Muscle fatigue response of rotator cuff muscles in different postures.

INTRODUCTION: Muscle fatigue is a leading cause of rotator cuff (RC) pathologies. Scapular orientation affected by changes in the thoracic spine account for differences in body postures leading to altered RC muscle activation. This posture-related alteration in RC muscle activation and its fatigue response needs to be analyzed. MATERIALS AND METHODS: This study included 50 healthy shoulders with no coexisting spine pathologies. Raw data were recorded using electromyography sensors for RC muscles during two isometric maneuvers of abduction and external rotation, performed at 30% maximum voluntary contraction at 30°, 45°, and 90° arm elevation in sitting and standing. The raw data were analyzed in DataLITE® software, and the mean power frequency (MPF) was extracted to analyze the fatigue response of RC muscles. The Wilcoxon signed-rank test and Kruskal-Wallis test with Bonferroni corrections analyzed fatigue differences between postures and various activities. P < 0.05 was considered significant for the results. RESULTS: Supraspinatus muscle demonstrated significant fatigue at 90° of arm elevation in standing as compared to sitting (MPF -5.40: -5.41; P = 0.03) posture. Between the three elevation angles, all the RC muscles showed increased fatigue at 90° (MPF range -5.22 to -6.64). When compared between abduction and external rotation, only infraspinatus showed fatigue in external rotation (MPF range -5.42 to -6.08). Among all the three RC muscles, infraspinatus showed the maximum fatigue of MPF -6.64 when compared to supraspinatus -5.22 and teres minor -5.36. CONCLUSION: The findings indicate that alterations in the body postures and different elevation angles affect the RC muscles' fatigue response.

Proportion and distribution of upper extremity musculoskeletal disorders and its association with disability in type 2 diabetes mellitus.

STUDY DESIGN: Cross-sectional INTRODUCTION: Globally, diabetes is a leading cause of disability with an increased prevalence rate in the past three decades. Chronic diabetes has been shown to affect collagenous tissue which often leads to subsequent musculoskeletal complications. Despite increasing prevalence of musculoskeletal disorders, the proportion and distribution of types of upper extremity musculoskeletal disorders resulting in disabilities is poorly understood. PURPOSE OF THE STUDY: This cross-sectional study aims to gather data on the prevalence, proportion and distribution of upper extremity musculoskeletal disorders among individuals with Type 2 Diabetes Mellitus. Further, this study examines the relationship between common upper extremity disorders and the resulting disability among individuals with Type 2 Diabetes Mellitus. METHODS: 170 individuals diagnosed with Type 2 Diabetes Mellitus were recruited at a tertiary care hospital. Routine upper extremity assessments were performed to identify the presence of Frozen Shoulder (FS), Limited Joint Mobility (LJM), Trigger Finger, Carpal Tunnel Syndrome (CTS), and Dupuytren's Contracture. Disability was measured using the Disabilities of arm, shoulder, and hand (DASH) questionnaire. Descriptive statistics, one-way analysis of variance, Tukey's test, and Pearson's test were used to examine the prevalence, proportion and distribution of musculoskeletal disorders and disabilities among individuals with type 2 Diabetes Mellitus. RESULTS: 83(48.9%) participants had one or a combination of multiple musculoskeletal disorders of the upper extremity. The proportion of LJM, FS, CTS, Trigger Finger, and Dupuytren's Contracture were n = 46(27.1%); n = 43(25.3%); n = 16(9.4%); n = 8(4.7%); n = 5(2.9%) respectively. Disability scores on the DASH were 25.8 ± 14.5, 10.3 ± 11.9, and 10.6 ± 10.4 respectively for individuals with FS, LJM and Trigger Finger. DASH scores were highest in individuals with both CTS and FS, 29.8 ± 19.3. Duration of diabetes was significantly associated (r = 0 .19; P < .01) with the disability scores on DASH. CONCLUSION: The prevalence of musculoskeletal disorders in people with type 2 Diabetes mellitus remains high despite advances in medical management over the last two decades. The overall prevalence of hand disorders (LJM, CTS, Dupuytren's contracture, Trigger Finger) was higher than shoulder disorders (FS), e.g. frozen shoulder. People with a diabetes that had a diagnosed upper extremity conditon had more upper extremity disability, than those with diabetes but no diagnosed hand condition, Disability was highest for frozen shoulder and lowest for Dupuytren's diagnoses. Carpal tunnel syndrome was the most disabling hand condition. People with diabetes should be screened for upper extremity diagnoses that could limit their function. Poeple with disability resulting from hand disorders was lower than the shoulder disorders. A combination of hand and shoulder disorders resulted in greater disability.

Inter-examinerreliability study of physical examination procedures to assess the cervical spine.

