pain interference during enjoyment of life was significantly associated with greater percent stance time variability (ρ = 0.5, p = 0.05). Greater pain catastrophizing was correlated with decreased step width variability in children with HSD/hEDS (ρ = -0.49, p = 0.05). SIGNIFICANCE: Pain interference and catastrophe were significantly associated with gait spatiotemporal variability. Our findings suggest that assessing pain-associated gait alterations may help understand the clinical features and gait kinematics of children with HSD/hEDS.

Rate of tarsal and metatarsal bone mineral density change in adults with diabetes mellitus and peripheral neuropathy: a longitudinal study.

BACKGROUND: In people with diabetes (DM) and peripheral neuropathy (PN), loss of bone mineral density (BMD) in the tarsals and metatarsals contribute to foot complications; however, changes in BMD of the calcaneal bone is most commonly reported. This study reports rate of change in BMD of all the individual bones in the foot, in participants with DM and PN. Our aim was to investigate whether the rate of BMD change is similar across all the bones of the foot. METHODS: Participants with DM and PN (n = 60) were included in this longitudinal cohort study. Rate of BMD change of individual bones was monitored using computed tomography at baseline and 6 months, 18 months, and 3-4 years from baseline. Personal factors (age, sex, medication use, step count, sedentary time, and PN severity) were assessed. A random coefficient model estimated rate of change of BMD in all bones and Pearson correlation tested relationships between personal factor variables and rate of BMD change. RESULTS: Mean and calcaneal BMD decreased over the study period (p < 0.05). Individual tarsal and metatarsal bones present a range of rate of BMD change (-0.3 to -0.9%/year) but were not significantly different than calcaneal BMD change. Only age showed significant correlation with BMD and rate of BMD change. CONCLUSION: The rate of BMD change did not significantly differ across different foot bones at the group level in people with DM and PN without foot deformity. Asymmetric BMD loss between individual bones of the foot and aging may be indicators of pathologic changes and require further investigation. TRIAL REGISTRATION: Metatarsal Phalangeal Joint Deformity Progression-R01. Registered 25 November 2015, https://clinicaltrials.gov/ct2/show/NCT02616263.

Pain Characteristics and Symptom Management in Children with Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorder.

AIMS: This study aims to investigate pediatric hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorder (HSD) pain features and management strategies. METHODS: This is a mixed-methods, cross-sectional study design using patient-reported outcomes in 21 children diagnosed with hEDS/HSD. Children who reported bothersome pain were interviewed for pain features. The Child Activity Limitation Interview-21, the Brief Pain Inventory pain interference items, and the Functional Disability Inventory were used to investigate pain interference. To evaluate psychological symptoms regarding pain, the pediatric version of the Survey of Pain Attitude and the child version of the Pain Catastrophizing Scale were used. RESULTS: Nineteen children had bothersome pain and of them, eight children reported constant pain. The most frequently reported regions of pain were at the ankle (mild pain) and the back (moderate-to-severe pain). Children reported mild-to-moderate pain interference and believed medications were beneficial for their pain management. Nineteen children sought treatment and of those 16 children used to exercise and acetaminophen and 13 visited physicians as a means of treatment. Parents were overall satisfied with their child's treatment (13 out of 19). CONCLUSIONS: Sufficient awareness of pain-related symptoms and understanding of the treatment strategies in early childhood is needed to prevent deleterious consequences in adulthood.

Remote Research: Resources, Intervention Needs, and Methods in People with Diabetes and Peripheral Neuropathy.

