Methodological quality of a systematic review on physical therapy for temporomandibular disorders: influence of hand search and quality scales.

The validity of a systematic review depends on completeness of identifying randomised clinical trials (RCTs) and the quality of the included RCTs. The aim of this study was to analyse the effects of hand search on the number of identified RCTs and of four quality lists on the outcome of quality assessment of RCTs evaluating the effect of physical therapy on temporomandibular disorders. In addition, we investigated the association between publication year and the methodological quality of these RCTs. Cochrane, Medline and Embase databases were searched electronically. The references of the included studies were checked for additional trials. Studies not electronically identified were labelled as "obtained by means of hand search". The included RCTs (69) concerning physical therapy for temporomandibular disorders were assessed using four different quality lists: the Delphi list, the Jadad list, the Megens & Harris list and the Risk of Bias list. The association between the quality scores and the year of publication were calculated. After electronic database search, hand search resulted in an additional 17 RCTs (25%). The mean quality score of the RCTs, expressed as a percentage of the maximum score, was low to moderate and varied from 35.1% for the Delphi list to 54.3% for the Risk of Bias list. The agreement among the four quality assessment lists, calculated by the Interclass Correlation Coefficient, was 0.603 (95% CI, 0.389; 0.749). The Delphi list scored significantly lower than the other lists. The Risk of Bias list scored significantly higher than the Jadad list. A moderate association was found between year of publication and scores on the Delphi list (r = 0.50), the Jadad list (r = 0.33) and the Megens & Harris list (r = 0.43).

Intra-examiner reliability of sensory nerve conduction measurements.

The objective of this study was to investigate the intra-examiner reliability of consecutive sensory nerve action potential amplitude measurements with short time intervals. Amplitudes were compared in repeated sensory nerve action potential recordings of the lateral antebrachial cutaneous nerve on 63 healthy subjects. There were two sets of each two consecutive measurements, each set separated by a controlled interval of 90 minutes. Intraclass correlation coefficients were 0.996 and 0.998 for consecutive measurements, and 0.919 and 0.926 for measurements before and after a controlled interval of 90 minutes. The presented research clarifies the difference between measurement variability versus intra-subject variability and the influence on test-retest results in sensory nerve conduction measurements. This is of importance for correct interpretation of results when performing serial testing. It is demonstrated that a single tester can obtain reliable amplitude measurements of sensory nerve action potentials of the lateral antebrachial cutaneous nerve in asymptomatic subjects with surface recording electrodes. It is also proven that it is sufficient to control ambient temperature instead of limb temperature for this type of study on asymptomatic subjects.

Influence of the transverse distance between surface recording electrodes and sensory nerves.

The extent of the influence of the transverse distance between surface recording electrodes and the lateral antebrachial cutaneous and sural nerves when performing orthodromic recordings of sensory nerve action potential amplitudes was investigated on 60 healthy volunteers, using a stringent protocol. The recording electrodes were positioned on top of the studied nerves and per 5 mm to each side. A sensory nerve action potential was measured and recorded on every position until no action potential could be measured any more. The mean range varied from 65 mm ulnar to 60 mm radial for the lateral antebrachial cutaneous nerve and from 55 mm medial to 55 mm lateral for the sural nerve. Since amplitude decreases 16% every 5 mm for the lateral antebrachial cutaneous nerve and 12% every 5 mm for the sural nerve, it is better not to determine the location of recording electrodes merely in accordance anatomical charts, but to adjust the electrode placement individually in order to detect the location where maximal amplitude of a SNAP can be recorded.

Relationship of chronic ankle instability to muscle activation patterns during the transition from double-leg to single-leg stance.