OBJECTIVE: The objective of this study was to establish the level of inter-examiner reliability for six common cervical manual and physical examination procedures used to assess the cervical spine. MATERIALS: Reliability study that used a convenience sample of 51 patients between the ages of 16-70 years presenting with a chief complaint of neck pain. Two physical therapists independently performed the same series of cervical physical examination procedures on each of the participant. The clinicians were blinded to each other's findings and the clinical status of the patient. Kappa coefficients (κ) were calculated for levels of agreement between the clinicians for each procedure. RESULTS: When assessing for asymmetrical motion, excellent levels of reliability (κ range: 0.88-0.96) were observed for the Bilateral Modified Lateral Shear (asymmetry criterion), Bilateral C2 Spinous Kick (asymmetry criterion) and Flexion-Rotation Tests. When pain provocation was used as the indicator of a positive test during palpation of the cervical facet joints, moderate to substantial levels of reliability (κ range: 0.53-0.76) were observed. When patients were instructed not to provide feedback to the clinicians about pain provocation during facet joint palpation and clinicians relied solely on their qualitative assessment of segmental mobility, the level of reliability was lower (κ range: 0.45-0.53). Due to 100 % prevalence of negative findings, Kappa values could not be calculated for the Sharp-Purser test or the Unilateral C2 Spinous Kick Test. CONCLUSIONS: Most physical examination procedures examined in this study demonstrated moderate to excellent levels of inter-examiner reliability. Palpation for segmental mobility without pain provocation demonstrated a lower level of reliability compared to palpation for pain provocation. Correlation with clinical findings is necessary to establish validity and the applicability of these procedures in clinical practice.

Accuracy of MRI scan in the diagnosis of ligamentous and chondral pathology in the ankle.

BACKGROUND: The aim of our study is to determine the accuracy of magnetic resonance imaging (MRI) scan in relation to arthroscopic findings in patients presenting with chronic ankle pain and/or instability. METHODS: All patients who underwent arthroscopy of the ankle as well as MRI from December 2005 to July 2008 in our institution were reviewed by the Orthopaedic surgeons. Twenty-four patients were identified and the results of MRI scans were compared with arthroscopic findings. This study specifically looked at anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) and osteochondral lesions (OCD). Arthroscopic findings were considered as a gold standard. There were 12 female and 12 male patients with an average age 39 years (11-65 years). Time interval between MRI scan and arthroscopy was 7.0 months (2-18 months). RESULTS: In our study MRI showed 100% specificity for the diagnosis of ATFL and CFL tears and osteochondral lesions. However sensitivity was low particularly for CFL tears. Accuracy of MRI in detecting ATFL tear was 91.7%, CFL tear was 87.5% and osteochondral lesion was 83.3%. CONCLUSIONS: We conclude that MRI scan has very high specificity and positive predictive value in diagnosing tears of ATFL, CFL and osteochondral lesions. However sensitivity was low with MRI. In a symptomatic patient negative results on MRI must be viewed with caution and an arthroscopy may still be required for a definitive diagnosis and treatment. However high resolution scans may differ in their ability to pick up these lesions and further research is required to assess their efficiency as evidence is not currently available.

Inter-examiner reliability of radiographic measurements from Open-mouth lateral bending cervical radiographs.

BACKGROUND: Following head and neck trauma, the involvement of the cranio-cervical junction (CCJ) and its contribution to a patients transition to chronic pain, is poorly understood. The detection of hypermobility in this region is dependent on clinical examination and static imaging modalities such as x-ray, CT and MRI. Sagittal plane hypermobility of the CCJ is evaluated using saggital view, flexion-extension cervical radiographs. Frontal plane hypermobility is typically assessed using lateral bending and open mouth cervical radiographs. Unfortunately there is no established reliability surrounding the use of these measures. This study explores the reliability of radiographic measurements of lateral-bending open-mouth cervical radiographs. METHODS: Cervical open-mouth lateral-bending X-ray images were collected from 56 different patients between 18 and 60 years of age patients following cervical spine injury. These images were interpreted by two musculoskeletal radiologists and two clinicians (physiatrist and chiropractor), using a standard set of measurements. Measurements included qualitative and quantitative assessments of the amount of asymmetry noted between various osseous landmarks. Reliability statistics were calculated for levels of agreement using kappa coefficients (κ) and Intraclass Correlation Coefficients (ICC) for dichotomous and continuous variables, respectively. RESULTS: Reliability (κ) for qualitative assessments were moderate to substantial for asymmetry of neutral C2 spinous position, dens-lateral mass spacing, and "step off" between the lateral borders of the articular pillars of C2 and C1 lateral mass (κ range = .47-.78). ICC values for the quantitative measurements of dens-lateral mass spacing and "step off" between the lateral borders of the C2 articular pillars and C1 lateral mass were moderate to excellent (ICC range = .56-.97). CONCLUSIONS: The qualitative and quantitative measurements used in this study demonstrated good to excellent inter-examiner reliability. Correlation with clinical findings is necessary to establish the utility of these measurements in clinical practice.