BACKGROUND: Stay-at-home orders associated with the SARS-CoV-2 (COVID-19) pandemic were particularly important for older adults with type 2 diabetes, at risk for severe COVID-19 complications. In response, research shifted to remote telehealth methodology. Study participant interests, equipment needs, and ability to adapt methods to the remote/telehealth environment were unknown. Study purposes to assess (1) resource needs (internet/devices accessibility), (2) future telehealth interests, and (3) ability to adapt common research and clinical measures of glycemic control, physical function, activity measures, and quality of life outcomes to a telehealth setting. METHOD: Twenty-one participants with type 2 diabetes and peripheral neuropathy were recruited from a longitudinal study (11 female; age: 66.3 ± 8.3 years; DM: 15.1 ± 8.7 years). Technology needs and future telehealth interests were assessed. A glycemic measure (HbA1c), a five-times chair rise, a one-week activity monitor, and surveys (self-efficacy, depression, and balance) were collected. All aspects of the study were completed remotely over email and video/phone call. RESULTS: Twelve participants used computers; nine used phones for study completion. Participants had the following resource needs: connectivity (n = 3), devices (n = 6), and technical support (n = 12). Twenty people expressed interest in participating in future telehealth studies related to balance, exercise, and diabetes management. Methodological considerations were primarily the need for assistance for participants to complete the home HbA1c test, five-time chair rise, wearable activity monitoring, and surveys. CONCLUSIONS: Older adults with type 2 diabetes and peripheral neuropathy would need technological and personal assistance (connection, device, guidance) to complete a long-term telehealth intervention. Despite technology needs, participants were interested in telehealth interventions. CLINICAL TRIAL: Parent study, "Metatarsal Phalangeal Joint Deformity Progression-R01 (NCT02616263) is registered at https://clinicaltrials.gov/.

Midfoot and ankle movement coordination during heel rise is disrupted in people with diabetes and peripheral neuropathy.

BACKGROUND: A heel rise task can be used to evaluate midfoot and ankle movement dysfunction in people with diabetes mellitus and peripheral neuropathy. Quantifying movement coordination during heel rise is important to better understand potentially detrimental movement strategies in people with foot pathologies; however, coordination and the impact of limited excursion on coordination is not well-understood in people with diabetes. METHODS: Sixty patients with diabetes mellitus and peripheral neuropathy, and 22 older and 25 younger controls performed single-limb heel rise task. Midfoot (forefoot relative to hindfoot) sagittal and ankle (hindfoot relative to shank) sagittal and frontal kinematics were measured and normalized to time (0 to 100%). Cross-correlation coefficients were calculated across individuals in each group. A graphical illustration was used to interpret the relationship of midfoot and ankle excursion and cross-correlation coefficient during heel rise. FINDINGS: People with diabetes mellitus and peripheral neuropathy showed significantly lower midfoot and ankle cross-correlation coefficients during heel rise compared to older controls (p = 0.003-0.007). There was no difference in the midfoot and ankle cross-correlation coefficients during heel rise for the older and younger controls (p = 0.059-0.425). The graphic data illustrated a trend of greater excursion of two joints and a higher cross-correlation coefficient. Some individuals with lower excursion showed a high cross-correlation coefficient. INTERPRETATION: Foot pathologies, but not aging, impairs midfoot and ankle movement coordination during heel rise task. Investigating both movement coordination as well as joint excursion would better inform and characterize the dynamic movements of midfoot and ankle during heel rise task.

Body mass index and maximum available midfoot motion are associated with midfoot angle at peak heel rise in people with type 2 diabetes mellitus and peripheral neuropathy.

PURPOSE: Midfoot movement dysfunction, as measured by heel rise performance, is associated with midfoot deformity in people with diabetes and peripheral neuropathy. Understanding contributors of midfoot movement dysfunction may help clinicians understand deformity progression. The purpose of this study was to determine the factors associated with midfoot angle at peak heel rise. METHODS: The outcomes of fifty-eight participants with type 2 diabetes mellitus and peripheral neuropathy were analyzed. Midfoot (forefoot on hindfoot) sagittal kinematics during unilateral heel rise task were measured using 3-dimensional motion analysis. A multivariate linear regression model was used to predict midfoot sagittal movements at peak heel rise. Independent variables that were entered in the model were (in order of entry): age, body mass index, intrinsic foot muscle volume, and maximum available midfoot plantarflexion range of motion. Intrinsic foot muscle volume was obtained from magnetic resonance imaging and maximum available midfoot motion was measured during non-weightbearing plantarflexion using 3-dimensional motion analysis. RESULTS: Body mass index (R2 = 30.5%, p < 0.001) and maximum available midfoot plantarflexion range of motion (R2 = 10.9%, p = 0.001) were significant factors that accounted for 41.4% of variance of midfoot angle at peak heel rise, while age and intrinsic foot muscle volume were not significant predictors. CONCLUSIONS: Greater body mass index and less available midfoot plantarflexion range of motion were associated with greater midfoot movement dysfunction. These two significant predictors are potentially modifiable, suggesting possible improvements in midfoot movements with reduction in body weight and increasing midfoot plantarflexion range of motion. Health care professionals should consider patient's weight and joint motion when prescribing foot exercise(s) to prevent excessive midfoot collapse during weightbearing tasks.

