Inter-rater reliability of the dynamic neuromuscular stabilization diaphragm tests among individuals with non-specific low back pain and neck pain.

BACKGROUND: The Dynamic Neuromuscular Stabilization (DNS) diaphragm test and intra-abdominal pressure regulation test (IAPRT) are qualitative clinical tests that assess postural stability provided by the diaphragm. OBJECTIVE: Evaluate the inter-rater reliability of the diaphragm test and IAPRT between an experienced and novice DNS clinician among individuals with non-specific low back pain (LBP) and neck pain. METHODS: Forty-five participants with non-specific LBP and/or neck pain were assessed by an experienced and novice DNS physiotherapist in the diaphragm test and IAPRT, and scored on a visual analog scale (VAS) according to five different criteria. RESULTS: Moderate reliability was noted when assessing LBP and neck pain patients in the diaphragm test and IAPRT (p < 0.001). Moderate reliability also existed when assessing only LBP (p < 0.001) or neck pain (p = 0.002, p = 0.009) independently. Patients with lower pain (NPRS score of 5 or < ) demonstrated lower intra-class correlation coefficients, yet still moderate reliability in the diaphragm test (p = 0.004) and IAPRT (p = 0.001). Patients with higher pain (NPRS score of 6 or > ) demonstrated greater intra-class correlation coefficients, with the diaphragm test resulting in good reliability (p < 0.001). CONCLUSIONS: The diaphragm test and IAPRT demonstrate moderate reliability between an experienced and novice DNS clinician when evaluating LBP and neck pain patients, with a greater degree of reliability noted in patients suffering from higher reported pain.

Functional postural-stabilization tests according to Dynamic Neuromuscular Stabilization approach: Proposal of novel examination protocol.

This paper presents a set of eleven functional Dynamic Neuromuscular Stabilization (DNS) tests corresponding with specific infantile developmental stages, clarifying desired postural-locomotion patterns from a developmental perspective, while also describing frequently-observed disturbances of these patterns.

Clinical Practice Guideline: Chiropractic Care for Low Back Pain.

OBJECTIVE: The purpose of this article is to provide an update of a previously published evidence-based practice guideline on chiropractic management of low back pain. METHODS: This project updated and combined 3 previous guidelines. A systematic review of articles published between October 2009 through February 2014 was conducted to update the literature published since the previous Council on Chiropractic Guidelines and Practice Parameters (CCGPP) guideline was developed. Articles with new relevant information were summarized and provided to the Delphi panel as background information along with the previous CCGPP guidelines. Delphi panelists who served on previous consensus projects and represented a broad sampling of jurisdictions and practice experience related to low back pain management were invited to participate. Thirty-seven panelists participated; 33 were doctors of chiropractic (DCs). In addition, public comment was sought by posting the consensus statements on the CCGPP Web site. The RAND-UCLA methodology was used to reach formal consensus. RESULTS: Consensus was reached after 1 round of revisions, with an additional round conducted to reach consensus on the changes that resulted from the public comment period. Most recommendations made in the original guidelines were unchanged after going through the consensus process. CONCLUSIONS: The evidence supports that doctors of chiropractic are well suited to diagnose, treat, co-manage, and manage the treatment of patients with low back pain disorders.

The Torsional Upper Crossed Syndrome: A multi-planar update to Janda's model, with a case series introduction of the mid-pectoral fascial lesion as an associated etiological factor.

The Upper Crossed Syndrome (UCS) was presented by Janda to introduce neuromotor aspects of upper body muscle imbalances, describing sagittal plane postural asymmetries as barriers to recovery from chronic locomotor system pain syndromes. The UCS describes muscle imbalances of key antagonists causing forward postures of the head and shoulders and associated changes in the spinal curves -particularly an increased thoracic kyphosis - as well as changed function in the shoulder girdle. The role of fascial tissue has gained remarkable interest over the past decade, previously emphasizing its anatomic compartmental and binding role, while more recently emphasizing load transfer, sensory and kinetic chain function. The authors introduce the Mid-Pectoral Fascial Lesion (MPFL) as a myofascial disorder, describing 11 ipsilateral chest wall cases. While managing these cases, the authors encountered and subsequently designated the Torsional Upper Crossed Syndrome (TUCS) as a multi-planar addition to Janda's classic sagittal plane model. This article integrates published updates regarding the role of posture and fascia with the effects of chest wall trauma and a newly described associated postural syndrome as illustrated with this case series. An effective therapeutic approach to release the MPFL is then briefly described.

Effect of functional stabilization training on balance and motor patterns in a patient with Charcot-Marie-Tooth disease.

OBJECTIVES: Balance and motor disturbances are significant symptoms commonly associated with hereditary motor and sensory neuropathy (HMSN), also known as Charcot-Marie-Tooth disease (CMT). Although CMT is a progressive neurological disease, comprehensive physiotherapeutic strategies may improve balance and motor patterns, and, therefore, enhance the quality of life (ADL). CASE PRESENTATION: A 55-year-old HMSN patient with confirmed CMT X phenotype was evaluated for locomotor stability on a stabilometric platform. Stability tests were repeated after a 3-week, intensive in-patient rehabilitation program and the results were compared. CONCLUSIONS: Improvements in "modified clinical testing of sensory interaction on balance", "limits of stability" and "forward lunge" tests were observed. Subjectively, the patient noted a significant improvement in both balance and gait.

