Comparison of Pelvic Tilt Before and After Hip Flexor Stretching in Healthy Adults.

OBJECTIVE: The purpose of this study was to assess the association between hip flexor length and pelvic tilt or lumbar lordosis by quantifying the effect of stretching on pelvic tilt and lumbar lordosis. METHODS: We quantified pelvic tilt and lumbar lordosis before and after a single session of passive hip flexor stretching in a sample of 23 male participants. Changes in hip flexor length were also characterized, using a Thomas test protocol to measure passive hip extension in supine lying. We investigated both the mean effect of the stretching protocol and potential correlations between changes in passive hip extension and changes in pelvic tilt or lumbar lordosis. RESULTS: Following the stretching protocol, there was a mean increase of 2.6° (P < .001) in passive hip extension and a corresponding mean reduction of 1.2° (P < .001) in anterior pelvic tilt. However, there was no change in lumbar lordosis, nor were there any meaningful correlations between change in passive hip extension and change in pelvic tilt or lumbar lordosis. CONCLUSION: The results suggest that hip muscle stretching may lead to immediate reductions in pelvic tilt during relaxed standing. Such stretching programs could play an important role in interventions designed to improve standing postural alignment.

Management of Pyogenic Spinal Infection, review of literature.

OBJECTIVE: To evaluate the available evidence for the management of Pyogenic Spinal Infection (PSI). METHODS AND RESULTS: A comprehensive search for the relevant literature published between 1990 and 2018 to evaluate the management of PSI was conducted.Nonoperative management of carefully selected patients for an adequate duration of antibiotics can result in satisfactory outcomes with low recurrence rate. When there is an indication for surgery, posterior approach, with or without debridement of infected tissue reported to be associated with good outcomes. CONCLUSION: Studies with larger sample sizes and longer duration of follow up are recommended to formulate more comprehensive evidence.

Medium-term outcome of posterior surgery in the treatment of non-tuberculous bacterial spinal infection.

OBJECTIVE: to evaluate the outcome of posterior spinal stabilization surgery for the management of bacterial spinal infection. METHODS: 21 patients with bacterial infection were managed surgically with posterior stabilization. Outcome measures included neurological status. Follow-up data collected using Spine Tango COMI questionnaires and Euro Qol EQ-5D. RESULTS: The mean improvement in neurological deficits was 0.91 Frankel grade. Residual symptoms of pain had no or minor effect on the work or usual activities in 52% of subjects, with 88% reported having either no or mid problems with mobility. CONCLUSION: Posterior surgery can improve neurological outcome in approximately half of the patients.

A Systematic Review Investigating the Effectiveness of Surgical Versus Conservative Management of Unstable Ankle Fractures in Adults.

Nine percent of all fractures affect the ankle, with an annual incidence of 122/100,000 in Edinburgh, UK. While unstable fractures are usually treated surgically, there has been no recent systematic review of the evidence supporting this decision. In this systematic review, relevant electronic databases (such as MEDLINE and CINHAL) were searched from inception to February 2017. Five randomized controlled trials that examined surgical versus conservative interventions in 951 adults with closed ankle fractures, with follow-up for at least 6 months, were selected for further synthesis of evidence. The risk of selection bias in all selected trials was relatively low. However, most of the trials had a high risk of performance and detection bias. Three of the 5 selected trials used the validated functional Olerud Molander Ankle Score. One trial (n = 43), reported a statistically better score for the surgical group at 27-month follow-up, whereas a second (n = 81) and a third (n = 620) trial found no significant difference at 12 and 6 months, respectively. No significant differences between surgical and conservative treatments were reported in 2 trials (n = 111) and (n = 96) in nonvalidated functional outcome measures. Other outcomes were malunion (9/334 [2.6%] versus 48/301 [15.9%], p < .0001) and nonunion (3/408 [0.7%] versus 28/383 [7.3%], p < .0001) and were considerably higher in the conservatively treated group. Early treatment failure was significantly lower with surgery (7/435 [1.6%] versus 70/419 [16.7%], p < .0001). The risk of malunion, nonunion, and loss of reduction were greater in nonoperative care. However, the 2 treatment approaches provided equivalent functional outcomes.

The Effectiveness of Surgical Interventions in the Management of Malunited Calcaneal Fractures: A Systematic Review.