Association of toe-extension movement pattern magnitude and variability during three functional tasks with diabetic foot complications.

BACKGROUND: A toe-extension movement pattern may contribute to metatarsophalangeal joint deformity and ulceration in people with diabetes. We sought to quantify the relationship between toe extension magnitude and variability during three functional tasks (ankle range of motion, sit to stand, walking) with metatarsophalangeal joint deformity, and identify potential mechanisms associated with a toe-extension movement pattern. METHODS: Individuals with diabetes and peripheral neuropathy were included (n = 60). Metatarsophalangeal joint deformity was assessed using computed tomography (CT). Toe-extension movement was quantified using 3-dimensional motion capture. Linear regression was used to investigate the role of toe-extension movement pattern on metatarsophalangeal joint deformity. Regression analysis was used to identify mechanisms (neuropathy severity, foot intrinsic muscle deterioration ratio, ankle dorsiflexion range of motion) contributing to toe-extension movement pattern. FINDINGS: Toe extension with each functional task as well as the mean and coefficient of variation across all tasks were significantly related to metatarsophalangeal joint deformity (range of correlation coefficients = (-0.386, 0.692), p ≤ 0.001). Ankle dorsiflexion range of motion was associated with mean toe extension across all tasks (rsp = -0.282, p = 0.029). Neuropathy severity and foot intrinsic muscle deterioration ratio were associated with toe extension variability (rsp = -0.373, p = 0.003 and rsp = -0.266, p = 0.043; respectively). INTERPRETATION: Greater magnitude and lower variability of a toe-extension movement pattern was found to be associated with metatarsophalangeal joint deformity. These findings may support clinical assessment and treatment of movement across more than one task.

Heel Rise and Non-Weight-Bearing Ankle Plantar Flexion Tasks to Assess Foot and Ankle Function in People With Diabetes Mellitus and Peripheral Neuropathy.

OBJECTIVE: The objective of this study was to examine the effects of diabetes mellitus and peripheral neuropathy (DMPN), limited joint mobility, and weight-bearing on foot and ankle sagittal movements and characterize the foot and ankle position during heel rise. METHODS: Sixty people with DMPN and 22 controls participated. Primary outcomes were foot (forefoot on hindfoot) and ankle (hindfoot on shank) plantar-flexion/dorsiflexion angle during 3 tasks: unilateral heel rise, bilateral heel rise, and non-weight-bearing ankle plantar flexion. A repeated-measures analysis of variance and Fisher exact test were used. RESULTS: Main effects of task and group were significant, but not the interaction in both foot and ankle plantar flexion. Foot and ankle plantar flexion were less in people with DMPN compared with controls in all tasks. Both DMPN and control groups had significantly less foot and ankle plantar flexion with greater weight-bearing; however, the linear trend across tasks was similar between groups. The DMPN group had a greater percentage of individuals in foot and/or ankle dorsiflexion at peak unilateral heel rise compared with controls, but the foot and ankle position was similar at peak bilateral heel rise between DMPN and control groups. CONCLUSION: Foot and ankle plantar flexion is less in people with DMPN. Less plantar flexion in non-weight-bearing suggests that people with DMPN have limited joint mobility. However, peak unilateral and bilateral heel rise is less than the available plantar flexion range of motion measured in non-weight-bearing, indicating that limited joint mobility does not limit heel rise performance. A higher frequency of people with DMPN are in foot and ankle dorsiflexion at peak unilateral heel rise compared with controls, but the position improved with lower weight-bearing. IMPACT: Proper resistance should be considered with physical therapist interventions utilizing heel rise because foot and ankle plantar flexion position could be improved by reducing the amount of weight-bearing.