Chiropractic management of low back disorders: report from a consensus process.

OBJECTIVE: Although a number of guidelines addressing manipulation, an important component of chiropractic professional care, exist, none to date have incorporated a broad-based consensus of chiropractic research and clinical experts representing mainstream chiropractic practice into a practical document designed to provide standardized parameters of care. The purpose of this project was to develop such a document. METHODS: Development of the document began with seed materials, from which seed statements were distilled. These were circulated electronically to the Delphi panel until consensus was reached, which was considered to be present when there was agreement by at least 80% of the panelists. RESULTS: The panel consisted of 40 clinically experienced doctors of chiropractic, representing 15 chiropractic colleges and 16 states, as well as both the American Chiropractic Association and the International Chiropractic Association. The panel reached 80% consensus of the 27 seed statements after 2 rounds. Specific recommendations regarding treatment frequency and duration, as well as outcome assessment and contraindications for manipulation were agreed upon by the panel. CONCLUSIONS: A broad-based panel of experienced chiropractors was able to reach a high level (80%) of consensus regarding specific aspects of the chiropractic approach to care for patients with low back pain, based on both the scientific evidence and their clinical experience.

Spinal deformities in hereditary motor and sensory neuropathy: a retrospective qualitative, quantitative, genotypical, and familial analysis of 175 patients.

STUDY DESIGN: Retrospective study of 175 patients with hereditary motor and sensory neuropathy (HMSN), i.e., Charcot-Marie-Tooth (CMT) disease. OBJECTIVE: To investigate the frequency, age of onset, character, familial, and genotypical incidence of spinal deformities among HMSN patients. SUMMARY OF BACKGROUND DATA: Prior studies addressing HMSN discuss the associated spinal deformities. However, these data vary significantly while inconsistently including genotypes within the classification framework. METHODS: Plain-film radiographic spine studies of 175 HMSN patients were performed to determine the incidence, character, and severity of spinal deformity. The degree of the spinal deformity was evaluated measuring Cobb's angle of the main curve. The results of the entire cohort were initially assessed before being classified by genotype. RESULTS: The incidence of spinal deformity for the entire group was 26%. Of these, 58% demonstrated scoliosis, 31% had kyphoscoliosis, and 11% had thoracic hyperkyphosis; 73% of patients with spinal deformity were classified as HMSN Type I with confirmed duplication of the PMP 22 (peripheral myelin protein) gene on chromosome 17. The incidence of spinal deformity by genotype was: duplication of the PMP 22 gene: 29% (25 of 87); deletion of the PMP 22 gene: 0% (0 of 15); Cx32 (connexin 32) gene mutation: 24% (8 of 34); and MPZ (myelin protein zero) gene mutation: 100% (6 of 6). Familial incidence of spinal deformity was found in "MPZ gene mutation" and "duplication of PMP 22 gene" subgroups. CONCLUSION: This study demonstrates a 26% incidence of spinal deformity among HMSN patients. Spinal deformity was most frequently observed in patients with the MPZ gene mutation, where the most common familial incidence was also found.

Twenty-year-old pathogenic "active" postsurgical scar: a case study of a patient with persistent right lower quadrant pain.

OBJECTIVE: This case study describes a patient with persistent right lower quadrant and low back pain who experienced relief after manual mobilization techniques of an old appendectomy scar. CLINICAL FEATURES: A 53-year-old man with pain in the right lower quadrant of the abdomen and low back had previously failed several trials of multimodal treatments. He had an irritated old appendectomy scar in the right lower quadrant. Degenerative disk findings were also noted in the upper lumbar spine. INTERVENTIONS AND OUTCOMES: Manual mobilization of the superficial and deep layers of the scar tissue was applied. The patient experienced an immediate pain reduction after the first treatment. Nine treatments in total were administered to the patient. CONCLUSIONS: Assessment and treatment of "active" scar tissue may comprise an important component of the management of locomotor dysfunction and associated pain syndromes.

Vladimir Janda, MD, DSc: tribute to a master of rehabilitation.

The purpose of this presentation is to pay tribute to the life's work of Professor Vladimir Janda, a key figure in the 20th Century rehabilitation movement. An accomplished neurologist, he founded the rehabilitation department at Charles University Hospital in Prague, Czechoslovakia. He was one of the seminal members of the Prague school of manual medicine and rehabilitation that expanded its influence throughout Central and Eastern Europe. His observations regarding muscle imbalances, faulty posture and gait, and their association with chronic pain syndromes, etiologically, diagnostically, and therapeutically, influenced the rehabilitation world. The authors comprise a multinational, multiprofessional group representative of rehabilitation specialists around the world who would like to pay tribute and give a final word of thanks to this innovative educator, clinician, and author.