Advanced practice physiotherapy care in emergency departments for patients with musculoskeletal disorders: a pragmatic cluster randomized controlled trial and cost analysis.

BACKGROUND: Advanced practice physiotherapy (APP) models of care where physiotherapists are primary contact emergency department (ED) providers are promising models of care to improve access, alleviate physicians' burden, and offer efficient centered patient care for patients with minor musculoskeletal disorders (MSKD). OBJECTIVES: To compare the effectiveness of an advanced practice physiotherapist (APPT)-led model of care with usual ED physician care for persons presenting with a minor MSKD, in terms of patient-related outcomes, health care resources utilization, and health care costs. METHODS: This trial is a multicenter stepped-wedge cluster randomized controlled trial (RCT) with a cost analysis. Six Canadian EDs (clusters) will be randomized to a treatment sequence where patients will either be managed by an ED APPT or receive usual ED physician care. Seven hundred forty-four adults with a minor MSKD will be recruited. The main outcome measure will be the Brief Pain Inventory Questionnaire. Secondary measures will include validated self-reported disability questionnaires, the EQ-5D-5L, and other health care utilization outcomes such as prescription of imaging tests and medication. Adverse events and re-visits to the ED for the same complaint will also be monitored. Health care costs will be measured from the perspective of the public health care system using time-driven activity-based costing. Outcomes will be collected at inclusion, at ED discharge, and at 4, 12, and 26 weeks following the initial ED visit. Per-protocol and intention-to-treat analyses will be performed using linear mixed models with a random effect for cluster and fixed effect for time. DISCUSSION: MSKD have a significant impact on health care systems. By providing innovative efficient pathways to access care, APP models of care could help relieve pressure in EDs while providing efficient care for adults with MSKD. TRIAL REGISTRATION: ClinicalTrials.gov NCT05545917 . Registered on September 19, 2022.

Group-based exercice training programs for military members presenting musculoskeletal disorders - protocol for a pragmatic randomized controlled trial.

BACKGROUND: Musculoskeletal disorders are a leading cause of morbidity and the most prevalent source of disability among soldiers. Their high prevalence in armed forces and limited ressources have led to problems related to access to physical rehabilitation care. To increase access, supervised group-based exercise programs for the most prevalent musculoskeletal disorders (low back pain, patellofemoral pain, rotator cuff-related shoulder pain or lateral ankle sprain) have been developed at a Canadian Armed forces (CAF) base, but their effectiveness has not been evaluated. The primary objective of this randomized controlled trial is to evaluate the mid- and long-term effects of these group-based training programs on pain severity and functional limitations, in comparison with usual individual physiotherapy care. Secondary objectives include comparing both interventions in terms of health-related quality of life, pain-related fear, and patients' satisfaction. METHODS: One hundred and twenty soldiers with a new medical referral for physiotherapy services for one of the four targeted musculoskeletal disorders will be consecutively recruited. They will be randomly assigned to either group-based training program or usual individual physiotherapy care, and will take part in the assigned 12-week intervention. There will be four evaluation sessions over 26 weeks (baseline, week 6, 12 and 26). At each follow-up, functional limitations, pain severity, health-related quality of life and pain-related fears will be assessed. Patients satisfaction with treatment will also be evaluated at the end of the intervention period. Either two-way repeated measures ANOVA will be used to analyse and compare the effects of the interventions. DISCUSSION: This RCT will determine the effectiveness of group-based training programs compared to usual individual physiotherapy care. This new intervention model could represent an efficient, and more pro-active approach to manage a higher number of soldiers with musculoskeletal disorders. It could improve access to physical rehabilitation care and improve the health of soldiers. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT05235152 ), February 11th 2022.

A method of measuring three-dimensional scapular attitudes using the optotrak probing system.

OBJECTIVE: To develop a method to obtain accurate three-dimensional scapular attitudes and to assess their concurrent validity and reliability. STUDY DESIGN: In this methodological study, the three-dimensional scapular attitudes were calculated in degrees, using a rotation matrix (cyclic Cardanic sequence), from spatial coordinates obtained with the probing of three non colinear landmarks first on an anatomical model and second on a healthy subject. BACKGROUND: Although abnormal movement of the scapula is related to shoulder impingement syndrome, it is not clearly understood whether or not scapular motion impairment is a predisposing factor. Characterization of three-dimensional scapular attitudes in planes and at joint angles for which sub-acromial impingement is more likely to occur is not known. METHODS: The Optotrak probing system was used. An anatomical model of the scapula was built and allowed us to impose scapular attitudes of known direction and magnitude. A local coordinate reference system was defined with three non colinear anatomical landmarks to assess accuracy and concurrent validity of the probing method with fixed markers. Axial rotation angles were calculated from a rotation matrix using a cyclic Cardanic sequence of rotations. The same three non colinear body landmarks were digitized on one healthy subject and the three dimensional scapular attitudes obtained were compared between sessions in order to assess the reliability. RESULTS AND CONCLUSIONS: The measure of three dimensional scapular attitudes calculated from data using the Optotrak probing system was accurate with means of the differences between imposed and calculated rotation angles ranging from 1.5 degrees to 4.2 degrees. Greatest variations were observed around the third axis of the Cardanic sequence associated with posterior-anterior transverse rotations. The mean difference between the Optotrak probing system method and fixed markers was 1.73 degrees showing a good concurrent validity. Differences between the two methods were generally very low for one and two direction displacements and the largest discrepancies were observed for imposed displacements combining movement about the three axes. The between sessions variation of three dimensional scapular attitudes was less than 10% for most of the arm positions adopted by a healthy subject suggesting a good reliability. The Optotrak probing system used with a standardized protocol lead to accurate, valid and reliable measures of scapular attitudes. RELEVANCE: Although abnormal range of motion of the scapula is often related to shoulder pathologies, reliable outcome measures to quantify three-dimensional scapular motion on subjects are not available. It is important to establish a standardized protocol to characterize three-dimensional scapular motion on subjects using a method for which the accuracy and validity are known. The method used in the present study has provided such a protocol and will now allow to verify to what extent, scapular motion impairment is linked to the development of specific shoulder pathologies.