Midfoot and ankle motion during heel rise and gait are related in people with diabetes and peripheral neuropathy.

BACKGROUND: Midfoot and ankle movement dysfunction in people with diabetes mellitus and peripheral neuropathy (DMPN) is associated with midfoot deformity and increased plantar pressures during gait. If midfoot and ankle motion during heel rise and push-off of gait have similar mechanics, heel rise performance could be a clinically feasible way to identify abnormal midfoot and ankle function during gait. RESEARCH QUESTION: Is midfoot and ankle joint motion during a heel rise associated with midfoot and ankle motion at push-off during gait in people with DMPN? METHODS: Sixty adults with DMPN completed double-limb heel rise, single-limb heel rise, and walking. A modified Oxford multi-segment foot model (forefoot, hindfoot, shank) was used to analyze midfoot (forefoot on hindfoot) and ankle (hindfoot on shank) sagittal angle during heel rise and gait. Pearson correlation was used to test the relationship between heel rise and gait kinematic variables (n = 60). Additionally, we classified 60 participants into two subgroups based on midfoot and ankle position at peak heel rise: midfoot and ankle dorsiflexed (dorsiflexed; n = 23) and midfoot and ankle plantarflexed (plantarflexed; n = 20). Movement trajectories of midfoot and ankle motion during single-limb heel rise and gait of the subgroups were examined. RESULTS: Peak double-limb heel rise and gait midfoot and ankle angles were significantly correlated (r = 0.49 and r = 0.40, respectively). Peak single-limb heel rise and gait midfoot and ankle angles were significantly correlated (r = 0.63 and r = 0.54, respectively). The dorsiflexed subgroup, identified by heel rise performance showed greater midfoot and ankle dorsiflexion during gait compared to the plantarflexed subgroup (mean difference between subgroups: midfoot 3°, ankle 3°). SIGNIFICANCE: People with DMPN who fail to plantarflex the midfoot and ankle during heel rise have difficulty plantarflexing the midfoot and ankle during gait. Utilizing a heel rise task may help identify midfoot and ankle dysfunction associated with gait in people with DMPN.

Relationships within and between lower and upper extremity dysfunction in people with diabetes.

INTRODUCTION: Diabetes mellitus (DM) is associated with systemic musculoskeletal system impairments suggesting concurrent development of lower and upper extremity musculoskeletal problems. This study aims to examine relationships between lower and upper extremity function in people with DM. METHODS: Sixty people with type 2 DM and peripheral neuropathy [mean (standard deviation); 67(6) years old, DM duration 14(10) yrs] completed the following measures: 1) Self-reports of function: Foot and Ankle Ability Measure (FAAM; higher = better function) and Shoulder Pain and Disability Index (SPADI; lower = better function), 2) Range of motion (goniometry): ankle dorsiflexion and shoulder flexion, and 3) Strength: unilateral heel rise power (UHR, 3D kinetics) and hand grip dynamometry. Pearson correlations examined associations between lower and upper extremity measures, p < .05. RESULTS: Forty of 60 (67%) reported pain/disability in both the foot/ankle and shoulder and 95% of study participants had some limitation in foot or shoulder function. Significant between extremity correlations: FAAM and SPADI (r = -0.39), ankle dorsiflexion and shoulder flexion range of motion (r = 0.35), and UHR and hand grip strength (r = 0.40). Significant within extremity correlations: FAAM and UHR (r = .47) and SPADI with shoulder flexion (r = -0.44). CONCLUSION: Upper and lower extremity inter- and intra-relationships indicate systemic musculoskeletal impairments in people with DM. Healthcare practitioners should consider the potential for concurrent and disabling musculoskeletal problems in people with DM.