BACKGROUND: Impaired muscle activation may predispose subjects to develop chronic ankle instability. It has been suggested that impairments are found not only in structures around the injured ankle but also around the more proximal joint complexes. HYPOTHESIS: Subjects with chronic ankle instability were expected to show later onset times for lower limb and trunk muscle activation when compared with control subjects. They were expected to show less variability in muscle activation patterns compared with the control group. STUDY DESIGN: Controlled laboratory study. METHODS: Thirty control subjects and 10 subjects with chronic ankle instability participated in the study. The onset of muscle activity of 14 muscles of the lower limb and trunk was measured during the transition from a double-leg stance position to a single-leg stance position in eyes-open and eyes-closed test conditions. RESULTS: Subjects with chronic ankle instability showed significantly later onset times for the ankle, hip, and hamstring muscles compared with control subjects. They used a similar muscle activation pattern in both test conditions, whereas control subjects adjusted their activation pattern according to the condition. CONCLUSIONS: Differences in muscle activation patterns between subjects with chronic ankle instability and control subjects occur not only around the ankle but also around other joints. Subjects with chronic ankle instability show less variability in muscle activation patterns between test conditions. CLINICAL RELEVANCE: Knowledge of muscle activation patterns in the whole lower limb and trunk in noninjured subjects and the differences found in chronic ankle instability subjects broadens the physical therapy approach to the treatment of chronic ankle instability.

Three-dimensional manual contact force evaluation of graded perpendicular push force delivery by second-year physiotherapy students during simple feedback training.

OBJECTIVE: The purpose of this study was to investigate a quantitative biomechanical evaluation method for contact forces exerted during a manual examination and treatment technique used in a learning environment. The evaluation was based on three-dimensional (3D) force component data. METHODS: A hand-/palm-held computerized 3D force component measuring system was used during a simple feedback experiment involving 20 second-year university students of physiotherapy who delivered 5 sets of graded perpendicular manual push forces on the sensor part of the system, which was placed on the padded surface of an examination/treatment table. In an effect study with a multiple time-series design, a randomly chosen subgroup of subjects received concurrent visual 3D kinetic/dynamic force-time feedback. RESULTS: The students delivered graded perpendicular forces with good intrasubject consistency (intraclass correlation coefficient [3, 1]: mean, 0.80; range, 0.76-0.88) but with poor intersubject consistency (intraclass correlation coefficient [2, 1]: mean, 0.38; range, 0.15-0.74). A temporary performance improvement in forward-backward force direction deviations from the perpendicular in the subgroup given feedback indicates that students are sensitive to feedback training. CONCLUSION: An evaluation tool using 3D contact force component measurement enables the assessment of the overall magnitude of the manual contact force as well as its directional aspect. Compared with existing evaluations based on 1-dimensional force components, this 3D system allows for a more complete and, at the same time, more specific quantitative evaluation of the manual contact forces. Three-dimensional dynamic/kinetic augmented feedback has the additional potential of helping students and practitioners to improve their palpation and force delivery skills.

The assessment of erythema and thickness on burn related scars during pressure garment therapy as a preventive measure for hypertrophic scarring.

The aim of this study was threefold: (1) Assess the pressure loss of two types of pressure garments that are used in the treatment of hypertrophic scars after burn injury, (2) investigate the influence of two different levels of compression on erythema and thickness of burn scars and (3) examine the association between erythema and thickness. The study was a prospective trial in which 76 burn scars in 60 patients were objectively assessed with the Minolta Chromameter CR-300 for erythema and with the Dermascan C for thickness of the scar over a period of 3 months. Each patient was randomly assigned to a "normal" or "lower" compression class treatment, with respectively mean values of 15 and 10 mmHg pressure after wearing the garment for 1 month. Measurements for both parameters were taken at 0, 1, 2 and 3 months of treatment. Pressure garments with "normal" compression did lose significantly more compression over 1 month (4.82 mmHg) than did the garments from the low compression class (2.57 mmHg). Scars that were treated with garments from a "normal" compression class did score significantly better for thickness compared to the "low" compression class. The difference in thickness was most evident at 1 month. Thereafter no further significant improvement between the two different treatments over time could be obtained. This difference was not found for erythema. Positive correlations could be found between erythema and thickness values at all of the three test points while changes in erythema and thickness only correlated significantly after the first month. The pattern of change of both parameters correlated at a high level of significance after 3 months of treatment. These data suggest that pressure garments that deliver a pressure of at least 15 mmHg pressure tend to accelerate scar maturation and that measurements of the pattern of change of the erythema can be used to predict changes in scar thickness and vice versa.

Counseling and physical therapy as treatment for myofascial pain of the masticatory system.