Nonoperative management may result in calcaneal malunion with consequences of pain, deformity, and functional limitation. The aim of this review was to proffer an evidence-based scientific account of the effectiveness of contemporary surgical procedures in the management of malunited calcaneal fractures after initial conservative management. This systematic review included studies that evaluated the surgical procedures in the management of calcaneal malunion and systematically searched studies published between January 2005 and June 2016. The search was conducted using the following search engines: the Cochrane Library, Web of Science, PubMed/ MEDLINE, EMBASE, CINAHL, Academic Search Premier, and Open Grey. Methodologic assessment was conducted using the Cochrane Risk of Bias In nonrandomized Studies- of Interventions assessment tool version 7. Ten observational studies (212 patients) were included in this review. Five articles explored various means of achieving subtalar arthrodesis, 2 articles evaluated joint-sparing osteotomies, 1 examined corrective osteotomy for extra-articular os calcis malunion, and 2 articles explored combined procedures based on the Stephen and Sanders calcaneal malunion classification. Clinical and methodologic heterogeneity did not allow quantitative pooling of results. The overall risk of bias was considered moderate in 7 studies and 3 were considered at high risk of bias. The inability for any study to be considered at low risk of bias in this review might be mainly attributed to the lack of a valid and reliable outcome measure for the assessment of foot and ankle conditions. There is clear evidence that appropriately indicated procedures are effective in terms of pain alleviation, correction of deformity, and improved function. However, long-term outcomes may improve the acceptability to joint-preserving osteotomies, subtalar arthrodesis with the VIRA implant and subtalar distraction osteogenesis.

Development of a clinical examination in non-specific low back pain: a Delphi technique.

OBJECTIVE: To establish the discriminatory items of the clinical examination of non-specific low back pain, important to physiotherapists. DESIGN: A focus group and Delphi technique with UK physiotherapists. SUBJECTS: A purposive sample of 30 physiotherapists attended a focus group and completed 3 rounds of Delphi questionnaires. METHODS: Data were analysed using mixed qualitative and quantitative approaches. A frequency content analysis identified commonly identified tests and questions, whilst the Delphi consensus technique assumed consensus had been reached with greater than 80% agreement on item inclusion or exclusion. RESULTS: The focus group established the structure of the clinical examination with 15 domains of questioning or physical testing. Three rounds of Delphi questionnaires established the important items of the clinical examination. The list of tests and questions included items evaluating both the psychosocial and biomedical status of the patient as well as questions screening for red flags. CONCLUSION: This is the first work to establish discriminatory tests in the clinical examination of non-specific low back pain, important to physiotherapists. The clinical examination will subsequently be evaluated for item validity and data will undergo cluster analysis. The items of this clinical examination may provide evidence for the existence of homogenous sub-groups within the heterogeneous non-specific low back pain diagnosis.

Between-days reliability of electromyographic measures of paraspinal muscle fatigue at 40, 50 and 60% levels of maximal voluntary contractile force.

OBJECTIVE: To ascertain which percentage of maximal voluntary contractile force of the paraspinal muscles, when tested in a functional position, is most reliable for assessing electromyographic (EMG) fatigue changes. SUBJECTS: Ten healthy volunteers with no history of low back pain (six males). MAIN OUTCOME MEASURES: The surface EMG signal during 60-second isometric contractions of the paraspinal muscles at 40, 50 and 60% levels of maximal voluntary contractile force was captured and analysed. Each contraction level was assessed on two occasions, at least three days apart. The initial median frequency, the decline in median frequency slope and the increase in root mean square values were assessed for between-days reliability, using intraclass correlation coefficients (ICCs) and standard errors of measurements (SEM). Normalized median frequency and root mean square values were also assessed. RESULTS: At 40% of maximal voluntary contraction, little or no EMG fatigue changes occurred in any of the observed parameters. At 50% maximal voluntary contraction the initial mean frequency and root mean square changes proved highly reliable, with ICCs ranging from 0.74 to 0.86 and 0.75 to 1.00 respectively. Normalizing the root mean square data reduced the reliability, but this was still acceptable with ICCs 0.70-0.83. The median frequency decline slope proved less reliable with ICCs 0.24-0.74 for raw and 0.26-0.77 for normalized data. At 60% maximal voluntary contraction the initial mean frequency proved as reliable as initial median frequency at 50% with ICCs 0.70-0.89. The raw and normalized root mean squares (ICCs 0.43-0.89 and 0.30-0.87 respectively) and raw and normalized median frequency (ICCs 0.27-0.51 and 0.24-0.53 respectively) changes were less reliable than at 50% MVC. Overall, the reliability is better at the L4/5 than at the L2/3 level. CONCLUSION: Outcome measures taken at 50% maximal voluntary contraction are the most reliable in functional testing the paraspinal muscles of healthy volunteers. With initial median frequency and root mean square values being more reliable parameters than median frequency decline. At the L4/5 level, however, all parameters were acceptably reliable at 50% of maximum effort. However the between-subject variability of the median frequency decline and root mean square incline slopes suggest that these parameters are not yet fully suitable for monitoring fatigue changes during prolonged isometric contraction.