Multi-System Factors Associated with Metatarsophalangeal Joint Deformity in Individuals with Type 2 Diabetes.

The underlying factors contributing to metatarsophalangeal joint deformity, a known precursor to skin breakdown in individuals with diabetes mellitus (DM), is likely to involve multiple body systems. The purpose of this cross-sectional study was to identify multi-system factors associated with metatarsophalangeal joint deformity in individuals with type 2 DM and peripheral neuropathy (n = 60). Metatarsophalangeal joint deformity was quantified with a computed tomography (CT) scan. System biomarkers included the musculoskeletal system (foot intrinsic muscle deterioration, tarsal/metatarsal bone mineral density, ankle dorsiflexion, metatarsophalangeal extension movement during a sit to stand task); the vascular system (ankle-brachial index); and the endocrine/immune systems (high sensitivity C-reactive protein, skin intrinsic fluorescence, and hemoglobin A1C). Muscle deterioration (r = 0.27), bone density (r = -0.35), metatarsophalangeal extension movement (r = 0.50), maximum dorsiflexion (r = -0.31), and ankle-brachial index (r = 0.33) were related to metatarsophalangeal joint deformity (p < 0.05). Bone mineral density and metatarsophalangeal extension movement were retained in a regression model relating to deformity (R2 = 0.34). All musculoskeletal system biomarkers and the ankle-brachial index demonstrated weak to moderate relationships to metatarsophalangeal joint deformity. Bone mineral density of the tarsal/metatarsal bones and extending the toes during a sit to stand task were the two strongest factors associated with metatarsophalangeal joint deformity. Evaluation and management of foot bone mineral density and toe extension movement pattern could reduce metatarsophalangeal joint deformity and the risk of skin breakdown and subsequent amputation.

Metatarsophalangeal joint flexion affects dorsiflexor activity in subjects with a dominant extensor hallucis longus.

BACKGROUND AND OBJECTIVES: Normal dorsiflexion (DF) required for normal gait is achieved through balance of the tibialis anterior (TA) and extensor hallucis longus (EHL). Imbalance may induce ankle and foot deformities and exacerbate pathology. EHL dominance is associated with progressive TA weakness, attributable to muscle non-use. When the EHL dominantly dorsiflexes the ankle, the big toe extends at the metatarsophalangeal joint (MTPJ) and pure ankle DF is absent. The effects of active MTPJ flexion on TA and EHL muscles, TA/EHL ratio, and the force applied during active DF in EHL-dominant (EHL-D) and EHL-non-dominant (EHL-ND) subjects were compared. METHODS: The 38 subjects were divided into EHL-D and EHL-ND groups. All subjects performed active ankle DF with and without active MTPJ flexion. Surface electromyographic data, ankle active range of motion, and DF force were measured. Two-way mixed analysis of variance was used to evaluate differences in dependent variables. RESULTS: Compared to the EHL-ND group, the EHL-D group exhibited less TA activity, more EHL activity, and a reduced TA/EHL activity ratio. Active application of MTPJ flexion during DF significantly reduced muscle imbalance, whereas EHL activity decreased and the TA/EHL activity ratio increased. The DF force decreased significantly with MTPJ flexion in both groups. CONCLUSIONS: Active MTPJ flexion can reduce EHL and/or increase TA activity and increase the TA/EHL activity ratio during active ankle DF in both EHL-D and EHL-ND subjects.

Stretching position can affect levator scapular muscle activity, length, and cervical range of motion in people with a shortened levator scapulae.