AIMS: To prospectively evaluate the effectiveness of a treatment regimen comprising counseling and physical therapy in patients with myofascial pain of the masticatory system, and to explore whether the duration of the physical therapy offered (4 vs 6 weeks) would influence the treatment result. METHODS: Twenty-six patients were randomly distributed over 2 groups. All patients received reassuring information, advice regarding relaxation of the jaws, avoiding parafunctions, and limited use of the jaws. In addition, a physical therapy program (heat application, massage, ultrasound and muscle stretching) was initiated 2 weeks after the start of the study (group I, receiving 4 weeks of physical therapy) or immediately from the start of the study (group II, receiving 6 weeks of physical therapy). The following parameters were taken at baseline, 2, 4, and 6 weeks: visual analog scale (VAS) scores of present pain; lowest and highest pain over the past period; percentage of pain relief; jaw function assessment by the Mandibular Function Impairment Questionnaire (MFIQ); and pressure pain thresholds (PPTs) of the masseter, temporalis, and thumb muscles. Statistical analysis used a linear mixed model and corrected for multiple testing (Tukey test). RESULTS: Pain and MFIQ scores decreased while PPTs increased in both groups. Only after 4 and 6 weeks, significant differences were present for the PPT of the masseter in group I (P < .02) and the temporalis in both groups (P < .01). Also, the VAS scores of present (P < .02), minimal (P < .01), and maximal (P < .0001) pain and the MFIQ score (P < .001) improved. After 6 weeks, a mean of 60% pain decrease was reported (P < .0001). There were no significant differences between the groups receiving 4 weeks vs 6 weeks of physical therapy. CONCLUSION: A conservative approach involving counseling and physical therapy resulted in significant improvement in parameters of pain and jaw function in patients with myofascial pain. A controlled study will be necessary to elucidate the specific effectiveness of physical therapy over counseling or no treatment.

The immediate effects of a cervical lateral glide treatment technique in patients with neurogenic cervicobrachial pain.

STUDY DESIGN: Randomized clinical trial. OBJECTIVES: To analyze the immediate treatment effects of cervical mobilization and therapeutic ultrasound in patients with neurogenic cervicobrachial pain. BACKGROUND: Different treatment modalities have been described for patients with neurogenic cervicobrachial pain. Although it has been suggested that a more specific approach, like cervical mobilization, would be more effective, effect studies are scarce. METHODS AND MEASURES: Twenty patients with subacute peripheral neurogenic cervicobrachial pain were assessed. Besides other criteria, patients were included if a cervical segmental motion restriction was present which could be regarded as a possible cause of the neurogenic disorder. Patients were randomly assigned to a mobilization or ultrasound group. Mobilization consisted of a contralateral lateral glide technique. The range of elbow extension, symptom distribution, and pain intensity during the neural tissue provocation test for the median nerve were used as outcome measures. Results were analyzed using a 2-way mixed-design ANOVA. RESULTS: Significant differences in treatment effects between the 2 groups could be observed for all outcome measures (P < or = .0306). For the mobilization group, the increase in elbow extension from 137.3 degrees to 156.7 degrees, the 43.4% decrease in area of symptom distribution, and the decreased pain intensity from 7.3 to 5.8 were significant (P < or = .0003). For the ultrasound group, there were no significant improvements (P > or = .0521). CONCLUSIONS: When a cervical dysfunction can be regarded as a cause of the neurogenic disorder or as a contributing factor that impedes natural recovery, a cervical lateral glide mobilization has positive immediate effects in patients with subacute peripheral neurogenic cervicobrachial pain. This movement-based approach seems preferable to ultrasound.

Incorporating nerve-gliding techniques in the conservative treatment of cubital tunnel syndrome.