Treatment-based Classification System for Patients With Low Back Pain: The Movement Control Approach.

We present the movement control approach as part of the treatment-based classification system. This approach proposes a movement control schema that clarifies that movement control is a product of the interplay among multiple biopsychosocial components. The schema illustrates that for movement to occur in a dynamically controlled fashion, the lumbar spine requires both local mobility and global stability. Local mobility means that the lumbar spine and its adjacent regions possess adequate nerve and joint(s) mobility and soft tissue compliance (ie, the malleability of tissue to undergo elastic deformation). Global stability means that the muscles of the lumbar spine and its adjacent regions can generate activation that is coordinated with various joint movements and incorporated into activities of daily living. Local mobility and global stability are housed within the bio-behavioral and socio-occupational factors that should be addressed during movement rehabilitation. This schema is converted into a practical physical examination to help the rehabilitation provider to construct a clinical rationale as to why the movement impairment(s) exist. The examination findings are used to guide treatment. We suggest a treatment prioritization that aims to consecutively address neural sensitivity, joint(s) and soft tissue mobility, motor control, and endurance. This prioritization enables rehabilitation providers to better plan the intervention according to each patient's needs. We emphasize that treatment for patients with low back pain is not a static process. Rather, the treatment is a fluid process that changes as the clinical status of the patient changes. This movement control approach is based on clinical experience and indirect evidence; further research is needed to support its clinical utility.

Treatment-Based Classification System for Low Back Pain: Revision and Update.

The treatment-based classification (TBC) system for the treatment of patients with low back pain (LBP) has been in use by clinicians since 1995. This perspective article describes how the TBC was updated by maintaining its strengths, addressing its limitations, and incorporating recent research developments. The current update of the TBC has 2 levels of triage: (1) the level of the first-contact health care provider and (2) the level of the rehabilitation provider. At the level of first-contact health care provider, the purpose of the triage is to determine whether the patient is an appropriate candidate for rehabilitation, either by ruling out serious pathologies and serious comorbidities or by determining whether the patient is appropriate for self-care management. At the level of the rehabilitation provider, the purpose of the triage is to determine the most appropriate rehabilitation approach given the patient's clinical presentation. Three rehabilitation approaches are described. A symptom modulation approach is described for patients with a recent-new or recurrent-LBP episode that has caused significant symptomatic features. A movement control approach is described for patients with moderate pain and disability status. A function optimization approach is described for patients with low pain and disability status. This perspective article emphasizes that psychological and comorbid status should be assessed and addressed in each patient. This updated TBC is linked to the American Physical Therapy Association's clinical practice guidelines for low back pain.

Open grade III "floating ankle" injuries: a report of eight cases with review of literature.

INTRODUCTION: "Floating ankle" injuries result from high-energy trauma and are usually associated with extensive soft tissue damage. Such rare and complex injuries in the acute phase pose therapeutic dilemma to the treating surgeon. When salvage instead of amputation is preferred, a variety of treatment options are available ranging from open reduction along with minimal internal fixation to external fixation. In this retrospective case series study we report eight patients with open "floating ankle" injuries who had been treated with external fixation with or without internal fixation. MATERIALS AND METHODS: Eight consecutive patients (7M: 1F) with mean age of 28 years (range 18-35 years) were treated. All had Grade III open fractures of the distal tibia with foot fractures and various degrees of soft tissue injuries. ISS and MESS were used to assess injury severity. Immediate radical wound debridement; skeletal stabilization and early soft tissue coverage were done by combined trauma and plastic surgical services followed by standard post-operative rehabilitation. All the patients were assessed with SF-36 questionnaire at mean follow-up of 2.5 years (range 2-4 years). RESULTS: Three patients were treated primarily with Ilizarov ring fixators, one had hybrid fixation and the other four had Hoffman frames. Four patients needed further surgeries. One patient developed metatarsal osteomyelitis, which was debrided and treated with antibiotics. The SF-36 results were compared with age matched UK norms for men and women in all categories. Only two patients returned to their previous employment. Six suffered varying degrees of disability out of which one underwent amputation. CONCLUSIONS: External fixation with or without internal fixation is an option when salvaging rare injuries like open grade III "floating ankle" injuries. Salvaged patients do suffer a cocktail of crippling disease characterized by psycho-socio-economic and physical disability and result in increased hospital costs. We recommend more prospective studies with long-term follow-up of such complex injuries to identify the indications for salvage and also the criteria for a successful salvage.