OBJECTIVES: Levator scapulae (LS) muscle stretching exercises are a common method of lengthening a shortened muscle; however, the appropriate stretching position for lengthening the LS in people with a shortened LS remains unclear. The purpose of this study was to compare the effects of different stretching exercise positions on the LS and introduce effective stretching exercise methods to clinicians. PARTICIPANTS: Twenty-four university students (12 men, 12 women) with a shortened LS were recruited. METHODS: LS muscle activity, LS index (LSI), and cervical range of motion (ROM) were measured pre (baseline) and post three different stretching exercise positions (sitting, quadruped, and prone). RESULTS: The LSI and cervical ROM exceeded the minimal detectable change and had significant changes. The LSI was greater in the sitting position than at the baseline (p = 0.01), quadruped position (p < 0.01); the LSI in the prone position presented a higher increase than the quadruped position (p = 0.01). The cervical ROM increased in the sitting position when compared to the baseline (p < 0.01) and quadruped position (p < 0.01). CONCLUSIONS: Stretching the LS in the sitting position was the most effective exercise for improving LS muscle length and cervical ROM.

Effects of suboccipital release with craniocervical flexion exercise on craniocervical alignment and extrinsic cervical muscle activity in subjects with forward head posture.

BACKGROUND: Forward head posture is a head-on-trunk malalignment, which results in musculoskeletal dysfunction and neck pain. To improve forward head posture, both the craniocervical flexion exercise and the suboccipital release technique have been used. OBJECTIVES: The purpose of this study was to compare the immediate effects of craniocervical flexion exercise and suboccipital release combined with craniocervical flexion exercise on craniovertebral angle, cervical flexion and extension range of motion, and the muscle activities of the sternocleidomastoid, anterior scalene, and splenius capitis during craniocervical flexion exercise in subjects with forward head posture. METHODS: In total, 19 subjects (7 males, 12 females) with forward head posture were recruited using G-power software. Each subject performed craniocervical flexion exercise and suboccipital release combined with craniocervical flexion exercise in random order. After one intervention was performed, the subject took a 20min wash out period to minimize any carry-over effect between interventions. Craniovertebral angle, cervical flexion and extension range of motion, and the muscle activities of the sternocleidomastoid, anterior scalene, and splenius capitis were measured. A one-way, repeated-measures ANOVA was used to assess differences between the effects of the craniocervical flexion exercise and suboccipital release combined with craniocervical flexion exercise interventions in the same group. RESULTS: Craniovertebral angle (p<0.05), cervical flexion range of motion (p<0.05), and cervical extension range of motion (p<0.001) were significantly greater after suboccipital release combined with craniocervical flexion exercise compared to craniocervical flexion exercise alone. The muscle activities of the sternocleidomastoid, anterior scalene, and splenius capitis were significantly lower during suboccipital release combined with craniocervical flexion exercise than during craniocervical flexion exercise alone across all craniocervical flexion exercise phases except the first (all p<0.05). CONCLUSION: The addition of suboccipital release to craniocervical flexion exercise provided superior benefits relative to craniocervical flexion exercise alone as an intervention for subjects with forward head posture.

Reliability of levator scapulae index in subjects with and without scapular downward rotation syndrome.

OBJECTIVES: The objective of this study was to introduce levator scapulae (LS) measurement using a caliper and the levator scapulae index (LSI) and to investigate intra- and interrater reliability of the LSI in subjects with and without scapular downward rotation syndrome (SDRS). DESIGN: Two raters measured LS length twice in 38 subjects (19 with SDRS and 19 without SDRS). MAIN OUTCOME MEASURES: For reliability testing, intraclass correlation coefficients (ICCs), standard error of measurement (SEM), and minimal detectable change (MDC) were calculated. RESULTS: Intrarater reliability analysis resulted with ICCs ranging from 0.94 to 0.98 in subjects with SDRS and 0.96 to 0.98 in subjects without SDRS. These results represented that intrarater reliability in both groups were excellent for measuring LS length with the LSI. Interrater reliability was good (ICC: 0.82) in subjects with SDRS; however, interrater reliability was moderate (ICC: 0.75) in subjects without SDRS. Additionally, SEM and MDC were 0.13% and 0.36% in subjects with SDRS and 0.35% and 0.97% in subjects without SDRS. In subjects with SDRS, low dispersion of the measurement errors and MDC were shown. CONCLUSIONS: This study suggested that the LSI is a reliable method to measure LS length and is more reliable for subjects with SDRS.