OBJECTIVE: To discuss the diagnosis and treatment of a patient with cubital tunnel syndrome and to illustrate novel treatment modalities for the ulnar nerve and its surrounding structures and target tissues. The rationale for the addition of nerve-gliding techniques will be highlighted. CLINICAL FEATURES: Two months after onset, a 17-year-old female nursing student who had a traumatic onset of cubital tunnel syndrome still experienced pain around the elbow and paresthesia in the ulnar nerve distribution. Electrodiagnostic tests were negative. Segmental cervicothoracic motion dysfunctions were present which were regarded as contributing factors hindering natural recovery. INTERVENTION AND OUTCOMES: After 6 sessions consisting of nerve-gliding techniques and segmental joint manipulation and a home exercise program consisting of nerve gliding and light free-weight exercises, a substantial improvement was recorded on both the impairment and functional level (pain scales, clinical tests, and Northwick Park Questionnaire). Symptoms did not recur within a 10-month follow-up period, and pain and disability had completely resolved. CONCLUSIONS: Movement-based management may be beneficial in the conservative management of cubital tunnel syndrome. As this intervention is in contrast with the traditional recommendation of immobilization, comparing the effects of both interventions in a systematic way is an essential next step to determine the optimal treatment of patients with cubital tunnel syndrome.

Reliability of detecting 'onset of pain' and 'submaximal pain' during neural provocation testing of the upper quadrant.

BACKGROUND AND PURPOSE: Conflicting results have been reported with regard to the reliability of neural tissue provocation tests and it is unclear whether repeated testing affects the test results. In the present study, the stability and reliability of the occurrence of 'onset of pain' and 'submaximal pain' throughout the range of motion during neurodynamic testing was analysed, in both a laboratory and a clinical setting. METHOD: A repeated-measures study design within and between sessions was used. In the laboratory and clinical settings, the base neurodynamic test for the median nerve was performed during a single session on a total of 27 patients with neurogenic cervico-brachial pain. In addition, the base test and three common variations were performed on two occasions by two examiners on 10 asymptomatic subjects in laboratory conditions only. Patients indicated the moment of 'submaximal pain' occurrence, whereas asymptomatic subjects indicated 'onset of pain' and 'submaximal pain'. Corresponding angles at the elbow were recorded by use of an electrogoniometer. RESULTS: In the asymptomatic group, the intra- and inter-tester reliability within the same session was excellent (intraclass correlation coefficient (ICC2.1 > or = 0.95; standard error of measurement (SEM) < or = 4.9 degrees). Reliability after a 48-hour interval was moderate (ICC2.1 > or = 0.69; SEM < or = 9.9 degrees). The reliability coefficients for the symptomatic group within the same session were comparable with the excellent results of the asymptomatic group, for both the laboratory (ICC2.1 = 0.98; SEM = 2.8 degrees) and clinical settings (ICC2.1 > or = 0.98; SEM < or = 3.4 degrees). Consequently, from a statistical perspective, improvements in range of motion as small as approximately 7.5 degrees may be interpreted meaningfully. No significant trend due to repeated testing could be observed when three consecutive repetitions were analysed. CONCLUSIONS: Pain provocation during neurodynamic testing is a stable phenomenon and the range of elbow extension corresponding with the moment of 'pain onset' and 'submaximal pain' may be measured reliably, both in laboratory and clinical conditions.

Stability of measurement outcomes for voluntary task performance in participants with chronic ankle instability and healthy participants.

CONTEXT: Acceptable measurement stability during data collection is critically important to research. To interpret differences in measurement outcomes among participants or changes within participants after an intervention program, we need to know whether the measurement is stable and consistent. OBJECTIVE: To determine the within-session stability of muscle activation patterns for a voluntary postural-control task in a group of noninjured participants and a group of participants with chronic ankle instability (CAI). DESIGN: Descriptive laboratory study. SETTING: Musculoskeletal laboratory. PATIENTS OR OTHER PARTICIPANTS: Twenty control participants (8 men, 12 women; age = 21.8 ± 2.4 years, height = 164.3 ± 13.4 cm, mass = 68.4 ± 17.9 kg) and 20 participants with CAI (12 men, 8 women; age = 21.2 ± 2.1 years, height = 176 ± 10.2 cm, mass = 71.7 ± 11.3 kg). INTERVENTION(S): Participants performed 4 barefoot standing trials, each of which included a 30-second double-legged stance followed by a 30-second single-legged stance in 3 conditions: with vision, without vision, and with vision on a balance pad. MAIN OUTCOME MEASURE(S): The activity of 7 muscles of the lower limb was measured for the stance task in the 3 different conditions for each trial. The onset of muscle activity and muscle recruitment order were determined and compared between the first and the fourth trials for both groups and for each condition. RESULTS: We found no differences in the onset of muscle activity among trials for both groups or for each condition. The measurement error was 0.9 seconds at maximum for the control group and 0.12 seconds for the CAI group. In the control group, 70% to 80% of the participants used the same muscle recruitment order in both trials. In the CAI group, 75% to 90% used the same recruitment order. CONCLUSIONS: Within 1 session, measurement stability for this task was acceptable for use in further research. Furthermore, no differences were found in measurement stability across conditions in the control or CAI groups.