Comparisons of mechanical and electromyographical muscular utilization ratios.

The physical loading of a muscle during functional activities can be estimated by the muscular utilization ratio. This ratio is defined as the percentage of muscular involvement relative to the maximal capacity. Either mechanical or electromyographical approaches can be used to obtain the muscle utilization ratio. However, the non-linear relationship between electromyographical activity and muscle force, as well as the non-equivalence between agonist muscles, may create differences between the mechanical muscle utilization ratio calculated from joint moments and the electromyographical muscle utilization ratio calculated from electromyographical data. The aim of this study was to compare, during a squat test, the mechanical muscle utilization ratio and the electromyographical muscle utilization ratio estimated by three different methods; direct linear approximation, second order polynomial regression and linear interpolation. The knee extensor moment and electromyographical data of rectus femoris and vastus medialis of 11 subjects were recorded during both knee extension and squat. Both tests were performed with the knee maintained at 90 degrees of flexion. The results showed that: a) the electromyographical muscle utilization ratio, calculated from the average of vastus medialis and rectus femoris, significantly underestimates the mechanical muscle utilization ratio (ANOVA, p < 0.01), b) the differences between the mechanical muscle utilization ratio and the electromyographical muscle utilization ratio are larger for the direct linear approximation method than for the second order polynomial regression (ANOVA, p < 0.01) or the linear interpolation method (ANOVA, p < 0.01), and c) independent of the method utilized, there is no difference between the electromyographical muscle utilization ratio predicted by the vastus medialis as compared with the rectus femoris (ANOVA, p > 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Patellofemoral pain syndrome: the possible role of an inadequate neuromuscular mechanism.

The patellofemoral pain syndrome is described by a great number of papers as a pathology related mainly to the knee extensor mechanism. However, this knee problem may have an influence on the other joints of the lower extremity. To explain the interdependence between joints of the lower extremity, the support moment concept was used as a framework for the present study. Based on this concept we hypothesized that patellofemoral pain syndrome subjects reduce the stress on their painful patellofemoral joint by decreasing the use of the knee extensor muscles during functional activities. In order to achieve the same support moment, a smaller contraction of the knee extensors could be compensated by an overuse of the hip extensors and ankle plantarflexors. The aim of this study was to verify these compensations in a strenuous functional activity for the knee by comparing 11 subjects having a patellofemoral pain syndrome with 11 normal subjects. Three squat tests were performed:NATURAL, IMPOSED, and TIP TOES. The results obtained in the tip toes test indicated that patellofemoral pain subjects have: (a) a significantly greater knee extensor moment, and (b) a significantly lower hip extensor moment as compared to the normal. A greater straightening of the trunk was observed on patellofemoral pain syndrome patients during the tip toes test as compared to the other tests. Contrary to the expected hypothesis, the patellofemoral pain subjects did not show a strategy tending to decrease the knee extensor moments. In fact in the squat test on tip toes, the subjects affected by a patellofemoral pain syndrome overused the knee extensor muscles.

Attacking today's tuberculosis problem: a multifaceted, coordinated effort.

Tuberculosis is making a comeback in communities across the nation. Increased rates of the disease, particularly with those having HIV/AIDS, have sounded the alarm that quick and decisive action is needed to halt the spread of TB. Multidrug-resistant TB is becoming a primary concern with public health officials. Specific plans and efforts, instigated by the Centers for Disease Control, have outlined the appropriate steps local public health workers, the medical community, and civic and community organizations should take in order to eliminate TB by the year 2010. With the creation of the Task Force on Drug Resistant Tuberculosis, Louisiana has a vehicle with which to combat its growing TB problem.

Effect of pronation and supination tasks on elbow flexor muscles.