Various shrug exercises can change scapular kinematics and scapular rotator muscle activities in subjects with scapular downward rotation syndrome.

Scapular dyskinesis, characterized by scapular downward rotation syndrome (SDRS) affects scapula-humeral rhythm and results in shoulder dysfunction. Previous study has led to the recommendation of standard shrug exercise to contend with SDRS and strengthen the upper trapezius (UT) muscle. However, few researchers have examined which shrug exercise is most effective. The aim of this research was to compare scapular kinematic changes and scapular rotator muscles activity across three different shrug exercises in SDRS. The amounts of scapular downward rotation were measured by a caliper and the scapular upward rotation angle was measured using two digital inclinometers. Surface electromyography was used to measure EMG amplitude from the UT, lower trapezius (LT), serratus anterior (SA), and levator scapula (LS). Seventeen subjects with SDRS were recruited for this study. The subjects performed three shrug exercises with 30° shoulder abduction (preferred shrug, frontal shrug, and stabilization shrug). The stabilization shrug showed a significantly greater scapular upward rotation angle compared with the preferred shrug (P=0.004) and frontal shrug (P=0.006). The UT activity was significantly greater in the frontal shrug than in the preferred shrug (P=0.002). The UT/LS muscle activity ratio was also significantly greater in the frontal shrug than in the preferred shrug (P=0.004). The stabilization shrug should be preferred to enhance the upward rotation angle. In addition, the frontal shrug can be used as an effective method to increase UT activity and to decrease LS activity in SDRS.

Shrug exercises combined with shoulder abduction improve scapular upward rotator activity and scapular alignment in subjects with scapular downward rotation impairment.

The aim of this research was to investigate which shoulder abduction angle (30°, 90°, 150°) during shrug exercise is superior for (1) activating the scapular upward rotators and (2) improving scapular and clavicular position in subjects with scapular downward rotation impairment. Twenty subjects performed shrug exercises at three different shoulder abduction angles (30°, 90°, 150°) which were obtained and maintained actively. Surface EMG data were collected from the levator scapulae (LS), upper trapezius (UT), lower trapezius (LT), and serratus anterior (SA) during shrug exercises. Scapular downward rotation index (SDRI) and clavicular tilt angle (CTA) were measured immediately after each shrug exercise. Oneway repeated-measures analysis of variance was used to determine the significance. UT muscle activity was greater at 90° and 150° than at 30° of shoulder abduction. UT/LS muscle activity ratio was greater at 90° than at 30°. LT and LT/LS increased as shoulder abduction angle increased. SA was greater at 150° than at 30° or 90°. SA/LS was greater at 150° than at 30°. SDRI was lower at 90° and 150° than at 30°. CTA was greater at 90° and 150° than at 30°. In conclusion, shrug exercises at 90° or 150° of shoulder abduction angle may be advocated to activate scapular upward rotators, decrease SDRI, and increase CTA in patients with scapular downward rotation impairment.

Trunk muscle activation during different quadruped stabilization exercises in individuals with chronic low back pain.

BACKGROUND AND PURPOSE: The aim of this study was to compare the trunk muscle activities and the local/global activity ratios of the abdominal, back and trunk muscles during stabilization exercises such as one arm raise (AR), one leg raise (LR), and opposing arm/leg raise (ALR) in patients with chronic low back pain (LBP). METHOD: Ten individuals with chronic LBP (five men and five women) participated in this study. The external oblique abdominis, internal oblique abdominis, multifidus, thoracic part of the lumbar iliocostalis and the local/global activity ratio were assessed, while quadruped stabilization exercises were performed (AR, LR, and ALR); each exercise was carried out three times. RESULT: One-way repeated ANOVA was used to measure the differences in the trunk muscle activity and the local/global activity ratio. Post hoc analyses were performed (α = 0.05/3 = 0.017). In the right internal oblique, muscle activity during LR was significantly greater than that during AR. In the bilateral multifidus and lumbar iliocostalis, each ALR muscle activity was significantly greater than those of AR and LR. In addition, the local/global activity ratios of the back and trunk muscle in LR and ALR were significantly greater compared with AR. CONCLUSIONS: LR should be recommended over AR for individuals with chronic LBP. Moreover, the application of ALR should be approached carefully on the basis of progress and ability to stabilize the spine in this patient population.