Psychosocial variables in patients with (sub)acute low back pain: an inception cohort in primary care physical therapy in The Netherlands.

STUDY DESIGN: A prospective cohort study of patients with episodes of acute or subacute low back pain, seeking physical therapy in primary care, with follow-up at weeks 2, 4, 8, and 12. OBJECTIVES: To evaluate the association between psychosocial factors and the transition from acute or subacute low back pain to chronicity. SUMMARY OF BACKGROUND DATA: Psychosocial factors have long been thought to be associated with chronic pain only. Recent prospective studies, however, suggest that these factors may also be important in acute or subacute low back pain. METHODS: Demographic, psychosocial, and psychological baseline data were collected and analyzed from a sample of 66 acute or subacute patients with low back pain in order to predict the 3-month outcome. RESULTS: After 3 months, response rate was 85% (56 patients). Forty-five percent rated their current status as "not recovered." Twelve percent reported work absenteeism. Using multiple regression analyses, baseline scores on the Acute Low Back Pain Screening Questionnaire, Pain Coping Inventory, Fear-Avoidance Beliefs Questionnaire, and Tampa Scale for Kinesiophobia were not significantly associated with non-recovery at 3 months. The only significant predictor at baseline was the subscale pain of the ALBPSQ, correctly classifying 80% of the patients. The relative risk for not being recovered was 3.72 (95% confidence interval, 1.63-8.52) for the subjects with high scores on the subscale for pain. Pain scores and scores on psychosocial variables at 12 weeks were not associated. CONCLUSIONS: The study strongly revealed pain-related items to be essential factors in the development of chronicity and long-term disability in primary care physical therapy. Health status at 8 weeks seems crucial in developing chronicity.

Reproducibility of repeated measurements on post-burn scars with Dermascan C.

The present study investigated the reproducibility of measurements with the Dermascan C on post-burn scars. Intra- and inter-rater reproducibility and test-retest reliability with a one week time lapse were examined on 40 post-burn scars of 6 volunteering burn patients by means of intra-class- correlation coefficients (ICC) and standard error of measurements (SEM). Results showed good to excellent values for ICC in all the three conditions. On the basis of these results, we concluded that the instrument provides reliable information and can be used in comparative clinical trials that examine therapeutic strategies on healing scars.

Isometric strength measurement for muscle weakness in cancer patients: reproducibility of isometric muscle strength measurements with a hand-held pull-gauge dynamometer in cancer patients.

Our aim was to determine several indexes of reproducibility for strength measurements with a hand-held pull-gauge dynamometer (MFB50K) in cancer patients. Two independent testers performed repeated measurements of maximal isometric elbow and knee strength. The measurements were gathered in a convenience sample of 40 patients (27 men, age 20-72 years) with various types and stages of cancer. These patients were recruited from the medical oncology clinic of a university hospital. The Pearson product moment correlation coefficient, the intraclass correlation coefficient (ICC), the standard error of measurement (SEM) and its associated 95% confidence interval, the smallest detectable difference (SDD) and the limits of agreement were determined as outcome measures for reproducibility. The results for the Pearson product moment correlation and the ICC were 0.90 for elbow and 0.96 for knee extension strength. The results in terms of the SDDs were 29.4 newton (N) for elbow and 54.8 N for knee strength. The limits of agreement for elbow strength were -21.7 N and 38.5 N (mean 8.4 N). For knee strength the limits of agreement were -49.8 N and 59.8 N (mean 5 N). The Pearson product moment correlation and the ICC suggested good reproducibility. However, the more informative indices of reproducibility, i.e. the SEM and the SDD, showed relatively large measurement error between the testers. Therefore, the current use of the MFB50K for the measurement of muscle strength is not supported in cancer patients.