The aim of this study was to verify the presence of modulatory effects of pronation (P) and supination (S) on biceps brachii (BB) and brachioradialis (BR) electromyographic (EMG) signals while performing isometric elbow flexions at different angles (50, 90, and 130°). The EMG activity of BB and BR was recorded for normal subjects (N = 6) with surface electrodes during an isometric ramp contraction of elbow flexion (F) that was combined with 20% of maximal voluntary contraction (MVC) in pronation or in supination. The results indicate that (a) the BB muscle presents an increased EMG activity in the combined task of S-F and a decreased EMG activity in the combined task of P-F (Friedman ANOVA, p < 0.01); (b) the EMG activity of the BR is not significantly influenced by the different tasks (Friedman's ANOVA, p > 0.05); and (c) the modulation of the BB occurs only at a midrange angle of flexion. This study partly supports results that were previously reported by other authors, suggesting that a combined task can modulate the EMG activity of elbow flexor muscles. However, this modulation, observed especially for the BB, appears to be limited to elbow flexion angles that are close to 90°.

Cocontraction of the elbow muscles during combined tasks of pronation-flexion and supination-flexion.

The aim of this study was to determine if the antagonist activity of the triceps brachii (TB) and anconeus (AN) muscles is modulated when the activity of the biceps brachii (BB) and brachioradialis (BR) is modulated by the performance of combined tasks and to verify if this behavior is similar at different elbow angles. Electromyographic (EMG) activity of BB, BR, AN and TB was recorded for normal subjects (N = 6) with surface electrodes during a ramp isometric contraction in elbow flexion (F) which was performed alone or combined with 20% of maximal voluntary contraction (MVC) in pronation (P) or in supination (S). Two cocontraction ratios, using the EMG root mean square (rms) values of each muscle and identified as BB/TB and BR/AN were calculated. The results indicate that for low flexion torque levels, the BB/TB ratio is higher for the S-F condition while the BR/AN ratio is higher during the pure flexion task. Variations of the EMG activity across tasks were significant only for BB (Friedman ANOVA, p less than .01) whereas there was no significant change in EMG activity (rms) for TB, BR and AN (Friedman ANOVA, p greater than .01). Furthermore, the behavior of both ratios across tasks was similar at 50 degrees, 90 degrees and 130 degrees of elbow flexion. Thus, for isometric conditions, there appears to be no evidence of modulation of EMG activity of elbow extensors while performing combined tasks of S-F and P-F. In addition, cocontraction activity during these tasks tends to be similar across elbow angles.

Teen Advocate Program: a unique assessment of case management.

The Teen Advocate Program is a case management demonstration project developed with a block grant from the Maternal and Child Health Section of the Louisiana Department of Health. Family Counseling of East Baton Route Parish, a community-based agency, was contracted to develop outreach services for high risk adolescents. The purpose of the program is to provide structure, advocacy, and coordination, empowering teens to use primary and preventive health care providers. The initial referral base of clients was provided from a clinic of teen mothers and their infants, and an adolescent family planning clinic, both located at the East Baton Rouge Parish Health Unit. This interdisciplinary case management outreach services makes this model unique because it offers an organized, structured preventive health care intervention to teens at high risk of becoming pregnant. Goal attainment scales developed revealed that 96% of the study population improved. Sixty-seven percent have good attendance at clinics. Among the client population of teen mothers, there has only been a 4% repeat pregnancy rate. For the first six months of existence, there were no documented pregnancies among the adolescent seeking contraceptive counseling. The study results confirmed the positive influence of case management in preventing adolescent pregnancy. This model is being expanded to address other high risk adolescent behaviors.

PIP: A case management study was conducted on the Family Counseling Services of East Baton Rouge Parish. The aim of the study was to discover the effect of teen advocacy programs on teens in their own environment. The study group consisted of 107 teen mothers, 18 children of teen mothers, and 90 adolescents seeking family planning counseling. The teen advocacy program provides advice, structure and coordination. The study was conducted by monitoring the case managers in the following activities: client intake screening, assessment and service planning, referrals, advocacy, and support services. A goal attainment scale was created to measure any outcome. The results of the study are as follows: each teen was referred to an average of 5-6 resources; 81 of the 107 teen mothers (66%) developed plan and accepted contracts with particular programs; 64 of the 90 (67%) teens attended contraceptive services; 35 of 51 (69%) teens on contraception continued to use it for the 1st 6 months; no pregnancies were documented among those using contraception to prevent 1st pregnancies. The goal attainment score showed a 96% improvement among the teens counseled. The study has shown that the use of teen advocacy programs is an effective way to help reduce high risk behavior.

Streptococcal meningitis with an unusual port of entry.

An 18-month-old boy developed meningitis due to group A beta-hemolytic Streptococcus. Despite adequate antibiotic therapy with aqueous sodium penicillin G and chloramphenicol for more than eight weeks, he showed persistent abnormal spinal fluid findings, recurrent elevations of temperature, irritability, and poor feeding. Further investigation revealed a congenital dermal sinus of the nose, with an entry into the anterior fossa that made a small opening intradurally at the level of the cribiform plate. Surgical removal of the entire sinus tract resulted in a speedy and complete recovery.