A comparison of the reliability of the trochanteric prominence angle test and the alternative method in healthy subjects.

A wide range of intra- and inter-rater reliabilities of the trochanteric prominence angle test (TPAT) has been reported. We introduced the transcondylar angle test (TCAT) as an alternative to the TPAT and using a smartphone as a reliable measurement tool for femoral neck anteversion (FNA) measurement. The reliabilities of the TPAT and the TCAT, the reliability of using a smartphone as a clinical measurement tool, and the correlation between the difference value of medial knee joint space (KJS) between rest and tested positions and the difference value between the TPAT and TCAT were assessed. Two physical therapists independently determined the reliabilities of the TPAT with a digital inclinometer, the TCAT with a digital inclinometer, and the TCAT with a smartphone in 19 hips of 10 healthy subjects (5 male and 5 female, 22.2 ± 1.69 years). The medial KJS in rest and the tested position were assessed using a sonography. The intra-class correlation coefficients (ICC) for the intra-rater reliabilities of TPAT with a digital inclinometer (ICC = 0.92), TCAT with a digital inclinometer (ICC = 0.94) and a smartphone (ICC = 0.95) in both testers were substantial. The inter-rater reliability of TPAT with a digital inclinometer was fair (ICC = 0.48) while TCAT with a digital inclinometer (ICC = 0.89) and a smartphone (ICC = 0.85) were substantial. The correlation between the difference value of medial KJS between rest and tested positions and the difference value between TPAT and TCAT was low and statistically non-significant (r = 0.114; p = 0.325). The TCAT would be more reliable than the TPAT in inter-rater test. Using a smartphone is a clinically comparable measuring tool to a digital inclinometer.

Effects of different hip rotations on gluteus medius and tensor fasciae latae muscle activity during isometric side-lying hip abduction.

CONTEXT: Gluteus medius (Gmed) weakness is associated with some lower-extremity injuries. People with Gmed weakness might compensate by activating the tensor fasciae latae (TFL). Different hip rotations in the transverse plane may affect Gmed and TFL muscle activity during isometric side-lying hip abduction (SHA). OBJECTIVES: To compare Gmed and TFL muscle activity and the Gmed:TFL muscle-activity ratio during SHA exercise with 3 different hip rotations. DESIGN: The effects of different hip rotations on Gmed, TFL, and the Gmed:TFL muscle-activity ratio during isometric SHA were analyzed with 1-way, repeated-measures analysis of variance. SETTING: University research laboratory. PARTICIPANTS: 20 healthy university students were recruited in this study. INTERVENTIONS: Participants performed isometric SHA: frontal SHA with neutral hip (frontal SHAN), frontal SHA with hip medial rotation (frontal SHA-MR), and frontal SHA with hip lateral rotation (frontal SHA-LR). MAIN OUTCOME MEASURES: Surface electromyography measured the activity of the Gmed and the TFL. A 1-way repeated-measures analysis of variance assessed the statistical significance of Gmed and TFL muscle activity. When there was a significant difference, a Bonferroni adjustment was performed. RESULTS: Frontal SHA-MR showed significantly greater Gmed muscle activation than frontal SHA-N (P = .000) or frontal SHA-LR (P = .015). Frontal SHA-LR showed significantly greater TFL muscle activation than frontal SHA-N (P = .002). Frontal SHA-MR also resulted in a significantly greater Gmed:TFL muscle-activity ratio than frontal SHA-N (P = .004) or frontal SHA-LR (P = .000), and frontal SHA-N was significantly greater than frontal SHA-LR (P = .000). CONCLUSIONS: Frontal SHA-MR results in greater Gmed muscle activation and a higher Gmed:TFL muscle ratio.