Positioning in anesthesiology: toward a better understanding of stretch-induced perioperative neuropathies.

BACKGROUND: Stretch-induced neuropathy of the brachial plexus and median nerve in conventional perioperative care remains a relatively frequent and poorly understood complication. Guidelines for positioning have been formulated, although the protective effect of most recommendations remains unexamined. The similarity between the stipulated potentially dangerous positions and the components of the brachial plexus tension test (BPTT) justified the analysis of the BPTT to quantify the impact of various arm and neck positions on the peripheral nervous system. METHODS: Four variations of the BPTT in three different shoulder positions were performed in 25 asymptomatic male participants. The impact of arm and neck positions on the peripheral nervous system was evaluated by analyzing the maximal available range of motion, pain intensity, and type of elicited symptoms during the BPTT. RESULTS: Cervical contralateral lateral flexion, lateral rotation of the shoulder and fixation of the shoulder girdle in a neutral position in combination with shoulder abduction, and wrist extension all significantly reduced the available range of motion. Elbow extension also challenged the nervous system substantially. A cumulative impact could be observed when different components were simultaneously added, and a neutralizing effect was noted when an adjacent region allowed for unloading of the nervous system. CONCLUSIONS: The experimental findings support the experientially based guidelines for positioning. Especially when simultaneously applied, submaximal joint positions easily load the nervous system, which may substantially compromise vital physiologic processes in and around the nerve. Therefore, even when the positioning of all upper limb joints is carefully considered, complete prevention of perioperative neuropathy seems almost inconceivable.

Effect of size and pressure of surface recording electrodes on amplitude of sensory nerve action potentials.

The influence of electrode size on sensory nerve action potential (SNAP) amplitude of the lateral antebrachial cutaneous nerve (LACN) and sural nerve (SN) was studied in 63 healthy volunteers. The SNAP amplitudes were measured using surface recording electrodes of three different sizes, positioned across the nerve. Mean amplitudes using a 5-mm electrode were 9.0% (SN) and 15.3% (LACN) higher than with a 20-mm electrode and 19.4% (SN) and 25.8% (LACN) higher than using a 40-mm electrode. To study the influence of pressure on surface recording electrodes, studies were performed on the LACN in 31 healthy volunteers. Light pressure of the recording electrodes on the skin gave lower amplitudes (15.3%) than did greater pressure or pressure applied between active and reference electrodes. These studies demonstrate that standardized surface recording electrode size and pressure are imperative for obtaining valid and reliable results in experimental studies or in clinical follow-up of patients undergoing nerve conduction studies.

Aberrant protective force generation during neural provocation testing and the effect of treatment in patients with neurogenic cervicobrachial pain.

BACKGROUND: Observation of the occurrence of protective muscle activity is advocated in assessment of the peripheral nervous system by means of neural provocation tests. However, no studies have yet demonstrated abnormal force generation in a patient population. OBJECTIVES: To analyze whether aberrations in shoulder girdle-elevation force during neural tissue provocation testing for the median nerve (NTPT1) can be demonstrated, and whether possible aberrations can be normalized following cervical mobilization. STUDY DESIGN: A single-blind randomized comparative controlled study. SETTING: Laboratory setting annex in a manual therapy teaching practice. PARTICIPANTS: Twenty patients with unilateral or bilateral neurogenic cervicobrachial pain. METHODS: During the NTPT1, we used a load cell and electrogoniometer to record continuously the shoulder-girdle elevation force in relation to the available range of elbow extension. Following randomization, we analyzed the immediate treatment effects of a cervical contralateral lateral glide mobilization technique (experimental group) and therapeutic ultrasound (control group). RESULTS: On the involved side, the shoulder-girdle elevation force occurred earlier, and the amount of force at the end of the test was substantially, though not significantly, greater than that on the uninvolved side at the corresponding range of motion. Together with a significant reduction in pain perception after cervical mobilization, a clear tendency toward normalization of the force curve could be observed, namely, a significant decrease in force generation and a delayed onset. The control group demonstrated no differences. CONCLUSIONS: Aberrations in force generation during neural provocation testing are present in patients with neurogenic pain and can be normalized with appropriate treatment modalities.